3/14/2018 Pediatric Appendicitis Clinical Presentation: History, Physical Examination

Pediatric Appendicitis Clinical Presentation

Updated: Aug 23, 2017
Author: Adam C Alder, MD; Chief Editor: Carmen Cuffari, MD more...

PRESENTATION

History
The classic history of anorexia and vague periumbilical pain, followed by migration of pain to the right
lower quadrant (RLQ) and onset of fever and vomiting, is observed in fewer than 60% of patients. [2] If
the appendix perforates, an interval of pain relief is followed by development of generalized abdominal
pain and peritonitis. Although some patients progress in the classical fashion, some patients deviate
from the classic model. Atypical presentations are common in neurologically impaired and
immunocompromised patients, as well as in children who are already on antibiotics for another illness.

In patients with a retrocecal appendix, who constitute 15% of cases, signs and symptoms may not
localize to the RLQ but instead to the psoas muscle, the flank or right upper quadrant. In other
patients, the tip of the appendix is deep in the pelvis, and the signs and symptoms localize to the
rectum or bladder resulting in pain with defecation or voiding.

Certain features of a child's presentation may suggest a perforated appendix. A child younger than 6
years with symptoms for more than 48 hours is much more likely to have a perforated appendix. The
child may have generalized abdominal pain and may have a high heart rate and a temperature higher
than 38°C.

A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one study and was found
to increase with duration of symptoms. While perforation was directly related to the duration of
symptoms before surgery, the risk was associated more with prehospital delay than with in-hospital
delay. [1]

Pain
All patients with appendicitis have abdominal pain, and many have anorexia; absence of both of these
findings should place the diagnosis of appendicitis in question. A child who states that the ride to the
hospital is painful when the vehicle hits bumps in the road suggests peritoneal irritation.

Acute onset of severe pain is not typical of acute appendicitis but is seen with acute ischemic
conditions such as volvulus, testicular torsion, ovarian torsion, or intussusception. If the pain is initially
located in the right lower quadrant, severe constipation should be considered. A high index of
suspicion should be maintained when attributing pain to constipation, especially in a child who does
not have a prior history of constipation. Many children do not report the early symptoms of appendicitis
and only appreciate the pain when it localizes to the RLQ. In addition, children with a retrocecal
appendicitis may have a delay in the appreciable pain, leading to a delay in presentation.

As appendicitis progresses, the pain migrates to the RLQ due to inflammation of the parietal
peritoneum. This pain is more intense, continuous, and localized than the initial pain. This shift of pain
rarely occurs in other abdominal conditions.
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3/14/2018 Pediatric Appendicitis Clinical Presentation: History, Physical Examination

Atypical pain is common and occurs in 40-45% of patients. This includes children who initially have
localized pain and those with no visceral symptoms. Pain on urination can be seen with pelvic
appendicitis.

Nausea and vomiting

A unique feature of appendicitis is gradual onset of pain followed by vomiting. Vomiting first is more
typical of gastroenteritis.

Generally, vomiting that occurs prior to pain is unusual. However, in patients with retrocecal
appendices, particularly those that extend cephalad along the posterior surface of the right colon,
inflammation of the appendix irritates the nearby duodenum, resulting in nausea and vomiting prior to
the onset of RLQ pain.

Diarrhea

Significant diarrhea is atypical in appendicitis, and the physician should consider other diagnoses,
while not ruling out appendicitis. In patients with an appendix in a pelvic location, inflammation of the
appendix occasionally results in an irritative stimulation of the rectum. These patients often report
diarrhea. However, upon closer questioning, such patients usually describe frequent, small-volume,
soft stools rather than true diarrhea.

Fever
Most children with appendicitis are afebrile or have a low-grade fever and characteristic flushing of
their cheeks. Severe fever is not a common presenting feature unless perforation has occurred, and
even then it may still be rare. According to one study, vomiting and fever are more frequent findings in
children with appendicitis than in children with other causes of abdominal pain.

Physical Examination
The physical examination findings in children may vary depending on age. Irritability may be the only
sign of appendicitis in a neonate. Older children often seem uncomfortable or withdrawn. They may
prefer to lie still because of peritoneal irritation. Teenaged patients often present in a classic or near-
classic fashion.

Examination of the child requires skill, patience, and warm hands. Initial and continued observation of
the child is of critical importance. An ill-appearing quiet child who is lying very still in bed, perhaps with
the legs flexed, is much more a cause for concern than a child who is laughing, playing, and walking
around the room.

The examination should be thorough and start with areas other than the abdomen. Because lower
lobe pneumonias can cause abdominal findings, a history of such should be elicited and a thorough
chest examination performed. It is also important to exclude urinary tract infection (UTI) as a cause of
abdominal pain.

Children vary in their ability to cooperate with the physical examination. It is important to tailor the
physical examination to the child's age and developmental stage.

General examination

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3/14/2018 Pediatric Appendicitis Clinical Presentation: History, Physical Examination

Patients’ general state should be observed before interacting with them. The patient’s state of activity
or withdrawal may lend information into their condition. The child's gait may be observed if they are
well enough to ambulate. A patient in obvious distress with abdominal pain gives the impression of an
infectious process; however, other causes must be ruled out.

Cardiac and pulmonary examination

The findings on evaluation of the heart and lungs typically reflect the patient’s overall state more than
they may suggest appendicitis. Patients are often dehydrated or in pain and may be tachycardic or
tachypneic. Pediatric patients have great physiological reserves and may not show any general
symptoms until they are very ill.

Abdominal examination

Full exposure of the abdomen is key. Before examining the abdomen, ask the child to point with one
finger to the site of maximal pain. Begin palpation of the abdomen at a site distant to this, with the
most tender area examined last. If the child is particularly anxious, palpation may be performed with a
stethoscope.

Distracting questions concerning school and family members may be helpful to relieve anxiety during
the examination. Observing the child's facial expressions during this questioning and palpating is
critical.

Palpation of the abdomen should be performed with a gentle and light touch, searching for involuntary
guarding of the rectus or oblique muscles. In early appendicitis, children may not have significant
guarding or peritoneal signs. Younger children are much more likely to present with diffuse abdominal
pain and peritonitis, perhaps because their omentum is not well developed and cannot contain the
perforation.

Typically, maximal tenderness can be found at the McBurney point in the RLQ. A mass may be
palpable in the RLQ if the appendix is perforated.

However, the appendix may lie in many positions. Patients with a medially positioned appendix may
present with suprapubic tenderness. Patients with a laterally positioned appendix often have flank
tenderness. Patients with a retrocecal appendix may not have any tenderness until appendicitis is
advanced or the appendix perforates.

Presence of the Rovsing sign (pain in the RLQ in response to left-sided palpation or percussion)
strongly suggests peritoneal irritation.

To assess for the psoas sign, place the child on the left side and hyperextend the right leg at the hip. A
positive response suggests an inflammatory mass overlying the psoas muscle (retrocecal
appendicitis).

Check for the obturator sign by internally rotating the flexed right thigh. A positive response suggests
an inflammatory mass overlying the obturator space (pelvic appendicitis).

During the abdominal examination, try to avoid eliciting rebound tenderness. This is a painful practice
and certainly destroys any trust that has been garnered during the examination. Peritonitis can be
confirmed with gentle percussion over the right lower quadrant. Involuntary contraction of the
abdominal wall musculature (involuntary guarding) and tenderness can be elicited with minimal stress
or discomfort to the child.

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3/14/2018 Pediatric Appendicitis Clinical Presentation: History, Physical Examination

Other methods can be used to establish that the patient has peritoneal irritation. Asking the patient to
sit up in bed, cough, jump up and down, or bounce his or her pelvis off the bed while in the supine
position may elicit pain in the presence of peritoneal irritation. Alternatively, other acceptable
maneuvers are tapping the patient's soles and shaking the stretcher. A child with advanced
appendicitis typically prefers to lie still due to peritoneal irritation.

Rectal examination
The digital rectal examination is often deferred but can be helpful in establishing the correct diagnosis,
especially in sexually active adolescent girls. The patient should be told that the examination is
uncomfortable but should not cause sharp pain. The caliber of the patient's anus should be taken into
consideration, and smaller digits should be used for examining younger patients.

The rectal examination is particularly important in the child with a pelvic appendix, in whom the
findings on the abdominal examination for appendicitis may be equivocal and indicative of peritoneal
irritation.

Objective information to ascertain includes impacted stool or an inflammatory mass. Right-sided

tenderness of the rectum is the classic finding in patients with pelvic appendicitis or in those with pus
that pools in the pelvis from an inflamed appendix elsewhere in the abdomen.

Patients who are able to communicate should be asked if they have tenderness in different areas of
the rectum. The rectal examination in a young child may have to be completely objective because they
may not be able to communicate variations in tenderness or may have general discomfort from the
examination.

Genitourinary examination

An external genitourinary (GU) examination is helpful to rule out testicular or scrotal tenderness in
males and hematocolpos in pubertal girls.

Pelvic examination
A pelvic examination should be considered in sexually active adolescent girls to evaluate for
tenderness (adnexal and/or cervical motion tenderness), masses, bleeding, or discharge.

Atypical findings

Becker et al found that 44% of patients diagnosed with appendicitis presented with 6 or more of the
following atypical features [3] :

No fever
Absence of Rovsing sign
Normal or increased bowel sounds
No rebound pain
No migration of pain
No guarding
Abrupt onset of pain
No anorexia
Absence of maximal pain in the RLQ
Absence of percussive tenderness

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3/14/2018 Pediatric Appendicitis Clinical Presentation: History, Physical Examination

Differential Diagnoses

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