Pediatric Appendicitis

Updated: Oct 25, 2018
Author: Adam C Alder, MD; Chief Editor: Carmen Cuffari, MD 



Acute appendicitis is acute inflammation and infection of the vermiform appendix, which is most commonly referred to simply as the appendix. The appendix is a blind-ending structure arising from the cecum. Acute appendicitis is one of the most common causes of abdominal pain and is the most frequent condition leading to emergent abdominal surgery in children. The appendix may be involved in other infectious, inflammatory, or chronic processes that can lead to appendectomy; however, this article focuses on acute appendicitis. Appendicitis and acute appendicitis are used interchangeably. (See Anatomy, as well as Pathophysiology.)

Images of pediatric appendicitis are provided below.

Ultrasonographic examination of the right lower qu Ultrasonographic examination of the right lower quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross section. Discomfort was noted as the probe was depressed over this structure. A small amount of free fluid is also noted surrounding the appendix.
CT scan depicting a distended tubular structure de CT scan depicting a distended tubular structure descending into the pelvis and containing a round calcification (ie, an appendicolith).

See Appendicitis: Avoiding Pitfalls in Diagnosis, a Critical Images slideshow, to help make an accurate diagnosis.

Also see the 12 Can't-Miss Findings on Pediatric Imaging Studies slideshow to help correctly evaluate abnormal findings in imaging studies for pediatric patients.

Common symptoms of acute appendicitis include abdominal pain, fever, and vomiting. The diagnosis of appendicitis can be difficult in children because the classic symptoms are often not present. (See Clinical Presentation.)

A delay in the diagnosis of appendicitis is associated with rupture and associated complications, especially in young children. Improvements in rupture rates have been made with advanced radiologic imaging. Appendicitis is a clinical diagnosis with imaging used to confirm equivocal cases. (See Workup.)

The definitive treatment for appendicitis is currently appendectomy. Initiation of antibiotics upon diagnosis is critical to initiate treatment, slow the infectious process and prevent progression of a nonperforated appendix. Key to any evaluation and treatment plan are the following: relieve the patient's pain and discomfort early and consistently; communicate with the patient and family about the plans; repeat the examination often; adjust the differential diagnosis as appropriate; and keep the patient for observation if a firm diagnosis is not made. (See Treatment and Management.)

The most widely used antibiotic regimen is a penicillin based regimen such as piperacillin/tazobactam or ampicillin/clavulanic acid or the combination of ampicillin, clindamycin (or metronidazole), and gentamicin.  If a penicillin allergy exists, regimens including cephalosporins, aminoglycosides and clindamycin may be used. (See Medication.)

Patient education

For patient education information, see the Digestive Disorders Center, as well as Appendicitis and Abdominal Pain in Children.


The vermiform appendix is generally 5-10 cm in length. It arises from the cecum, which in most children is located in the right lower quadrant of the abdomen.

Although the base of the appendix is fixed to the cecum, the tip can be located in the pelvis, retrocecal, or extraperitoneal. Note that the anatomic position of the appendix determines the symptoms and the site of tenderness when the appendix becomes inflamed. Because the visceral nerve fibers associated with the appendix typically become inflamed first, there is often vague and referred symptoms to the periumbilical region through the T10 dermatome. As the somatic sensory fibers of the peritoneal lining become involved in the inflammatory process, the pain will frequently shift to the right lower abdomen and tenderness is focused at the site of inflammation.

The appendix is lined by typical colonic epithelium. The submucosa contains lymphoid follicles, which are very few at birth. This number gradually increases to a peak of about 200 follicles at age 10-20 years and then subsequently declines. In persons older than 30 years, less than half that number is present, and the number continues to decrease throughout adulthood. The appendix may act as a reservoir for the flora of the gut which may aid in recovery from intestinal infections. However, this function is not vital for life and removal of the appendix is well tolerated.


Tradition holds that once the appendix becomes obstructed, bacteria trapped within the appendiceal lumen begin to multiply, and the appendix becomes distended. The increased intraluminal pressure obstructs venous drainage, and the appendix becomes congested and ischemic.

The combination of bacterial infection and ischemia produce inflammation, which progresses to necrosis and gangrene. When the appendix becomes gangrenous, it may perforate. The progression from obstruction to perforation usually takes place over 72 hours.

One study noted that appendiceal perforation is more common in children, specifically younger children, than in adults. A substantial risk of perforation within 24 hours of onset was noted (7.7%) 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]

During the initial stage of appendicitis, the patient may feel only periumbilical pain due to the T10 innervation of the appendix. As the inflammation worsens, an exudate forms on the appendiceal serosal surface. When the exudate touches the parietal peritoneum, a more intense and localized pain develops.

Perforation results in the release of inflammatory fluid and bacteria into the abdominal cavity. This further inflames the peritoneal surface, and peritonitis develops. The location and extent of peritonitis (diffuse or localized) depends on the degree to which the omentum and adjacent bowel loops can contain the spillage of luminal contents.

If the contents become walled off and form an abscess, the pain and tenderness may be localized to the abscess site. If the contents are not walled off and the fluid is able to travel throughout the peritoneum, the pain and tenderness become generalized.


Acute appendicitis is a complex disease with quite a bit of variability in presentation and pathophysiology. Several theories have been promoted to explain the etiology, epidemiology and natural history of the disease. Many contend that appendicitis is due to obstruction of the blind ending appendix, resulting in a closed loop. In children, obstruction usually results from lymphoid hyperplasia of the submucosal follicles. The cause of this hyperplasia is controversial, but dehydration and viral infection have been proposed. Another common cause of obstruction of the appendix is a fecalith.

Rare causes include foreign bodies, parasitic infections (eg, nematodes), and inflammatory strictures.

The obstructive theory of appendicitis is widely taught but may not explain all the data regarding providers' experience with this common disease.  Outbreaks and clusters of appendicitis have been reported making a true infectious etiology a possible etiologic agent.  Appendicitis seems to run in families with first degree relatives of those who have had appendicitis being at a much higher risk of developing the condition which suggests an role of the host genetics. Finally, perforated and non-perforated appendicitis, which should be linked by the progression from early to late appendicitis, appear to act epidemiologically as two separate disease processes. Even though appendicitis is very common, much is not understood about the etiology or pathophysiology of this disease process.


Appendicitis has an incidence of 70,000 pediatric cases per year in the United States. The incidence between birth and age 4 years is 1-2 cases per 10,000 children per year. The incidence increases to 25 cases per 10,000 children per year between 10 and 17 years of age. Overall, 7% of people in the United States have their appendix removed during their lifetime. The male-to-female ratio is approximately 2:1.

Appendicitis is much more common in developed countries. Although the reason for this discrepancy is unknown, potential risk factors include a diet low in fiber and high in sugar, family history, and infection. Gut flora and exposure to gastrointestinal infections have also been proposed as a hygiene theory of appendicitis. There may also be a role of the genetics of the host and the microbiome of the gut in the development of appendicitis and, possibly, with the risk of perforated appendicitis.

Appendicitis occurs in all age groups but is rare in infants. Appendicitis is most common in the second decade of life (age 10-19 y), occurring at a rate of 23.3 cases per 10,000 per year. Thereafter, the incidence continues to decline, although appendicitis occurs in adulthood and into old age.

Interestingly, non-perforated appendicitis and perforated appendicitis are not linked when the epidemiology of the diseases is explored.  The incidence for these two diagnoses differs over time suggesting that they are potentially unrelated to each other and may represent different pathologic processes. Similarities have been shown to other diseases such as diverticulitis and even hospital admissions for influenza.


Generally, the prognosis is excellent. At the time of diagnosis, the rate of appendiceal perforation is 20-35%. The rate of perforation is 80-100% for children younger than 3 years, compared with 10-20% in children 10-17 years old. Children with ruptured appendicitis are at risk for intra-abdominal abscess formation and small bowel obstruction, and they can have a prolonged hospital stay (several weeks or more). The mortality rate for children with appendicitis is 0.1-1%.

Initiation of antibiotics represents the single most critical step in the treatment of acute appendicitis.  Multiple studies in children report safety and no increase in rates of perforation once antibiotics are initiated even if the appendectomy is delay to the next morning.  Commonly, the most advanced cases of acute appendicitis are managed exclusively with antibiotics with the appendectomy delayed for several weeks to months, the so-called interval appendectomy.  Data is mounting to expand this approach of using just antibiotics for the acute episode of appendicitis to all types of appendicitis.  Many centers are pursuing this approach in ongoing research trials.

Death from appendicitis is most common in neonates and infants for the following 2 reasons:

  • Appendicitis is rare in this age group; thus, unless the physician’s index of suspicion is high, appendicitis is often low on the list of suspected differential diagnoses.

  • Very young patients are unable to communicate the location and nature of their pain. Some neonates may not even become febrile. Often, the patient’s only symptom is irritability or inconsolability.




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]


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.

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.


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.


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

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.

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



Diagnostic Considerations

The signs and symptoms of appendicitis are nonspecific and are common with other diagnoses. Do not diagnose gastroenteritis rather than appendicitis unless the patient has nausea, vomiting, and diarrhea. Even with the presence of vomiting and diarrhea, consider the unusual presentations of retrocecal or pelvic appendicitis. Additionally, appendicitis can develop as a sequela of gastroenteritis associated with lymphoid hyperplasia.

Diagnose abdominal pain of unknown etiology in patients with nonspecific abdominal symptoms if a diagnosis cannot be established. These patients may be discharged with close follow up. Instruct patients to be reevaluated in 8-12 hours by their primary care physician or to return to the emergency department. Patients with equivocal examination findings but suspected to have early appendicitis should be admitted for observation for serial abdominal examinations or to undergo imaging with ultrasonography or abdominal CT scanning.

If constipation is diagnosed and treated with enemas and/or stool softeners with resolution of the signs and symptoms, inform the patient and family that recurrence of the abdominal pain in the future could be recurrent constipation or acute appendicitis and to seek medical advice.

Appendicitis should be considered in special patient populations, such as the immunocompromised and developmentally delayed. Appendicitis is rare in infants. If an infant has appendicitis, the diagnosis of Hirschsprung disease should also be considered.

Other problems to consider include the following:

  • Ovarian cyst

  • Ovarian torsion

  • Pelvic inflammatory disease (PID)

  • Pregnancy

  • Ectopic pregnancy

  • Renal calculi

  • Mesenteric lymphadenitis

  • Mittelschmerz

  • Pneumonia (right lower lobe)

  • Neutropenic typhilitis

  • Lymphoma

  • Epiploic appendagitis

  • Paratubal cysts

  • Volvulus

  • Typhlitis

  • Omental torsion

The major differential diagnoses for acute appendiceal abscess or mass include Crohn disease and malignancy.

Differential Diagnoses



Approach Considerations

Making a timely diagnosis of appendicitis is a difficult challenge in children with abdominal pain. Laboratory findings may increase suspicion of appendicitis but are not diagnostic. The minimum laboratory workup for a patient with possible appendicitis includes a white blood cell (WBC) count with differential and urinalysis. Liver function tests and amylase and lipase assessments are helpful when the etiology is unclear. Baseline blood urea nitrogen and creatinine are needed prior to intravenous contrast CT scanning.

Other studies, such as interleukin 6 and C-reactive protein (CRP) assays, have been advocated by some in the diagnosis of appendicitis. However, in multiple clinical series, these studies have not been shown to be of clear benefit and, for the most part, only add to the cost of the evaluation.

CBC Count

The WBC count becomes elevated in approximately 70-90% of patients with acute appendicitis. However, the WBC count is elevated in many other abdominal conditions, as well. Furthermore, the WBC count is often within the reference range within the first 24 hours of symptoms. Elevation tends to occur only as the disease process progresses, and it is usually mild. Therefore, its predictive value is limited. Elevation of the neutrophil or band count can be seen without elevation of the total WBC count and may support the diagnosis of appendicitis.

If the WBCs exceed 15,000 cells/μL, the patient is more likely to have a perforation. However, one study found no difference in the WBC counts of children with simple appendicitis and those with perforated appendicitis. In the immunocompromised patient, a neutrophil count of less than 800 may suggest typhlitis.


Urinalysis is useful for detecting urinary tract disease, including infection and renal stones. However, irritation of the bladder or ureter by an inflamed appendix may result in a few urinary WBCs. The presence of 20 or more WBCs per high-power field (hpf) suggests a urinary tract infection.

Hematuria may be caused by renal stones, urinary tract infection, Henoch-Schönlein purpura, or hemolytic-uremic syndrome. However, small numbers of red blood cells (RBCs) can be found in as many as 20% of patients with appendicitis when an overlying phlegmon or abscess lies adjacent to the ureter. Typically, urinary RBCs are fewer than 20/hpf.

Ketonuria is suggestive of dehydration and is more common with perforated appendicitis.

Normal urinalysis results have no diagnostic value for appendicitis. However, a grossly abnormal result may suggest an alternative cause of abdominal pain

Abdominal Radiography

Abdominal radiography findings are normal in many individuals with appendicitis. However, plain films may be helpful in the setting of severe constipation. A calcified appendiceal fecalith is present in less than 10% of persons with inflammation, but its presence suggests the diagnosis.

Radiographic signs suggestive of appendicitis include convex lumbar scoliosis, obliteration of the right psoas margin, right lower quadrant (RLQ) air-fluid levels, air in the appendix, and localized ileus. In rare incidents, a perforated appendix may produce pneumoperitoneum.

If no other imaging studies are to be performed, an abdominal series may be helpful.

For more information, see the Medscape Reference article Appendicitis Imaging.


Given the potential risks of radiation from CT scans, graded compression ultrasonography may be the preferred initial imaging modality in the evaluation of pediatric acute appendicitis. This technique involves locating the appendix and then attempting to compress its lumen.

For ultrasonography to be diagnostic of appendicitis, the operator must visualize the appendix. Even if the appendix is not visualized, however, appendicitis can be excluded more confidently if ultrasonography shows no secondary signs of appendicitis (eg, hyperechoic mesenteric fat, fluid collection, localized dilated small bowel loop).[4, 5]

A positive finding is a noncompressible tubular structure 6 mm or wider in the RLQ (see the images below). This structure is tender during palpation with the ultrasonographic probe. Additional supportive findings include an appendicolith, fluid in the appendiceal lumen, focal tenderness over the inflamed appendix (sonographic McBurney point), and a transverse diameter of 6 mm or larger. In patients with a perforated appendix, ultrasonography may reveal a periappendiceal phlegmon or abscess formation.

Ultrasonographic examination of the right lower qu Ultrasonographic examination of the right lower quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross section. Discomfort was noted as the probe was depressed over this structure. A small amount of free fluid is also noted surrounding the appendix.
Ultrasonographic examination of the right lower qu Ultrasonographic examination of the right lower quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross section. Discomfort was noted as the probe was depressed over this structure. A small amount of free fluid is also noted surrounding the appendix.

Abdominal ultrasonography has proved to be valuable for diagnosing appendicitis in children, with most published reports indicating a sensitivity, specificity, and accuracy of at least 90-95%. Furthermore, some authors have found that ultrasonography is more sensitive and specific than clinical impression and increases diagnostic accuracy when used either alone or in conjunction with laboratory results.[6]

The advantages of ultrasonography include its noninvasiveness, lack of radiation, no contrast medium, and minimal pain. The downside of ultrasonography is that the examination is operator dependent and may not be available at some institutions. Factors that add difficulty to the examination include obesity and gaseous distention of the intestines overlying the appendix. However, results of one study determined that ultrasonography should continue to be the first diagnostic imaging study in suspected appendicitis, regardless of the child's body mass index (BMI).[7]

Ultrasonography is also useful in diagnosing alternative pathologies (eg, tubo-ovarian abscess, ovarian torsion, ovarian cyst, mesenteric adenitis).

A prospective study by Lowe et al comparing noncontrast CT scanning and ultrasonography revealed a sensitivity, specificity, and accuracy of 97%, 100%, and 98%, respectively, for unenhanced CT scanning, compared to 100%, 88%, and 91%, respectively, for ultrasonography.[8] Still others have shown that the perforation rate and negative appendectomy rate can be decreased by using both tests in tandem.

A study assessed the outcomes in the change of preference in imaging modalities from computed tomography (CT) to ultrasonography (US) due to concerns about ionizing radiation exposure. The study reported that among children with suspected appendicitis, the use of US imaging has increased substantially as the use of CT has declined. Despite the increased reliance on the diagnostically inferior US, important condition-specific quality measures, including the frequency of appendiceal perforation and ED revisits, remained stable, and the proportion of negative appendectomy declined slightly.[9]  Another study by Nicole et al showed a high proportion of inconclusive examinations from point-of-care ultrasounds to detect appendicitis in a pediatric emergency department.[25]


For more information, see the Medscape Reference article Appendicitis Imaging.

Computed Tomography

CT scanning is a useful modality for diagnosing appendicitis in children. Although radiation exposure is a concern, CT scans have been shown to have an accuracy of 97% in diagnosing appendicitis. Advantages of CT scan include the availability at most institutions, the ability to evaluate the entire abdomen and locate abscesses and phlegmon, the lack of dependence on operator skill, and physician familiarity with reading CT scans.

CT findings that are indicative of appendicitis include a thickened appendix, fat streaking around the appendix, or thickening of the cecal wall (see the images below).

CT scan depicting a distended tubular structure de CT scan depicting a distended tubular structure descending into the pelvis and containing a round calcification (ie, an appendicolith).
CT scan revealing an enhancing tubular structure d CT scan revealing an enhancing tubular structure descending into the pelvis. Periappendiceal inflammation and streaking, so-called dirty fat, is noted surrounding the appendix.

CT findings that suggest perforated appendicitis include periappendiceal or pericecal air, abscess, phlegmon, and extensive free fluid. Because the disease is due to obstruction of the appendix and the inflammation occurs distal to the obstruction, extravasation of contrast or extensive free air is rarely seen. If a patient is found to have free air throughout the abdomen or under the diaphragm, other diagnoses should be entertained.

CT scanning may be helpful in obese patients or those in whom a localized appendiceal abscess is clinically suspected. In patients with abscesses, CT scanning may also be helpful in the CT-guided drainage of the abscess.

CT scanning has been found to have sensitivity, specificity, and accuracy similar to those of ultrasonography.[8, 10] Disadvantages include the aforementioned radiation exposure, the need for oral and intravenous contrast and its related disadvantages, and the need for the patient to be still, which is often difficult for small children.

Anderson et al investigated the effectiveness of recommendations to minimize CT imaging for pediatric appendicitis by analyzing the use of CT in children’s and non-children’s hospitals. The study found significant differences in the use of CT (23% vs 70%) and ultrasonography (75% vs 20%) in children’s and non-children’s hospitals for pediatric patients undergoing appendectomy for acute appendicitis.[11]

Because of the advantages of CT scans, 62% of surveyed North American pediatric surgeons preferred it for evaluation of appendicitis. Of note, less than 1% of pediatric surgeons favored CT scanning for every case of suspected appendicitis. Most preferred CT scanning on a selected basis, with 51-58% of patients with suspected appendicitis undergoing CT scanning.[12]

However, despite now-widespread use of CT scanning for evaluation of appendicitis with its superior sensitivity and specificity, the negative appendectomy rate in children has not shown a statistically significant reduction.

Peck et al and Mullins et al have reported sensitivities of 92-97% and sensitivities of 99.6-99%, respectively, using noncontrast helical CT scanning.[10, 13] Callahan et al reported equivalent results using helical CT scanning and rectally administered contrast material.[14] They reported that this technique results in decreased total number of inpatient observation days, decreased number of negative laparotomies, and decreased per-patient cost.

Additional radiographic testing is clearly indicated in patients who present with equivocal signs and symptoms of appendicitis. Whether noncontrast CT scanning, rectally administered contrast-enhanced CT scanning, CT scanning with oral and intravenous contrast, or ultrasonography is used may be a function of the institution or time of day. The data clearly show that each has sensitivities and specificities over 90% and that each can be helpful in clinical decision-making.

For more information, see Appendicitis Imaging.

Chest Radiography

If the history, physical examination, laboratory tests, and imaging studies have failed to produce a satisfactory differential diagnosis, anteroposterior (AP) and lateral chest radiography should be performed to look for right lower lobe pneumonia.

Typically, histologic findings range from acute inflammatory infiltrate most apparent in the submucosal level in early appendicitis to transmural infarction in perforated appendicitis.

The finding of an apparently normal appendix at surgery requires careful follow-up of the histologic findings. Occasionally, early appendicitis is histologically identified and clinically correlates with the resolution of preoperative symptoms. Additionally, unsuspected findings of luminal nematodes should indicate further anthelmintic therapy (eg, mebendazole [Vermox]). Chronic inflammation or fibrosis of the tip of the appendix are occasionally seen and coincide with resolution of the symptoms.

Many surgeons now encounter patients with “early appendicitis” based on history, physical examination findings, and/or CT scans who had minimal changes found in the appendix in the operating room or only intraluminal inflammatory cells on histology. Most of these patients have complete resolution of their signs and symptoms after appendectomy. Whether this is because the appendectomy is performed at an earlier stage of appendicitis or is due to the placebo effect of the appendectomy is unknown.

For more information, see the Medscape Reference article Appendicitis Imaging.

Electrolyte levels

Electrolyte assessments and renal function tests are more helpful for management than diagnosis. Indications for these tests include a significant history of vomiting or clinical suspicion of significant dehydration.

Pregnancy Testing

A beta–human chorionic gonadotropin (beta-HCG) test should be performed to rule out pregnancy or ectopic pregnancy in adolescent girls.

Scoring Systems

Evaluation rules and algorithms have been proposed to help the clinician make the correct diagnosis and treatment plan. Although these decision rules may help predict which children are at low risk for appendicitis, they are not used consistently

Kharbanda et al scoring system

The system proposed by Kharbanda et al assigns scores based on the following 6 findings[15] :

  • Nausea (2 points)

  • History of focal RLQ pain (2 points)

  • Migration of pain (1 point)

  • Difficulty walking (1 point)

  • Rebound tenderness/pain with percussion (2 points)

  • Absolute neutrophil count of greater than 6.75 X 103/µL (6 points)

A score of 5 or less had a sensitivity of 96.3%, a negative predictive value of 95.6%, and a negative likelihood ratio of 0.102 in the validation set.

The Samuel score (pediatric appendicitis score)

This scoring system is based on 8 variables, as follows[16] :

  • RLQ tenderness elicited by cough, hopping, or percussion

  • Anorexia

  • Elevated temperature

  • Nausea/vomiting

  • Tenderness over the right iliac fossa

  • Leukocytosis

  • Increased polymorphonuclear neutrophil percentage (ie, left shift on white blood cell differential)

  • Migration of pain

Samuel recommended that patients with a score of 5 or lower should be observed, while those with a score of 6 or higher should undergo surgical consultation.

The Alvarado score (MANTRELS score)

The MANTRELS score is based on the following 8 variables:

  • Migration of pain to RLQ

  • Anorexia

  • Nausea/vomiting

  • Tenderness in RLQ

  • Rebound pain

  • Elevated temperature (>37.3° C)

  • Leukocytosis (>10,000/µL)

  • Left shift

Schneider et al found that an Alvarado score of 7 or higher yielded a sensitivity of 73% and a specificity of 80%.[17] Use of this scoring system is limited to risk stratification of suspected appendicitis in children.


The clinical staging of appendicitis has important implications in the postoperative treatment of the child. Although somewhat subjective at the time of surgery, appendicitis may be divided into 3 broad categories: acute (nongangrenous), suppurative or gangrenous (nonperforated), and perforated. Perforated appendicitis can be divided further into cases with diffuse or with localized peritonitis.

Acute (nongangrenous) appendicitis

This stage of appendicitis is referred to as early appendicitis. No mural gangrene or infarction is present. This type requires no further antibiotic therapy in most settings. The child may be discharged home as soon as diet and oral pain medications can be tolerated.

Suppurative or gangrenous (nonperforated) appendicitis

Patients with exudative appendicitis, particularly those with mural gangrene, have an increased rate of postoperative intra-abdominal and wound infections, even in the absence of demonstrable perforations. Often, microperforations are present and may be identified if cultures of the fluid are obtained. However, if the the child is clinically improved and Gram stain and culture findings, if available, are negative, the intravenous antibiotics can be stopped in approximately 24 hours, and the child may be discharged home as soon as diet and oral pain medications can be tolerated. A decision can be made by the surgeon to continue oral antibiotics at home.

Perforated appendicitis

Perforated appendicitis (diagnosed either by intraoperative findings or by positive intraoperative cultures) is associated with a postoperative infection rate of as high as 30%. Children with perforated appendicitis require antibiotic therapy for a minimum of 7-10 days. Often, intra-abdominal abscesses that require drainage may develop. A high index of suspicion for a postoperative abscess is required in the patient with perforated appendicitis who has fevers or ileus that last more than 5 days. A child who develops a postoperative abscess or a small bowel obstruction may need additional surgery and may have a prolonged hospital stay.



Approach Considerations

Given that patients with possible appendicitis may have an equivocal history and physical examination findings and inconclusive supporting test results, the following measures are key to any evaluation and treatment plan:

  • Relieve the patient's pain and discomfort early and consistently

  • Communicate with the patient and family about the plans

  • Repeat the examination often

  • Adjust the differential diagnosis as appropriate

  • Keep the patient for observation if a firm diagnosis is not made or for follow-up

Algorithms, scoring systems, imaging studies, and consultation reports are part of the clinician's armamentarium. Documentation of medical decision making is important, as is knowledge of the current literature. Consultations with a pediatrician or general surgeon may be appropriate.

Because of the short time from obstruction of the appendix to perforation, 20-35% of patients who present with acute appendicitis have already perforated. In fact, estimates suggest that most patients perforate within 72 hours of symptom onset. 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]

If a patient presents beyond 72 hours from symptom onset, perforation is highly likely. However, if a patient presents with symptoms of appendicitis beyond 72 hours and has not perforated, diagnoses other than appendicitis must be entertained.

Avoid treating vague abdominal pain by administering parenteral opiates and then discharging the patient. Narcotics and potent nonsteroidal anti-inflammatory drugs may be needed for pain control. Large doses or ongoing use should be avoided until after surgical consultation.

Patients with a classic history require prompt surgical consultation. Maintain nothing-by-mouth status in patients with suspected appendicitis, and start intravenous fluids to restore intravascular volume. Antibiotics should be started upon diagnosis of appendicitis.

Emergency medical service (EMS) personnel are well trained and cognizant of how to assess and begin treatment of the febrile, vomiting child with abdominal pain. Intravenous fluid administration, pain management, and antiemetic medication should be administered based on local EMS protocols.

The insertion of nasogastric tubes (when necessary), intravenous lines, and urethral catheters (when necessary) and the administration of antibiotics, antiemetic drugs, antipyretic drugs, and analgesia should ideally be part of the emergency department protocol for preoperative management.

Fluid Resuscitation

Ensure adequate hydration for patients who present with suspected appendicitis. Even in early acute appendicitis, children frequently have not had sufficient oral intake and present with some degree of intravascular dehydration. Intravenous hydration often improves abdominal symptoms in children who do not have appendicitis.

Patients with appendicitis usually require fluid boluses prior to operation in order to counteract dehydration. However, these patients need continued fluid resuscitation appropriate to their fluid status and severity of appendicitis.

If fluid status is unclear, urine output is the most common measure. Urine output should be no lower than 0.5 mL/kg/h. If dehydration is suspected, Foley catheter placement, monitoring of urine output, and correct fluid replacement are indicated.

Postoperatively, the spectrum of fluid management ranges from patients with early appendicitis who are started on clear fluids postoperatively and can have intravenous (IV) fluids discontinued when advanced to a regular diet, to patients with perforated appendicitis who require postoperative fluid boluses.

Antibiotic Therapy

Antibiotic therapy is an important aspect of the treatment of ruptured appendicitis. Intravenous antibiotics should be started once the diagnosis of acute appendicitis is confirmed. Antibiotic therapy should be directed against gram-negative and anaerobic organisms such as Escherichia coli and Bacteroides species.

If the appendix is not gangrenous or perforated, no postoperative antibiotics are indicated. A gangrenous appendix warrants antibiotics for 24-72 hours, depending on clinical improvement and/or Gram stain, if one was obtained during surgery.

Antibiotic therapy for ruptured appendicitis is continued for a minimum of 7-10 days, but a longer course may be needed. Intravenous antibiotics are used during the hospitalization. Oral antibiotics may be used to complete therapy if a child is well enough for discharge.

While appendectomy remains the definitive treatment for appendicitis, many patients with perforated appendicitis are now treated with intravenous antibiotics alone with drainage of the abscess if needed. Additionally, some advocate nonoperative treatment with antibiotics only for early appendicitis, especially when the diagnosis is vague.

A study by Kronman et al compared the effectiveness of extended-spectrum versus narrower-spectrum antibiotics for children with appendicitis. The study found that extended-spectrum antibiotics seem to offer no advantage over narrower-spectrum agents for children with surgically managed acute uncomplicated or complicated appendicitis.[18]


The definitive treatment for appendicitis is appendectomy. Historically, appendectomy had a 10-20% false-positive rate, but the widespread use of imaging studies has reduced this rate.

Patients with perforated appendicitis can be divided into 2 cohorts; those whose perforation is discovered in the operating room during appendectomy and those with preoperative evidence of perforation, most commonly seen on CT scans or ultrasounds. Increasingly, the approach in the latter group is conservative (nonoperative) management, with percutaneous drainage if possible and surgery after 8-12 weeks (ie, interval appendectomy).

Patients discovered to have perforated appendicitis during appendectomy should be treated in the same fashion as those with nonperforated appendicitis. The surgeon should complete the appendectomy in a normal fashion.

If a laparoscopic appendectomy is being performed, perforation alone is not a reason for conversion to open appendectomy. However, if an abscess is encountered and drained, placement of a drain in the abscess cavity should be considered. In addition, when an open appendectomy is being performed on a patient with a perforated appendix, the high incidence of wound infection should be considered in terms of skin closure.

In rare instances, the inflammation can be so severe that the appendix cannot be safely identified and removed. To avoid unnecessary morbidity, drainage procedures with subsequent interval appendectomy (see conservative [nonoperative] management) is acceptable.

To see complete information on Pediatric Appendectomy, please go to the main article.

Conservative (Nonoperative) Management

Historically, a patient with appendicitis, especially perforated appendicitis, was rushed to the operating room for appendectomy; however, this is no longer the case. Conservative management with interval appendectomy may be appropriate for perforated appendicitis. Whyte et al have suggested that interval appendectomy may be safely performed as an outpatient procedure.[19]

Conservative management begins with a trial of medical therapy. A patient found to have perforated appendicitis based on imaging study findings should be admitted to the hospital, should be placed on a nothing-by-mouth (NPO) diet, and should be given intravenous (IV) fluid resuscitation.

If the patient is hemodynamically unstable or if urine output cannot be measured, a Foley catheter should be placed. IV antibiotics should be started. Generally, antibiotics for this condition are targeted at enteric flora (eg, second-generation cephalosporin, gentamicin, metronidazole; see Medication). If the patient has an abscess that is accessible, percutaneous drainage is performed. Discharge from the hospital is based on lack of fever, tolerance of pain on oral medications, and adequate oral intake.

A patient who does not improve after admission and intravenous antibiotic therapy should undergo surgery for drainage of the infection and appendectomy, if technically feasible. Factors that suggest failure of conservative management include bandemia on admission CBC count, fever of more than 38.3° C after 24 hours of medical therapy, and multisector involvement on CT scan. Medical therapy is deemed to have failed at a median of 3 days. Medical therapy fails in as many as 38% of children with perforated appendicitis.

In children who recover with medical therapy, an alternative to interval appendectomy is to postpone surgery indefinitely. Most patients do well with this approach. Appendicitis recurrence rates range from 0-20%, with a pooled rate of 8.9% found by one large meta-analysis.[20]

A much higher recurrence rate (72%) is seen in pediatric patients with an appendicolith present during the initial acute episode. Consequently, many experts suggest that interval appendectomy may be needed only in patients with appendicolith.

Most patients who experience recurrence do so within the first 6 months after their initial episode of appendicitis; the longest follow-up to date is 13 years. However, it is not known whether pediatric patients who receive conservative treatment for appendicitis are at risk for recurrence during adulthood. Because of this uncertainty, many pediatric surgeons prefer to perform interval appendectomy.

Delaying definitive surgery is associated with significant resource use, including increased imaging, drainage procedures, and additional admissions. In addition, conservative management with laparoscopic appendectomy performed at a later date poses the risk of misdiagnosis. The major differential diagnoses for acute appendiceal abscess or mass include Crohn disease and malignancy.

The increased use of CT scanning or ultrasonography in the emergent setting has decreased this risk of misdiagnosis. These studies help to confirm the diagnosis of appendiceal mass and also guide drainage interventions. The increased use of technology, combined with improvements in antibiotics, makes conservative management a more attractive and less risky choice in terms of misdiagnosis or treatment failure.

Nonoperative management with antibiotics for early appendicitis is a new concept in the pediatric population and further studies are required prior to routine recommendation of this practice.

A study by Minneci et al looked to determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. The study enrolled 102 patients, 65 patients/ families chose appendectomy and 37 patients/families chose nonoperative management. The success rate of nonoperative management was 89.2% at 30 days and 75.7% at 1 year. The incidence of complicated appendicitis was 2.7% in the nonoperative group and 12.3% in the surgery. After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days and lower appendicitis-related health care costs.[21]

A study by Bachur et al reported that of the 4,190 out of 99,001 pediatric appendicitis patients managed nonoperatively, nonoperative management patients were more likely during the 12-month follow-up period to have advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). The study also found that 46% of the patients managed nonoperatively had a subsequent appendectomy.[22]

Percutaneous Drainage

Often, patients with gangrenous or perforated appendicitis develop intra-abdominal abscesses.[23] These may be present at the time of presentation or may develop after surgery or during hospitalization if an interval appendectomy is planned. Commonly, a patient who has a prolonged ileus or fever for more than 5 days postoperatively has an intra-abdominal abscess.

The usual approach is to perform a CT scan of the abdomen and pelvis with oral and intravenous contrast to define the presence of an abscess. If this study confirms the presence and accessibility of an abscess, percutaneous drainage should be performed.

A drain is commonly left in the abscess cavity, and continued drainage is monitored. Once drainage decreases, the drain can be removed. Repeat imaging is not always needed.

Postoperative Pain Management

Patients who have undergone an appendectomy should be prescribed pain medication upon discharge. Liquid acetaminophen usually suffices in smaller children, with liquid acetaminophen plus codeine or hydrocodone administered for breakthrough pain. The same medication combination in a tablet form can be used in older patients, assuming they are able to swallow the tablets.

Patients who received inpatient narcotics or who are discharged on outpatient narcotics should be cautioned about the possibility of becoming constipated. These patients may need prescribed stool softeners.

Diet and Bowel Function

Patients with nonperforated appendicitis may be started on clear fluids postoperatively. Diet is advanced as tolerated.

Patients who can tolerate regular diet may be discharged home. These patients have minimal delay in the return of bowel function and do not need to have a bowel movement prior to discharge.

Patients with perforated appendicitis who have immediate appendectomy should remain NPO until their bowel function returns. They should then be started on clear fluids, and the diet advanced as tolerated. Total parental nutrition may be needed in children with prolonged hospitalization from a ruptured appendicitis.


Complications may include the following:

  • Perforation

  • Sepsis[24]

  • Shock

  • Postoperative adhesions

  • Infertility

  • Wound dehiscence

  • Wound infection

  • Bowel obstruction



Medication Summary

Administer 1 dose of preoperative antibiotics to children with suspected appendicitis. Antibiotics can be discontinued after surgery if no perforation is noted.

Antibiotics are selected to provide coverage for aerobic and anaerobic organisms. The most widely used regimen is the combination of ampicillin, clindamycin (or metronidazole), and gentamicin. Alternative regimens include the following:

  • Ampicillin/sulbactam

  • Cefoxitin

  • Cefotetan

  • Piperacillin/tazobactam

  • Ticarcillin/clavulanate

  • Imipenem/cilastatin

Resistant organisms develop in 15% of patients with a ruptured appendix. Antibiotic substitutions are made for patient allergies, poor clinical improvement or deterioration on current regimen, or culture-proven antibiotic resistance.

Patients with appendicitis also require medication for pain control. Antiemetic and antipyretic agents may also be indicated.

Antibiotic regimens should cover the most commonly encountered organisms, including Escherichia coli and Bacteroides, Klebsiella, Enterococcus, and Pseudomonas species.


Class Summary

The penicillins are bactericidal antibiotics that work against sensitive organisms at adequate concentrations and inhibit the biosynthesis of cell wall mucopeptide. Examples of extended-spectrum penicillins include ticarcillin and clavulanate (Timentin) and ampicillin and sulbactam (Unasyn).

Ampicillin (Marcillin, Omnipen, Polycillin, Principen)

Ampicillin is a beta-lactam antibiotic with activity against some gram-positive and gram-negative organisms. It inhibits bacterial cell wall synthesis during active multiplication.

Ampicillin/sulbactam (Unasyn)

A combination of ampicillin with a beta-lactamase inhibitor, this agent has activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria.

Piperacillin/tazobactam (Zosyn)

A combination of a beta-lactamase inhibitor with piperacillin, this agent has activity against some gram-positive organisms, gram-negative organisms, and anaerobic bacteria. It inhibits biosynthesis of bacterial cell wall mucopeptide and is effective during the stage of active multiplication.

Ticarcillin and clavulanate potassium (Timentin)

This combination of an antipseudomonal penicillin plus a beta-lactamase inhibitor provides coverage against most gram-positive and gram-negative organisms and most anaerobes. It inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth.

Imipenem and cilastatin (Primaxin)

This combination agent is indicated for treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated because of potential for toxicity.


Class Summary

Aminoglycosides are bactericidal antibiotics used to primarily treat gram-negative infections. They interfere with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.

Gentamicin (Garamycin, Gentacidin)

Gentamicin is an aminoglycoside antibiotic with activity against gram-negative bacteria, including Pseudomonas species. It is synergistic with beta-lactams against enterococci. Gentamicin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Dosing regimens are numerous; adjust the dose based on creatinine clearance and changes in volume of distribution. Gentamicin may be administered intravenously or intramuscularly.


Class Summary

Anti-infectives such as metronidazole and clindamycin are effective against some types of bacteria that have become resistant to other antibiotics.

Clindamycin (Cleocin)

Clindamycin is a lincosamide effective against gram-positive aerobic and anaerobic bacteria (except enterococci). It inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Metronidazole (Flagyl)

Metronidazole is often used in combination with an aminoglycoside, such as gentamycin. It provides broad gram-negative and anaerobic coverage. It appears to be absorbed into cells, and the intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death. Metronidazole is a synthetic, nitroimidazole-derivative antibacterial and antiprotozoal agent. Metronidazole may be administered intravenously or orally.


Class Summary

Cephalosporins are structurally and pharmacologically related to penicillins. They inhibit bacterial cell wall synthesis resulting in bactericidal activity.

Cefoxitin (Mefoxin)

A second-generation cephalosporin, cefoxitin has activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria. It inhibits bacterial cell wall synthesis during active multiplication by binding 1 or more penicillin-binding proteins.

Cefotetan (Cefotan)

Cefotetan is a second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.


Class Summary

Pain management is a contentious topic for some emergency physicians and surgeons. Several classes of analgesic medications have proven to be safe and efficacious in the preoperative pediatric patient.

It is ethical and prudent for emergency physicians, surgeons, anesthesiologists, pediatricians, and pharmacists to agree on a plan for providing pain relief to the pediatric patient. Topics to be agreed upon include type, route, dose, and frequency of administration of analgesic drugs.

Ketorolac (Toradol)

Ketorolac inhibits prostaglandin synthesis by decreasing the activity of cyclooxygenase, which results in decreased formation of prostaglandin precursors.

With proper dosing, it does not cause a significant decrease in hematocrit, increase in creatinine, or overall complications. Its use can decrease hospital stay and narcotic requirements in children who have undergone surgery.

Fentanyl citrate (Sublimaze)

Fentanyl is a synthetic opioid that is 75-200 times more potent and has a much shorter half-life than morphine sulfate. It has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal to no associated histamine release. By itself, it causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.

Consider continuous infusion of fentanyl because of its short half-life (30-60 min). Parenteral fentanyl is the drug of choice for conscious sedation analgesia. It is ideal for analgesia of short duration during anesthesia and the immediate postoperative period. It is readily titrated and is easily and quickly reversed by naloxone.

After the initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than every 3 or 6 hours. Fentanyl is highly lipophilic and protein bound. Prolonged exposure leads to accumulation in fat and delays the weaning process.


Morphine sulfate has the advantages of reliable and predictable effects, a favorable safety profile, and ease of reversibility with naloxone. Various IV doses are used; it is commonly titrated until the desired effect is obtained.

The Joint Commission on the Accreditation of Healthcare Organizations has placed "MSO4" on the banned abbreviation list, because it can be mistaken for magnesium sulfate. Therefore, in writing the prescription, spell out "morphine sulfate" in full, legibly and clearly.


Questions & Answers


What is pediatric appendicitis?

What is the anatomy of the appendix relevant to pediatric appendicitis?

What is the pathophysiology of pediatric appendicitis?

What causes pediatric appendicitis?

What is the US prevalence of pediatric appendicitis?

What is pediatric appendicitis more common in developed countries?

In which age groups is pediatric appendicitis most prevalent?

What evidence suggests that perforated and nonperforated appendicitis are different pathologic processes?

What is the prognosis of pediatric appendicitis?


Which clinical history findings are characteristic of pediatric appendicitis?

How is pain characterized in pediatric appendicitis?

How are nausea and vomiting characterized in pediatric appendicitis?

How is diarrhea characterized in pediatric appendicitis?

How is fever characterized in pediatric appendicitis?

Which physical findings are characteristic of pediatric appendicitis?

What is the initial focus of the physical exam to evaluate pediatric appendicitis?

Which cardiac and pulmonary findings are characteristic of pediatric appendicitis?

Which abdominal findings are characteristic of pediatric appendicitis?

Which rectal exam findings are characteristic of pediatric appendicitis?

Which genitourinary findings are characteristic of pediatric appendicitis?

Which pelvic exam findings are characteristic of pediatric appendicitis?

Which atypical findings appear with regularity in pediatric appendicitis?


How is gastroenteritis differentiated from pediatric appendicitis?

How is abdominal pain of unknown etiology differentiated from pediatric appendicitis?

How is constipation differentiated from pediatric appendicitis?

In which special patient populations should pediatric appendicitis be considered?

Which conditions are included in the differential diagnoses of pediatric appendicitis?

What are the differential diagnoses for Pediatric Appendicitis?


How is pediatric appendicitis diagnosed?

What is the role of CBC count in the workup of pediatric appendicitis?

What is the role of urinalysis in the workup of pediatric appendicitis?

What is the role of abdominal radiography in the workup of pediatric appendicitis?

What is the role of ultrasonography in the workup of pediatric appendicitis?

What is the role of CT scanning in the workup of pediatric appendicitis?

What is the role of chest radiography in the workup of pediatric appendicitis?

What is the role of electrolyte assessment in the workup of pediatric appendicitis?

What is the role of a beta–human chorionic gonadotropin (beta-HCG) test in the workup of pediatric appendicitis?

What is the role of evaluation rules in the diagnosis of pediatric appendicitis?

What is the Kharbanda scoring system for the diagnosis of pediatric appendicitis?

What is the Samuel score (pediatric appendicitis score)?

What is the Alvarado (MANTRELS) score for risk stratification of pediatric appendicitis?

What are the clinical stages of pediatric appendicitis?

How is acute (nongangrenous) pediatric appendicitis defined?

How is suppurative or gangrenous (nonperforated) pediatric appendicitis defined?

How is perforated pediatric appendicitis defined?


How is pediatric appendicitis treated?

What is the role of fluid resuscitation in the treatment of pediatric appendicitis?

What is the role of antibiotics in the treatment of pediatric appendicitis?

What is the role of surgery in the treatment of pediatric appendicitis?

What is included in conservative management of pediatric appendicitis?

What is the role of percutaneous drainage in the treatment of pediatric appendicitis?

How is postoperative pain managed following appendectomy to treat pediatric appendicitis?

Which dietary modifications are used in the treatment of pediatric appendicitis?

What are the possible complications of pediatric appendicitis?


What is the role of medications in the treatment of pediatric appendicitis?

Which medications in the drug class Analgesics are used in the treatment of Pediatric Appendicitis?

Which medications in the drug class Cephalosporins are used in the treatment of Pediatric Appendicitis?

Which medications in the drug class Anti-Infectives are used in the treatment of Pediatric Appendicitis?

Which medications in the drug class Aminoglycosides are used in the treatment of Pediatric Appendicitis?

Which medications in the drug class Penicillins are used in the treatment of Pediatric Appendicitis?