Aaron McCoy, MD, PGY2

11 yo hx of single left kidney, recurrent UTIs 2/2 Grade 4 VUR (none since 3 yo, but not surgically repaired), hx of nephrolithiasis and constipation 2 days abdominal pain, periumbilical with some radiation to right side 1 day decreased PO intake, emesis (nb, nb) Mom tried treating with an enema Some initial improvement in her pain, but then it returned

PMH/SH: per HPI IMMS: UTD Meds: PRN Miralax, Tylenol 2 hrs prior to presentation to ED Allergies: NKDA Diet: Normal for age FH: No FH of childhood illnesses, specifically no renal disease SH: Lives with mom, dad, 2 healthy sibs ROS: Per HPI, notable negative no fever

CMP WNL Clean Catch UA notable for Nitrite negative, Leuk Est. trace, Hgb negative, WBC 10, Epi 1, Bacteria 3+ CRP 5.9 CBC WBC 11.3, 75%N, 15%L, 10%M, HCT 44, PLTS 299 Urine Culture pending

20 cc/kg bolus 6 mg Morphine, Ceftriaxone x 1 Continued vomiting despite Zofran Exam: normal except abd: soft, nondistended, tender to palpation in suprapubic and R lower quadrant pain, no guarding or rebound tenderness Admitted to floor for pyelonephritis

Exam: 36.9, HR 85, RR 21, BP 108/68, 97% RA Gen: Looks very uncomfortable, moaning and writhing in pain HEENT: WNL CV: WNL, normal rate RESP: WNL ABD: Tender to palpation around umbilicus and RLQ, peritoneal irritation signaled by rebound tenderness and abdominal pain with heal strike

Pain migrated to RLQ night prior to admission Pain abruptly improved around 7pm night of admission then worsened Wheelchair ride from ED particularly painful

Perforated appendicitis, solitary left kidney with scarring at the lower pole, stone in the lower pole of the left kidney without evidence of obstruction.

7% lifetime risk (age 10-30) Obstruction of appendix by fecalith, reactive lymphoid hyperplasia, foreign bodies, tumor, or parasite Dynamic disease process over 24-36 hours Begins with vague, colicky umbilical or epigastric pain, usually within 12 hours shifts to RLQ as a steady ache that worsens with walking or coughing. Nausea and vomiting (1-2x) are common. Low grade (<38.0) fever is common. Localized tenderness, guarding, coughing or tapping heals can cause localization of pain, rebound tenderness common.

Migration of pain 1 Anorexia 1 N/V 1 Tender RLQ 2 Rebound 1 Elevated Temp 1 Leukocytosis 2 Shift on CBC 1 Alvarado reported sens 89% and spec of 80% for patients with score > or equal to 7 Actual use by others sens 38-97% and spec 85-95

Psoas Sign: pain on passive extension of right hip Obturator Sign: pain with passive flexion and internal rotation of right hip Rovsings Sign: palpation of LLQ results in more pain in the RLQ than LLQ Strongly indicative of appendicitis Caveat- as frequent as 30% will be atypical due to pelvic, retrocolic or retroileal position

WBC 10-20K common (>80% will have WBC >10) Microscopic hematuria and pyuria common (25%) Labs more helpful to rule out- if no leukocytosis, no shift, no elevated CRP it is not appendicitis Abdominal US or CT scan (CT sens 88-97% and spec 94-97% vs Abd US sens 78-94 and spec 8998) KUB not useful unless using to rule out other processes

20% Suspected in pain >36hrs, high fever, diffuse pain or peritoneal signs or marked leukocytosis

Uncomplicated: Appendectomy, systemic broad abx x 1 dose pre-op to reduce post-op wound infections (Cefoxitin, Flagyl plus aminoglycoside/quinolone) Perforated: CT guided emergency appendectomy, systemic abx 5-7 days (here were use 5 days Zosyn) Pediatric age group mortality: Uncomplicated is virtually zero, Perforated 0.2%

McPee and Papadakis, CMDT 2008, pg 537-538 Brennan, Pediatric Appendicitis: pathophysiology and appropriate use of diagnostic imaging, CJEM 2006, 8(6):425-432 Hardin, Acute appendicitis: Review and Update, Am Fam Physician, 1999 Nov 1:60(7): 2027-2034 Woods, Current Guidelines for antibiotic prophylaxis of surgical wounds, Am Fam Physician, 1998 Jun 1;57 (11):2731-2740