How is pain characterized in pediatric appendicitis?

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

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