Appendicitis: How to Avoid a Delayed Diagnosis

Justin L. Berk, MD, MPH, MBA; Jessica Hane, MD


December 20, 2022

This transcript has been edited for clarity.

Justin L. Berk, MD, MPH, MBA: Welcome back to The Cribsiders. This is one of our Medscape video recaps of a recent podcast episode. Jessica, what topic are we reviewing today?

Jessica Hane, MD: Today we are going to be talking about appendicitis. We recently discussed this with Dr Alex Hirsch and Dr Prathima Nandivada from Boston Children's Hospital and Harvard Medical School. In this recap today, we will chat about the pathophysiology, diagnosis, and management of appendicitis from that podcast, Appendicitis – Tips and Tricks for When It's the Appendix.

Berk: Let's start with the basics. What is appendicitis? Can you tell us a little bit about the pathophysiology?


Hane: The definition of appendicitis is pretty simple. It's inflammation of the appendix. As Dr Nandivada reminded us, the name does not actually specify the reason for inflammation. There are many different causes of inflammation, including an obstruction from fecalith, tumor, or lymphoid tissue, or secondary inflammation from surrounding ileitis, colitis, or peritonitis.

Berk: Who gets appendicitis?

Hane: It's most common in teenagers and young adults, but it is important to remember that it can be seen in any age. The lifetime risk of appendicitis is 7%-10%. Another interesting statistic we discussed was that up to 8% of children presenting with abdominal pain will end up having appendicitis.

Berk: That's crazy. That means 1 in 10 listeners may have appendicitis at some point. Unbelievable. So if a child does present with abdominal pain and we're considering appendicitis because there is an 8% chance, what other signs and symptoms might you look for?

Hane: The classic presentation is migration of pain to the right lower quadrant, decreased appetite, nausea, vomiting, and fever. But we also talked about worsening pain with cough or hopping, or that story that they were in excruciating pain during the drive to the hospital  with each speed bump. We also discussed how challenging it is to diagnose appendicitis in toddlers. One red flag to look out for in the toddler group is refusal to walk or difficulty walking, which could indicate possible peritoneal signs. So definitely have a low threshold to consider appendicitis because it can mimic a lot of common pediatric problems such as gastroenteritis, constipation, and UTI. We talked a lot about how challenging it can be to make this diagnosis.

Berk: Let's talk about workup. Is there any way to risk-stratify patients? Are there labs we should be getting? What do the experts recommend?

Hane: There's a great tool called the pediatric appendicitis score. It's a good, real-time tool to think about how likely it is that a patient has appendicitis. Another tool we discussed is called the Pediatric Appendicitis Risk Calculator. It's also validated. It's a little more accurate, but it can't be done at the bedside. It needs a few more numbers from the EMR as far as workup goes.

The initial labs would be a CBC with differential to look specifically at the white blood cell count and the absolute neutrophil count. If the degree of suspicion for appendicitis is high enough, Dr Hirsch recommends drawing your labs and starting imaging at the same time, as opposed to waiting for the lab results to come back. Most clinicians start with an ultrasound — either a point-of-care or a formal ultrasound, depending on your institution. But if the results are equivocal, you should get a CT or MRI. CT is typically considered the gold standard, with sensitivity and specificity greater than 90%. But some institutions are moving toward MRI to avoid radiation in kids. Most institutions have their own imaging pathway, so you can follow that wherever you are.

Berk: Let's say we did all this and we found someone with acute appendicitis. What were the recommendations for how to manage appendicitis?

Hane: As soon as the diagnosis is made, children should be started on antibiotics that cover both gram-negative and anaerobic bacteria. So, for example, you could use piperacillin-tazobactam or ceftriaxone and metronidazole for uncomplicated appendicitis. The first-line treatment is laparoscopic appendectomy. The operative risk is very low and the surgery is highly successful. In fact, we talked about how many kids actually get to go home from the recovery room.

But occasionally families prefer nonoperative management with only antibiotics. In this rare situation, Dr Nandivada will recommend treating well-appearing kids with a 7-day course of amoxicillin-clavulanate and then repeating labs and imaging if they aren't better within a few days. But it's really important if you're doing that to get close follow-up. And it also is important to remember that 10%- 20% of children treated nonoperatively will have recurrent appendicitis.

We also talked about complicated appendicitis, which is perforated appendicitis, periappendicular abscess, or peritonitis. There's a lot more variability in the management for complicated appendicitis. If the child has a perforated abscess, Dr Nandivada still recommends offering an urgent appendectomy. But if they have a walled-off abscess, the recommendation is typically for interventional radiology to do drainage and then do intravenous antibiotics and an interval appendectomy in 6-8 weeks.

Berk: Any other final pearls?

Hane: One final thing we talked about was health disparities in appendicitis and the outcomes. It's difficult to measure rates of delayed diagnosis in appendicitis, but studies using complicated appendicitis as a proxy for delayed diagnosis found that Black and Hispanic children were more likely to be diagnosed with complicated, perforated appendicitis. They were unfortunately less likely to have undergone a laparoscopic procedure and less likely to have received opioid pain medications. We talked about using the pediatric appendicitis score and appendicitis algorithms because these tools can reduce implicit bias.

Berk: That's a great pearl. We try to talk about health equity in every episode. It's an important part of our mission. You can hear the full podcast at Appendicitis – Tips and Tricks for When It's the Appendix or download it on any podcast player. Check out our website to learn more. Thank you for joining us.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.