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Surgical Causes


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This series of posts will look at the best approach to assessing the child with abdo pain, and will cover the common conditions presenting to PED. In this post we look at surgical causes.

Appendicitis is the most common non-traumatic surgical emergency. The peak is at 12-18 years.

Classic v atypical appendicitis

Classic appendicitis is easy to spot, but “atypical” appendicitis is common in children. Beware of false localising signs such as diarrhoea or dysuria.

A 2010 article highlighted that classic signs of appendicitis are less common in children:

  • No migration of pain in >50% of children
  • No anorexia in >50% of children
  • No focal tenderness in >50% of children
  • No rebound tenderness in >50% of children
  • Time course of pain of <24 hours is common

What investigations should I be doing?

There is no single diagnostic test for appendicitis.

When choosing investigations, the aim is: high sensitivity/specificity; minimse missed appendicits; minimise normal appendicectomy rate; minimise delay to OT

Urinalysis – there will pyuria in approx 30%

FBC – neither sensitive nor specific

Ultrasound – sensitivity~ 87%, specificity  ~ 89%, not visualised in  ~ 10% of children with appendicitis and upto 20% of children without appendicitis

CT – sensitivity 91%, specificity 94%, RIM risk (single CT in a 5 year old – 20-25:100000)

See Klein (2007) and Doria (2009).

Are there are useful scoring systems?

The Alvarado appendicitis score can be used in children. The scoring system is as follows:

  • M – migration of pain to RIF (1)
  • A – anorexia (1)
  • N – nausea (1)
  • T – tenderness is right lower quadrant (2)
  • R – rebound pain (1)
  • E – elevated temperature (1)
  • L – leukocytosis (2)
  • S – shift to left of WBC (1)

This leads to a total possible score of 10.

<5 should rule out appendicitis; >7 should rule it in

Alvarado scoring is probably good at ruling out appendicitis in children, but is not great at ruling it in. It tends to overestimate appendicitis in children with intermediate scores.

Intussusception is the telescopic invagination of one section of the bowel into another. It’s usually ileo-colic. It can be a great ‘mimic’.

It is mostly idiopathic but consider the lead point particularly with very young or older children. Patients present classically with vomiting, pain, and blood in the stools – this classic tried only occurs in <30%. The most common age is 5-10 months, but it can occur at any age.

It is more common in males than females (3:1) and its incidence is 1-4 per 1000.

An x-ray can show signs of intussusception, but an ultrasound has sensitivity of around 100%.

Treatment is with an air enema.

Meckel’s diverticulum is due to omphalomesenteric duct vestige (vitelline duct). It contains gastric mucosa and can mimic appendicitis.

Don't forget the rule of 2s...

  • affects 2% of the population
  • 2% are symptomatic (actually 4%)
  • 2 inches long
  • 2 feet proximal to the terminal ileum
  • 2 times more common in boys
  • 2 types of ectopic tissue (gastric and pancreatic)

It can present with pain, bleeding, perforation, or obstruction. The classic presentation is of painless bleeding. It can be a lead point for intussusception.

A Meckel’s scan has 80% sensitivity and 95% specificity.

Treatment is by surgical excision

Ovarian torsion is rare in children but important to consider.  It is usually seen with ovarian pathology. It often presents with colicky lower abdominal pain of acute onset. The right tends to tort more commonly than the left. It may be associated with nausea, vomiting, and a raised WCC.

Ultrasound has a high specificity and sensitivity.


About the authors

  • Arjun Rao is a Staff Specialist Paediatrician at Sydney Children's Hospital.


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