Suspected Appendicitis Clinical Pathway

June 2020
Outcomes/Goals 1. Create an efficient, timely, team oriented, standardized approach for the
evaluation, work up, and accurate diagnosis of children with suspected
appendicitis
2. Decrease radiation exposure where possible during diagnostic workup
Inclusion criteria Patients aged 3-18 years who present with right lower quadrant abdominal pain
and/or suspected appendicitis
Exclusion criteria Patient with known inflammatory GI disease (e.g. IBD); kids < 3 present
atypically
NURSE Chief complaint. Onset and duration of pain/nausea/vomiting/diarrhea.
Documentation Abdominal exam including ambulatory status, last PO intake, last bowel
movement, fever history.
INTERVENTIONS ESI Triage level III
Initiate on arrival Full set of vitals
Ondansetron ODT 0.1-0.2mg (maximum dose 8mg/dose) for nausea
Place topical Lidocaine (LMX) in anticipation of peripheral IV start
Place on monitor if toxic appearance or suspected peritonitis
UA
UHCG (if indicated)
CMP
Lipase
CBC with differential
Initiate NS bolus 20 ml/kg if clinically indicated

DIAGNOSTICS Labs (CBC with diff, CMP, lipase, UA, UHCG)

Ultrasound for intermediate or high-risk patients
Consider MR/CT for non-diagnostic US results or first-line for obese patients
PHYSICIAN (LIP) Score patient using Alvarado Score. If score is ≤3, patient is low risk and may be
Scoring Criteria discharged home with close follow-up vs observed. If intermediate or high risk,
obtain imaging and follow pathway according to results.
IV Fluids (if indicated) NS bolus 20 ml/kg
Maintenance fluid
Medication Use opioids as needed to treat pain
Pain Medication  Tylenol 15 mg/kg PO/PR Q4 hours for fever/mild pain
 Fentanyl 1 mcg/kg IV maximum 50 mcg q 10 minutes prn or
 Morphine 0.1 mg/kg IV maximum 8 mg q 10 minutes prn
 Ondansetron
Anti-emetics Oral dose
 2-4 years of age: 2-4 mgs (0.15mg/kg)
 4-11 years of age: 4 mgs
 >11 years of age: 4-8 mgs
IV dose
 6 months-18 years of age: 0.15mg/kg/dose (maximum dose 4mg)

DISPOSITION If confirmed appendicitis, consult pediatric surgery.

Prepare family/infant for admission/transfer.
Clinical presentation differs depending on age.
Special Infants: vomiting (85-90%), pain (35-77%), diarrhea (18-46%), fever (40-60%),
Considerations irritability (35-40%), grunting respirations (15%), R hip complaint (3-23%)
PreSchool: abdominal pain (89-100%), vomiting (66-100%), fever (80-87%),
anorexia (53-60%)
School Age: pain with movement (41-75%), pain with cough (95%), pain with
jumping (93%), vomiting (68-95%, nausea (36-90%, anorexia (47-75%)
 Clinical Pathway Decision Making Process
Suspected Acute Appendicitis (3-18 years)

Place peripheral IV
CBC with differential, CMP, Lipase
Urinalysis (HCG if indicated)
Apply clinical scoring system

Score ≤3: Low Risk (LR

Alvarado Score
0.02)
1. Discharge home with PCPPoints
f/u <24
Anorexia hours 1
Nausea or vomiting 1
Score ≥7: High
Migration of pain to RLQ Risk (LR 4.21)
1
Fever > 1.
37.3°
NPOC (>99.2°F) 1
2. IV access
RLQ Rebound (if not already obtained)
tenderness 1
3. IV pain medications, fluid bolus
RLQ tenderness
4. Obtain US abdomen to evaluate 2
WBC > 10,000appendicitis (also rule out 2
ANC + bands > 75%
ovarian WBC for females)
torsion 1

US
Total Points Appendix not seen
Positive OR
Appendix normal

Score 3-6: Intermediate Diagnosis of Appendicitis

US
Risk Positive
1. Consult to Pediatric Surgery
1. NPO 2. Consider broad spectrum antibiotics
2. IV access (if not already obtained) if surgery requests or perforation
3. Consider IV pain medications, detected
fluid bolus CT positive (wall
4. Obtain US abdomen to thickening, appendix >
evaluate appendicitis (also 6mm, + appendicolith,
rule out ovarian torsion for fat stranding)
US Appendix not
Negative seen Inconclusive
1. Repeat PE. Consider alternative dx
2. If appendicitis still considered likely,
Likely NOT Appendicitis consider abdominal CT vs transfer for
1. Repeat PE further evaluation
2. Consider alternative
CT Negative (appendix CT Equivocal (appendix not
diagnoses NML OR appendix not visualized AND + RLQ fat
3. PO challenge seen but no RLQ fat stranding OR ANY free fluid in
4. Consider discharge vs stranding; no free fluid males OR more than
observation in males or expected physiologic volume in females)
physiologic volume in
females) Diagnosis Uncertain
1.Repeat PE. Consider alternative dx
2.Consult Pediatric Surgery.
3.Avoid empiric antibiotics unless suspected
Pediatric Suspected Acute Appendicitis
sepsis
Goals of Clinical Pathway
1. Create an efficient, timely, team-oriented, standardized and accurate approach for the evaluation and
work up of children with suspected appendicitis
2. Decrease radiation exposure where possible during diagnostic workup
Data Interventions Rationale
Considerations
 Appendicitis is the most common surgical emergency in children. Symptoms
Diagnosis overlap many childhood illnesses making this a challenge to diagnosis. Delayed
diagnosis and rupture are associated with increased morbidity, mortality and
prolonged hospital stays. Initial misdiagnosis rates range from 28-57% for children
age 12 years or younger to 100% to those 2 years or younger.

Several clinical scoring systems have been prospectively

Clinical studied in children to aid in the diagnosis of appendicitis,
Assessment including the Pediatric Appendicitis Score, the Alvarado Score,
and the Low-Risk Appendicitis Score. The Alvarado Score
appears to be the most effective tool in identifying low risk
patients, with a score of ≤ 3 being low risk.
Though ultrasound is inferior to CT scan for the diagnosis of
Ultrasound appendicitis, both ACEP and ACR recommend US as the initial
study to minimize radiation exposure in pediatric patients. A
multicenter study at major pediatric centers by Mittal showed
ultrasound to have sensitivity of 73% and specificity of 97%.
However, utility of US for diagnosis of appendicitis very likely
depends on pretest probability. A study combining US and PAS
found that in kids with high risk PAS, 19% of US were falsely
negative and 45% with equivocal results had appendicitis. For
intermediate risk, 13% of equivocal had appendicitis, while 6%
with negative US did.
CT is superior to US and in most studies to MRI. CT with
CT Scan contrast is the preferred study in the diagnosis of appendicitis
with rupture. There is not good evidence suggesting oral
contrast improves diagnostic accuracy, though IV contrast is
useful. At OHSU, sensitivity of CT is ~100% while specificity is
99%.
Limited abdominal MRI has been studied in children as an
Abdominal MRI alternative to CT. In a 2012 retrospective single center study,
MRI had sensitivity of 97.6%, specificity of 97.0%, PPV 88.9%,
and NPV 99.4% with minimum f/u of 30 days for clinical
confirmation. A 2014 study using contrast-enhanced MRI
showed similar test-characteristics, with sensitivity 96.2%,
specificity 95.7%, PPV 92.7%, and NPV 97.8%. Appendix was
visualized in 67% of cases in this latter study and was
visualized in 36% of true negative cases in the former. This
study can be performed at OHSU and deferring CT scan to
obtain a quick abdomen MRI is a reasonable option to avoid
excess radiation.
Citations:
Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of appendicitis in
children in a multicenter cohort. Acad Emerg Med, 20 (2013). 697-702.

Bachur RG, Callahan MJ, Monuteaux MC, et al. Integration of Ultrasound Findings and a Clinical Score in the
Diagnostic Evaluation of Pediatric Appendicitis. J of Pediatr, 166(5) 2015: 1134-39

Moore MM, Gustas CN, Choudhary AK, et al. MRI for clinically suspected pediatric appendicitis: an
implemented program. Pediatr Radiol 42 (2012): 1056-63

Mushtaq R, Desoky SM, Morello F. First Line Diagnostic Evaluation with MRI for Children Suspected of
Having Acute Appendicitis. Radiology 29 (2019): 170-7

Ebell MH, Shinholser J. What are the most clinically useful cutoffs for the Alvarado and Pediatric
Appendicitis Scores? A systematic review. Ann Emerg Med 64 (2014): 365-372