Welcome to the case of the month series of our paedsoc blog! This will hopefully just provide some informal, chill revision and learning opportunities!
We are going to keep our first case nice and simple just to introduce everyone to our cases – this one will be relevant for 4th, 5th AND 6th years!!!
You are a junior doctor working in the emergency department.
Your next patient is Noah Smith, a 12 year old boy who has presented with his mother.
You read the notes and see that the presenting complaint is a pain in the lower right quadrant of his abdomen.
Before seeing the patient, come up with a list of differentials
- Renal colic
- Mesenteric adenitis
- Testicular torsion
If our patient was female, we might also consider ovarian cysts/torsion, pelvic inflammatory disease or ectopics (although less likely in this age group)
With your differentials in mind, you go to speak with Noah and his mum. You remember reading about an acronym to help you structure any history relating to pain…
What is this classic acronym and what do all the letters stand for?
S – site – where is the pain? Has it always been there or moved?
O – Onset – sudden or gradual onset? What was the pt doing?
C – Character – sharp, dull etc
R – Radiation – does the pain move anywhere?
A – Associated symptoms – fever? change in bowel habit? Diarrhoea or vomiting?
T – Time course – how long have they had the pain? Is it getting better or worse?
E – Exacerbating factors and relieving factors
S – severity – out of 10
Questioning reveals that Noah has had this pain for two days. Yesterday it was around his belly-button and was coming and going. Today it is constantly there and is now in the right lower quadrant. Noah is usually very active and never misses Basketball training but refused to go yesterday because moving around makes the pain worse. He has vomited four times and his mum says he feels feverish although she did not take his temperature at home. Your consultant next to you says that this is a classic presentation of Murphy’s triad!
What is Murphy’s Triad? Given that this triad is present, and the key points to the history above, what is the most likely diagnosis from the list of differentials you came up with earlier
Murphy’s triad is a combination of pain, vomiting and fever
This is a classic presentation of APPENDICITIS. Appendicitis can affect children of any age but is uncommon in children under 3 years of age. The pathophysiology is not completely understood but we think it may be caused when the lumen of the appendix becomes blocked, perhaps due to a faecolith (stone made of faeces), normal faeces or lymphoid hyperplasia in viral infections. This obstruction leads to less blood flow and allows bacteria in the appendix to multiply.
Symptoms include loss of appetite, vomiting, abdominal pain that starts colicky and centrally, but then moves to the right iliac fossa. This movement is due to inflammation of the local peritoneum. Fever and aggravation by movement are other features that may be revealed in the history, but more accurately in examination.
Observations are as follows:
Temp: 38oC, HR: 99bpm, RR: 19/min, BP: 104.68 mmHg
Your abdominal examination shows tenderness in the right iliac fossa, although there is no guarding or rebound tenderness. Pressing in the left iliac fossa causes pain in the right iliac fossa.
The consultant decides to give you a med school throwback and asks you to name the clinical sign you just elicited by pressing in the left iliac fossa
Rovsing’s sign – pressure in the left iliac fossa causes pain in the right iliac fossa in appendicitis patients
The consultant then asks you to state which of the following signs is NOT seen in appendicitis. A) Psoas sign B) Cope sign C) Kernig’s Sign D) McBurny’s sign
The correct answer is C – Kernig’s sign is associated meningitis and subarachnoid haemorrhage. Flex the hip with the knee at 90 degrees. Once the thigh is at a right angle with the bed, extend the knee further. Pain indicates a positive Kernig’s sign
Psoas, Cope (also called Obtrurator sign) and McBurny’s are all signs that can be elicited in appendicitis. Psoas is pain on extending the hip – seen if the appendix is in a retrocaecal position. Cope – pain on flexion and internal rotation of the right hip. McBurny’s – pain at McBurny’s point (1/3rd from the right anterior superior iliac spine to the umbilicus)
What investigations do you need to order?
Appendicitis is a largely clinical diagnosis. Investigations are done to rule out other differentials. If the case is classic, don’t delay diagnosis – this can be life-threatening as delaying treatment increases the risk of perforation and peritonitis!
FBC will show raised inflammatory markers.
May want to do an ultrasound although it is not always possible to see the appendix. However, if there are complications such as abscess development, you may be able to see this
Urinalysis can help exclude renal pathology. In female patients, think about a pregnancy test (not relevant for our male patient but do also think about whether this is age-appropriate in paediatrics)
Your consultant asks you if you know of any scoring systems to help you assess how likely the diagnosis is
The Alvarado score can be used if you like objective scoring systems. However, in trials, it hasn’t been shown to be any better than clinical judgement so this isn’t a compulsory thing to do
There are 10 points in this system. <4 means appendicitis is unlikely. 5-6 observe the patient. >7 = operate
In this scenario, we just did an abdominal examination. Sometimes you may consider a groin/scrotal examination if the history could be indicating an incarcerated hernia or testicular torsion. In female patients, you may also need to do a pelvic examination to exclude gynaecological causes for symptoms.
The case presented today was quite classic. However, diagnosis can be a lot more difficult in younger children; the abdominal pain may be non-specific, they may be off their food and appear withdrawn. So have appendicitis at the back of your mind for all acute abdominal pain in young children.
Please also note that in some people, the appendix may be in an abnormal position and this can lead to different presentations
- Retrocaecal – right loin pain, psoas test. Not always tender due to protection of overlying caecum
- Pre-ileal – may have diarrhoea due to irritation of the ileum
- Pelvic – suprapubic pain and urine frequency. May also have rectal irritation, causing diarrhoea and tenesmus
How do we manage appendicitis?
Appendicectomy – we prefer a laparoscopic approach over open surgery. A laparoscopic approach leads to less pain, less infection at surgical sites and decreased length of stay in hospital.
Post-operative complications include:
- Small bowel obstruction
- Wound infection
- Stump leakage
- Stump appendicitis – rare – inflammation of residual part of the appendix left behind, presents like acute appendicitis
If a patient cannot undergo surgery, IV antibiotics can reduce mortality by 50%
We hope that you found this case a useful learning/revision exercise.
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We will see you next month with something a bit more challenging – see you soon 🙂
Written by Dylan Birk (webmaster)