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Apendisitis akut adalah peradangan akut dan infeksi usus buntu berbentuk vermiform
(ulat), yang paling sering disebut sebagai apendiks. Apendiks adalah sebuah struktur
yang berakhir buntu yang timbul dari sekum. Apendisitis akut adalah salah satu
penyebab paling umum sakit perut dan merupakan kondisi yang paling sering
menyebabkan pembedahan perut emergensi pada anak-anak. Apendiks mungkin terlibat
dalam proses infeksi, inflamasi, atau kronis lainnya yang dapat mengarah kepada
apendiktomi; Namun, artikel ini berfokus pada apendisitis akut. Apendiks dan
apendisitis akut digunakan secara bergantian. (Lihat Anatomi, serta Patofisiologi.)
Gambar apendisitis anak di bawah ini.
Gejala umum apendisitis akut termasuk sakit perut, demam, dan muntah. Diagnosis
apendisitis bisa sulit pada anak-anak karena gejala klasik sering tidak ada. (Lihat Gejala
Klinis.)
Diagnosis apendisitis yang terlambat berkaitan dengan ruptur dan komplikasi, terutama
pada anak-anak. Peningkatan resiko rupture apendiks dapat diketahui menggunakan
Kombinasi infeksi bakteri dan iskemia menghasilkan peradangan atau inflamasi, yang
berkembang menjadi nekrosis dan gangren. Ketika apendiks menjadi gangren, mungkin
bisa perforasi. Perkembangan dari obstruksi menjadi perforasi biasanya berlangsung
selama 72 jam.
Sebuah penelitian mencatat bahwa perforasi appendiks lebih sering terjadi pada anakanak, khususnya anak-anak muda, dibandingkan pada orang dewasa. Risiko besar
terjadi perforasi dalam waktu 24 jam dari onset tercatat (7,7%) dan ditemukan
meningkat dengan durasi gejala. Sementara itu, perforasi berhubungan langsung dengan
durasi gejala sebelum operasi, risiko dikaitkan lagi dengan penundaan pra-rumah sakit
dibandingkan
dengan
penundaan
rawat
inap
di
rumah
sakit.
[1]
Pada tahap awal apendisitis, pasien mungkin merasa sakit hanya periumbilikalis karena
persarafan apendiks di T10. Peradangan memburuk, eksudat terbentuk pada permukaan
serosa appendiks. Ketika eksudat menyentuh peritoneum parietal, berkembang menjadi
sakit yang lebih sering dan terlokalisir.
Perforasi menyebabkan pengeluaran cairan inflamasi dan bakteri ke dalam rongga
perut. Hal ini semakin menyebabkan permukaan peritoneal inflamasi, dan berkembang
menjadi peritonitis. Lokasi dan luasnya peritonitis (difus atau lokal) tergantung pada
sejauh mana omentum dan loop usus yang berdekatan dapat berisi tumpahan isi lumen
usus.
Jika isi usus membentuk dinding dan abses, rasa sakit dan nyeri dapat dilokalisir di
tempat abses. Jika isi usus membentuk dinding dan cairan dapat menyebar di seluruh
peritoneum, rasa sakit dan nyeri menjadi umum serta tidak terlokalisir.
Etiologi
Apendisitis akut disebabkan obstruksi apendiks yang berakhir buntu, sehingga loop
usus tertutup. Pada anak-anak, obstruksi biasanya terjadi akibat hiperplasia limfoid
pada folikel submukosa. Penyebab hiperplasia ini kontroversial, kemungkinan dehidrasi
dan infeksi virus. Penyebab umum lainnya obstruksi apendiks adalah fekalith
Penyebab yang jarang termasuk benda asing, infeksi parasit (misalnya, nematoda), dan
striktur inflamasi.
Epidemiologi
Apendisitis memiliki insiden 70.000 kasus anak per tahun di Amerika Serikat. Insiden
antara baru lahir dan usia 4 tahun adalah 1-2 kasus per 10.000 anak per tahun. Insiden
meningkat menjadi 25 kasus per 10.000 anak per tahun antara 10 dan 17 tahun. Secara
Sejarah
Sejarah klasik anoreksia dan nyeri periumbilikalis jelas, diikuti oleh migrasi
nyeri ke kuadran kanan bawah (RLQ) dan timbulnya demam dan muntah,
diamati dalam waktu kurang dari 60% pasien. [2] Jika usus buntu perforasi,
selang nyeri lega diikuti dengan perkembangan nyeri perut umum dan
peritonitis. Meskipun beberapa pasien kemajuan dalam mode klasik,
beberapa pasien menyimpang dari model klasik. Presentasi atipikal yang
umum pada pasien neurologis gangguan dan immunocompromised, serta
anak-anak yang sudah pada antibiotik untuk penyakit lain.
Pada pasien dengan usus buntu retrocecal, yang merupakan 15% dari
kasus, tanda-tanda dan gejala mungkin tidak melokalisasi ke RLQ tetapi
sebaliknya ke otot psoas, panggul atau kuadran kanan atas. Pada pasien
lain, ujung usus buntu yang jauh di dalam panggul, dan tanda-tanda dan
gejala melokalisasi ke rektum atau kandung kemih yang mengakibatkan
rasa sakit dengan buang air besar atau buang air.
Fitur tertentu dari presentasi anak mungkin menyarankan lampiran
berlubang. Seorang anak muda dari 6 tahun dengan gejala selama lebih
dari 48 jam jauh lebih mungkin untuk memiliki usus buntu yang berlubang.
Anak mungkin telah umum sakit perut dan mungkin memiliki detak jantung
yang tinggi dan suhu yang lebih tinggi dari 38 C.
Sebuah risiko besar perforasi dalam waktu 24 jam dari onset tercatat (7,7%)
dalam satu studi dan ditemukan meningkat dengan durasi gejala.
Sementara perforasi berhubungan langsung dengan durasi gejala sebelum
operasi, risiko dikaitkan lagi dengan penundaan pra-rumah sakit
dibandingkan dengan di rumah sakit delay. [1]The classic history of anorexia
and vague periumbilical pain, followed by migration of pain to the right lower quadrant
(RLQ) and onset of fever and vomiting, is observed in fewer than 60% of patients.[2] If
the appendix perforates, an interval of pain relief is followed by development of
generalized abdominal pain and peritonitis. Although some patients progress in the
classical fashion, some patients deviate from the classic model. Atypical presentations
are common in neurologically impaired and immunocompromised patients, as well as
in children who are already on antibiotics for another illness.
In patients with a retrocecal appendix, who constitute 15% of cases, signs and
symptoms may not localize to the RLQ but instead to the psoas muscle, the flank or
right upper quadrant. In other patients, the tip of the appendix is deep in the pelvis, and
the signs and symptoms localize to the rectum or bladder resulting in pain with
defecation or voiding.
Certain features of a child's presentation may suggest a perforated appendix. A child
younger than 6 years with symptoms for more than 48 hours is much more likely to
have a perforated appendix. The child may have generalized abdominal pain and may
have a high heart rate and a temperature higher than 38C.
A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one study
and was found to increase with duration of symptoms. While perforation was directly
related to the duration of symptoms before surgery, the risk was associated more with
prehospital delay than with in-hospital delay.[1]
Pain
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.
Nausea and vomiting
A unique feature of appendicitis is gradual onset of pain followed by vomiting.
Vomiting first is more typical of gastroenteritis.
Generally, vomiting that occurs prior to pain is unusual. However, in patients with
retrocecal appendices, particularly those that extend cephalad along the posterior
surface of the right colon, inflammation of the appendix irritates the nearby duodenum,
resulting in nausea and vomiting prior to the onset of RLQ pain.
Diarrhea
Significant diarrhea is atypical in appendicitis, and the physician should consider other
diagnoses, while not ruling out appendicitis. In patients with an appendix in a pelvic
location, inflammation of the appendix occasionally results in an irritative stimulation
of the rectum. These patients often report diarrhea. However, upon closer questioning,
such patients usually describe frequent, small-volume, soft stools rather than true
diarrhea.
Fever
Most children with appendicitis are afebrile or have a low-grade fever and
characteristic flushing of their cheeks. Severe fever is not a common presenting feature
unless perforation has occurred, and even then it may still be rare. According to one
study, vomiting and fever are more frequent findings in children with appendicitis than
in children with other causes of abdominal pain.
Physical Examination
The physical examination findings in children may vary depending on age. Irritability
may be the only sign of appendicitis in a neonate. Older children often seem
uncomfortable or withdrawn. They may prefer to lie still because of peritoneal
irritation. Teenaged patients often present in a classic or near-classic fashion.
Examination of the child requires skill, patience, and warm hands. Initial and continued
observation of the child is of critical importance. An ill-appearing quiet child who is
lying very still in bed, perhaps with the legs flexed, is much more a cause for concern
than a child who is laughing, playing, and walking around the room.
The examination should be thorough and start with areas other than the abdomen.
Because lower lobe pneumonias can cause abdominal findings, a history of such should
be elicited and a thorough chest examination performed. It is also important to exclude
urinary tract infection (UTI) as a cause of abdominal pain.
Children vary in their ability to cooperate with the physical examination. It is important
to tailor the physical examination to the child's age and developmental stage.
General examination
Patients general state should be observed before interacting with them. The patients
state of activity or withdrawal may lend information into their condition. The child's
gait may be observed if they are well enough to ambulate. A patient in obvious distress
with abdominal pain gives the impression of an infectious process; however, other
causes must be ruled out.
Cardiac and pulmonary examination
The findings on evaluation of the heart and lungs typically reflect the patients overall
state more than they may suggest appendicitis. Patients are often dehydrated or in pain
and may be tachycardic or tachypneic. Pediatric patients have great physiological
reserves and may not show any general symptoms until they are very ill.
Abdominal examination
Full exposure of the abdomen is key. Before examining the abdomen, ask the child to
point with one finger to the site of maximal pain. Begin palpation of the abdomen at a
site distant to this, with the most tender area examined last. If the child is particularly
anxious, palpation may be performed with a stethoscope.
Distracting questions concerning school and family members may be helpful to relieve
anxiety during the examination. Observing the child's facial expressions during this
questioning and palpating is critical.
Palpation of the abdomen should be performed with a gentle and light touch, searching
for involuntary guarding of the rectus or oblique muscles. In early appendicitis,
children may not have significant guarding or peritoneal signs. Younger children are
much more likely to present with diffuse abdominal pain and peritonitis, perhaps
because their omentum is not well developed and cannot contain the perforation.
Typically, maximal tenderness can be found at the McBurney point in the RLQ. A mass
may be palpable in the RLQ if the appendix is perforated.
However, the appendix may lie in many positions. Patients with a medially positioned
appendix may present with suprapubic tenderness. Patients with a laterally positioned
appendix often have flank tenderness. Patients with a retrocecal appendix may not have
any tenderness until appendicitis is advanced or the appendix perforates.
Presence of the Rovsing sign (pain in the RLQ in response to left-sided palpation or
percussion) strongly suggests peritoneal irritation.
To assess for the psoas sign, place the child on the left side and hyperextend the right
leg at the hip. A positive response suggests an inflammatory mass overlying the psoas
muscle (retrocecal appendicitis).
Check for the obturator sign by internally rotating the flexed right thigh. A positive
response suggests an inflammatory mass overlying the obturator space (pelvic
appendicitis).
During the abdominal examination, try to avoid eliciting rebound tenderness. This is a
painful practice and certainly destroys any trust that has been garnered during the
examination. Peritonitis can be confirmed with gentle percussion over the right lower
quadrant. Involuntary contraction of the abdominal wall musculature (involuntary
guarding) and tenderness can be elicited with minimal stress or discomfort to the child.
Other methods can be used to establish that the patient has peritoneal irritation. Asking
the patient to sit up in bed, cough, jump up and down, or bounce his or her pelvis off
the bed while in the supine position may elicit pain in the presence of peritoneal
irritation. Alternatively, other acceptable maneuvers are tapping the patient's soles and
shaking the stretcher. A child with advanced appendicitis typically prefers to lie still due
to peritoneal irritation.
Rectal examination
The digital rectal examination is often deferred but can be helpful in establishing the
correct diagnosis, especially in sexually active adolescent girls. The patient should be
told that the examination is uncomfortable but should not cause sharp pain. The caliber
of the patient's anus should be taken into consideration, and smaller digits should be
used for examining younger patients.
The rectal examination is particularly important in the child with a pelvic appendix, in
whom the findings on the abdominal examination for appendicitis may be equivocal
and indicative of peritoneal irritation.
Objective information to ascertain includes impacted stool or an inflammatory mass.
Right-sided tenderness of the rectum is the classic finding in patients with pelvic
appendicitis or in those with pus that pools in the pelvis from an inflamed appendix
elsewhere in the abdomen.
Patients who are able to communicate should be asked if they have tenderness in
different areas of the rectum. The rectal examination in a young child may have to be
completely objective because they may not be able to communicate variations in
tenderness or may have general discomfort from the examination.
Genitourinary examination
An external genitourinary (GU) examination is helpful to rule out testicular or scrotal
tenderness in males and hematocolpos in pubertal girls.
Pelvic examination
A pelvic examination should be considered in sexually active adolescent girls to
evaluate for tenderness (adnexal and/or cervical motion tenderness), masses, bleeding,
or discharge.
Atypical findings
Becker et al found that 44% of patients diagnosed with appendicitis presented with 6 or
more of the following atypical features[3] :
No fever
No rebound pain
No migration of pain
No guarding
No anorexia
Diagnostic Considerations
The signs and symptoms of appendicitis are nonspecific and are common with other
diagnoses. Do not diagnose gastroenteritis rather than appendicitis unless the patient
has nausea, vomiting, and diarrhea. Even with the presence of vomiting and diarrhea,
consider the unusual presentations of retrocecal or pelvic appendicitis. Additionally,
appendicitis can develop as a sequela of gastroenteritis associated with lymphoid
hyperplasia.
Diagnose abdominal pain of unknown etiology in patients with nonspecific abdominal
symptoms if a diagnosis cannot be established. These patients may be discharged with
close follow up. Instruct patients to be reevaluated in 8-12 hours by their primary care
physician or to return to the emergency department. Patients with equivocal
examination findings but suspected to have early appendicitis should be admitted for
observation for serial abdominal examinations or to undergo imaging with
ultrasonography or abdominal CT scanning.
If constipation is diagnosed and treated with enemas and/or stool softeners with
resolution of the signs and symptoms, inform the patient and family that recurrence of
the abdominal pain in the future could be recurrent constipation or acute appendicitis
and to seek medical advice.
Appendicitis should be considered in special patient populations, such as the
immunocompromised and developmentally delayed. Appendicitis is rare in infants. If
an infant has appendicitis, the diagnosis of Hirschsprung disease should also be
considered.
Other problems to consider include the following:
Ovarian cyst
Ovarian torsion
Pregnancy
Ectopic pregnancy
Renal calculi
Mesenteric lymphadenitis
Mittelschmerz
Neutropenic typhilitis
Lymphoma
Epiploic appendagitis
Paratubal cysts
Volvulus
Typhlitis
Omental torsion
The major differential diagnoses for acute appendiceal abscess or mass include Crohn
disease and malignancy.
Differential Diagnoses
Constipation
Ectopic Pregnancy
Hemolytic-Uremic Syndrome
Henoch-Schoenlein Purpura
Meckel Diverticulum
Ovarian Cysts
Ovarian Torsion
Pancreatitis
Pediatrics, Gastroenteritis
Pediatrics, Intussusception
Pregnancy Diagnosis
Pregnancy, Ectopic
Pyelonephritis
Renal Calculi
Testicular Torsion
Approach Considerations
Making a timely diagnosis of appendicitis is a difficult challenge in children with
abdominal pain. Laboratory findings may increase suspicion of appendicitis but are not
diagnostic. The minimum laboratory workup for a patient with possible appendicitis
includes a white blood cell (WBC) count with differential and urinalysis. Liver function
tests and amylase and lipase assessments are helpful when the etiology is unclear.
Baseline blood urea nitrogen and creatinine are needed prior to intravenous contrast CT
scanning.
Other studies, such as interleukin 6 and C-reactive protein (CRP) assays, have been
advocated by some in the diagnosis of appendicitis. However, in multiple clinical
series, these studies have not been shown to be of clear benefit and, for the most part,
only add to the cost of the evaluation.
CBC Count
The WBC count becomes elevated in approximately 70-90% of patients with acute
appendicitis. However, the WBC count is elevated in many other abdominal conditions,
as well. Furthermore, the WBC count is often within the reference range within the first
24 hours of symptoms. Elevation tends to occur only as the disease process progresses,
and it is usually mild. Therefore, its predictive value is limited. Elevation of the
neutrophil or band count can be seen without elevation of the total WBC count and may
support the diagnosis of appendicitis.
If the WBCs exceed 15,000 cells/L, the patient is more likely to have a perforation.
However, one study found no difference in the WBC counts of children with simple
appendicitis and those with perforated appendicitis. In the immunocompromised
patient, a neutrophil count of less than 800 may suggest typhlitis.
Urinalysis
Urinalysis is useful for detecting urinary tract disease, including infection and renal
stones. However, irritation of the bladder or ureter by an inflamed appendix may result
in a few urinary WBCs. The presence of 20 or more WBCs per high-power field (hpf)
suggests a urinary tract infection.
Hematuria may be caused by renal stones, urinary tract infection, Henoch-Schnlein
purpura, or hemolytic-uremic syndrome. However, small numbers of red blood cells
(RBCs) can be found in as many as 20% of patients with appendicitis when an
overlying phlegmon or abscess lies adjacent to the ureter. Typically, urinary RBCs are
fewer than 20/hpf.
Ketonuria is suggestive of dehydration and is more common with perforated
appendicitis.
Normal urinalysis results have no diagnostic value for appendicitis. However, a grossly
abnormal result may suggest an alternative cause of abdominal pain
Abdominal Radiography
Abdominal radiography findings are normal in many individuals with appendicitis.
However, plain films may be helpful in the setting of severe constipation. A calcified
appendiceal fecalith is present in less than 10% of persons with inflammation, but its
presence suggests the diagnosis.
Radiographic signs suggestive of appendicitis include convex lumbar scoliosis,
obliteration of the right psoas margin, right lower quadrant (RLQ) air-fluid levels, air in
the appendix, and localized ileus. In rare incidents, a perforated appendix may produce
pneumoperitoneum.
If no other imaging studies are to be performed, an abdominal series may be helpful.
For more information, see the Medscape Reference article Appendicitis Imaging.
Ultrasonography
Given the potential risks of radiation from CT scans, graded compression
ultrasonography may be the preferred initial imaging modality in the evaluation of
pediatric acute appendicitis. This technique involves locating the appendix and then
attempting to compress its lumen.
For ultrasonography to be diagnostic of appendicitis, the operator must visualize the
appendix. Even if the appendix is not visualized, however, appendicitis can be excluded
more confidently if ultrasonography shows no secondary signs of appendicitis (eg,
hyperechoic mesenteric fat, fluid collection, localized dilated small bowel loop).[4, 5]
A positive finding is a noncompressible tubular structure 6 mm or wider in the RLQ
(see the images below). This structure is tender during palpation with the
ultrasonographic probe. Additional supportive findings include an appendicolith, fluid
in the appendiceal lumen, focal tenderness over the inflamed appendix (sonographic
McBurney point), and a transverse diameter of 6 mm or larger. In patients with a
perforated appendix, ultrasonography may reveal a periappendiceal phlegmon or
abscess formation.
Nausea (2 points)
Anorexia
Elevated temperature
Nausea/vomiting
Leukocytosis
Migration of pain
Samuel recommended that patients with a score of 5 or lower should be observed, while
those with a score of 6 or higher should undergo surgical consultation.
The Alvarado score (MANTRELS score)
The MANTRELS score is based on the following 8 variables:
Anorexia
Nausea/vomiting
Tenderness in RLQ
Rebound pain
Leukocytosis (>10,000/L)
Left shift
Keep the patient for observation if a firm diagnosis is not made or for follow-up
Algorithms, scoring systems, imaging studies, and consultation reports are part of the
clinician's armamentarium. Documentation of medical decision making is important, as
Patients with appendicitis usually require fluid boluses prior to operation in order to
counteract dehydration. However, these patients need continued fluid resuscitation
appropriate to their fluid status and severity of appendicitis.
If fluid status is unclear, urine output is the most common measure. Urine output should
be no lower than 0.5 mL/kg/h. If dehydration is suspected, Foley catheter placement,
monitoring of urine output, and correct fluid replacement are indicated.
Postoperatively, the spectrum of fluid management ranges from patients with early
appendicitis who are started on clear fluids postoperatively and can have intravenous
(IV) fluids discontinued when advanced to a regular diet, to patients with perforated
appendicitis who require postoperative fluid boluses.
Antibiotic Therapy
Antibiotic therapy is an important aspect of the treatment of ruptured appendicitis.
Intravenous antibiotics should be started once the diagnosis of acute appendicitis is
confirmed. Antibiotic therapy should be directed against gram-negative and anaerobic
organisms such as Escherichia coli and Bacteroides species.
If the appendix is not gangrenous or perforated, no postoperative antibiotics are
indicated. A gangrenous appendix warrants antibiotics for 24-72 hours, depending on
clinical improvement and/or Gram stain, if one was obtained during surgery.
Antibiotic therapy for ruptured appendicitis is continued for a minimum of 7-10 days,
but a longer course may be needed. Intravenous antibiotics are used during the
hospitalization. Oral antibiotics may be used to complete therapy if a child is well
enough for discharge.
While appendectomy remains the definitive treatment for appendicitis, many patients
with perforated appendicitis are now treated with intravenous antibiotics alone with
drainage of the abscess if needed. Additionally, some advocate nonoperative treatment
with antibiotics only for early appendicitis, especially when the diagnosis is vague.
Appendectomy
The definitive treatment for appendicitis is appendectomy. Historically, appendectomy
had a 10-20% false-positive rate, but the widespread use of imaging studies has reduced
this rate.
Patients with perforated appendicitis can be divided into 2 cohorts; those whose
perforation is discovered in the operating room during appendectomy and those with
preoperative evidence of perforation, most commonly seen on CT scans or ultrasounds.
Increasingly, the approach in the latter group is conservative (nonoperative)
management, with percutaneous drainage if possible and surgery after 8-12 weeks (ie,
interval appendectomy).
Patients discovered to have perforated appendicitis during appendectomy should be
treated in the same fashion as those with nonperforated appendicitis. The surgeon
should complete the appendectomy in a normal fashion.
If a laparoscopic appendectomy is being performed, perforation alone is not a reason
for conversion to open appendectomy. However, if an abscess is encountered and
drained, placement of a drain in the abscess cavity should be considered. In addition,
when an open appendectomy is being performed on a patient with a perforated
appendix, the high incidence of wound infection should be considered in terms of skin
closure.
In rare instances, the inflammation can be so severe that the appendix cannot be safely
identified and removed. To avoid unnecessary morbidity, drainage procedures with
subsequent interval appendectomy (see conservative [nonoperative] management) is
acceptable.
To see complete information on Pediatric Appendectomy, please go to the main article.
Conservative (Nonoperative) Management
Historically, a patient with appendicitis, especially perforated appendicitis, was rushed
to the operating room for appendectomy; however, this is no longer the case.
Conservative management with interval appendectomy may be appropriate for
perforated appendicitis. Whyte et al have suggested that interval appendectomy may be
safely performed as an outpatient procedure.[15]
Conservative management begins with a trial of medical therapy. A patient found to
have perforated appendicitis based on imaging study findings should be admitted to the
hospital, should be placed on a nothing-by-mouth (NPO) diet, and should be given
intravenous (IV) fluid resuscitation.
If the patient is hemodynamically unstable or if urine output cannot be measured, a
Foley catheter should be placed. IV antibiotics should be started. Generally, antibiotics
for this condition are targeted at enteric flora (eg, second-generation cephalosporin,
gentamicin, metronidazole; see Medication). If the patient has an abscess that is
accessible, percutaneous drainage is performed. Discharge from the hospital is based on
lack of fever, tolerance of pain on oral medications, and adequate oral intake.
A patient who does not improve after admission and intravenous antibiotic therapy
should undergo surgery for drainage of the infection and appendectomy, if technically
Perforation
Sepsis[18]
Shock
Postoperative adhesions
Infertility
Wound dehiscence
Wound infection
Bowel obstruction
Medication Summary
Administer 1 dose of preoperative antibiotics to children with suspected appendicitis.
Antibiotics can be discontinued after surgery if no perforation is noted.
Antibiotics are selected to provide coverage for aerobic and anaerobic organisms. The
most widely used regimen is the combination of ampicillin, clindamycin (or
metronidazole), and gentamicin. Alternative regimens include the following:
Ampicillin/sulbactam
Cefoxitin
Cefotetan
Piperacillin/tazobactam
Ticarcillin/clavulanate
Imipenem/cilastatin
Fentanyl is a synthetic opioid that is 75-200 times more potent and has a much shorter
half-life than morphine sulfate. It has less hypotensive effects and is safer in patients
with hyperactive airway disease than morphine because of minimal to no associated
histamine release. By itself, it causes little cardiovascular compromise, although the
addition of benzodiazepines or other sedatives may result in decreased cardiac output
and blood pressure.
Consider continuous infusion of fentanyl because of its short half-life (30-60 min).
Parenteral fentanyl is the drug of choice for conscious sedation analgesia. It is ideal for
analgesia of short duration during anesthesia and the immediate postoperative period. It
is readily titrated and is easily and quickly reversed by naloxone.
After the initial parenteral dose, subsequent parenteral doses should not be titrated more
frequently than every 3 or 6 hours. Fentanyl is highly lipophilic and protein bound.
Prolonged exposure leads to accumulation in fat and delays the weaning process.
View full drug information
Morphine
Morphine sulfate has the advantages of reliable and predictable effects, a favorable
safety profile, and ease of reversibility with naloxone. Various IV doses are used; it is
commonly titrated until the desired effect is obtained.
The Joint Commission on the Accreditation of Healthcare Organizations has placed
"MSO4" on the banned abbreviation list, because it can be mistaken for magnesium
sulfate. Therefore, in writing the prescription, spell out "morphine sulfate" in full,
legibly and clearly.