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Content Update: Pediatric Appendicitis March 2022

Prediction rules for the diagnosis of childhood appendicitis are the Alvarado Score, the Pediatric Appendicitis Score (PAS), the Appendicitis Inflammatory Response Score (AIR), and the Pediatric Appendicitis Risk Calculator (pARC). These tools are discussed under Specific Conditions, in Appendicitis, Diagnosis. Also refer to Tables 133-2 and 133-3 for helpful information.


The diagnoses in this chapter are challenging, as emergent surgical conditions in children may present with symptoms other than pain, including vomiting, fever, irritability, or lethargy. Table 133-1 classifies conditions by age, although many conditions cross categories.

TABLE 133-1Causes of Abdominal Pain by Age Group

The pathophysiology of abdominal pain is discussed in Chapter 71, “Acute Abdominal Pain.” Gynecologic causes are discussed in Chapter 97, “Abdominal and Pelvic Pain in the Nonpregnant Female.” Gastroenteritis is the most common cause of abdominal pain in children of all ages (see Chapter 131, “Vomiting, Diarrhea, and Dehydration in Infants and Children”).

The largest single group of children will have no definite diagnosis and will receive the diagnosis of exclusion of nonspecific abdominal pain. Patients should not be given unsubstantiated diagnoses such as gastroenteritis, gastritis, or constipation without strong support for these diagnoses. Patients discharged without a clear diagnosis should have a planned reexamination.


The assessment of young children depends on observation for subtle clues. Stillness suggests conditions that irritate the peritoneum, such as appendicitis. Writhing for a position of comfort suggests obstruction, such as intussusception or renal colic.

Inspect, auscultate, and then palpate the abdomen, starting away from the expected area of maximal tenderness. Bringing the knees up relaxes the abdominal muscles. Move the hips to test for hip pathology or irritation caused by appendicitis or a psoas abscess. Thoroughly examine the diaper area to identify testicular torsion, paraphimosis, hair tourniquet, hernia, and imperforate hymen, as the young child may be unable to articulate problems in that area and the older child may be embarrassed to do so. Rectal exam may identify gross or occult blood, constipation, abnormalities of anogenital anatomy, and inflammatory processes. Evaluate for extra-abdominal causes of abdominal pain such as pharyngitis or pneumonia.


Bedside glucose measurement ...

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