Clinical scenario 3: Lotta

You are now attending to seven year old Lotta, who has vomited a few times over the past 24 hours. She also presents with anorexia and a low grade fever. She complains about abdominal pain in the lower right quadrant. Previously the pain was localised more around the belly button.

The following six questions refer to Lotta's clinical scenario.

Question 12

Based on the history, which one of the following is your suspected diagnosis?

Right inguinal hernia
Urinary tract infection
Mesenteric adenitis
Acute appendicitis
Gastritis
Check answer

Explanation

Initially intermittent periumbilical pain (due to appendicular midgut colic) typically migrates to the right iliac fossa and becomes more persistent in character (due to localised peritoneal inflammation). Usually there are nil to only a few associated vomits. Low grade fevers and anorexia may accompany abdominal pain from appendicitis.

Question 13

You think Lotta has acute appendicitis. Which one of the following would you expect to find on abdominal examination?

Abdominal pain in the right lower quadrant, aggravated by movement and flushed face
Reduced skin turgor, abdominal pain in the central region and both lower quadrants, tummy soft
Negative Psoas sign, right and left inguinal fossa pain, no guarding
No McBurney tenderness, Rowsing’s sign negative
Tummy soft, periumbilical abdominal pain
Check answer

Explanation

Abdominal pain in the right lower quadrant, aggravated by movement and flushed face. This is the typical presentation of acute appendicitis.

Question 14

You examine Lotta. She has percussion and palpation tenderness in the right iliac fossa, which is aggravated when you make her jump. She is febrile at 38ºC and is flushed in the face. Which of the following clinical signs would be UNLIKELY to suggest peritonitis/perforation?
Hard abdomen
Increased bowel sounds
Pain when pulling in abdomen
Percussion tenderness
Vomiting
Check answer

Explanation

Vomiting, hard abdomen, pain when pulling abdomen and percussion tenderness are all signs of peritonitic inflammation/irritation warranting treatment for possible peritonitis, i.e. intravenous antibiotics prior to surgery.

Question 15

To support your clinical diagnosis, you ask for some laboratory tests and imaging studies. Which one of the following pathological results are you LEAST likely to encounter in appendicitis?

Increased white cell count
Anaemia
Neutrophilia
Enlarged/ thickened appendix vermicularis on abdominal ultrasound.
No visualisation of the appendix vermicularis on abdominal ultrasound.
Check answer

Explanation

Anaemia is the least likely finding in acute appendicitis. Might be seen as an inflammatory response however least likely to be encountered in acute appendicitis unless anemia is a comorbidity. However, no laboratory investigation or or imaging is consistently helpful in making the diagnosis. A neutrophilia is not always present on a full blood count. White blood cells or organisms in the urine are not uncommon in appendicitis as the inflamed appendix may be adjacent to the ureter or bladder.

Question 16

In preschool children, acute appendicitis might be more difficult to diagnose based on an abdominal examination. Which of these is LEAST common in this age group?
Faecoliths
High grade fever
Perforation
Check answer

Explanation

Answer: High grade fever. Faecoliths are more commonly found in younger children with acute appendicitis and may be seen on abdominal x-ray. Perforation is more common in young children as their omentum is less well developed and thus fails to surround the appendix.

Question 17

Your investigations of Lotta show a WCC of 18, with neutrophilia, an enlarged appendix measuring 8mm and a moderate amount of free abdominal fluid. Lotta remains febrile and lethargic and has now generalized guarding. Which one of the following is the most appropriate next step?
Intravenous antibiotics, admit to the surgical ward and reassess every few hours.
Intravenous antibiotics, fluid resuscitation and urgent laparoscopy
Blood culture, repeat abdominal ultrasound after a few hours and withhold antibiotics until culture results have come back
Intravenous antibiotics and plan for semi-urgent appendectomy after a few weeks
Oral antibiotics, send child home and review clinically the next day
Check answer

Explanation

There are clinical and radiological signs of acute perforated appendicitis with possible peritonitis. This is an indication to commence intravenous antibiotics (preferably triple antibiotics to cover for gram negative, gram positive and anaerobic bacteria) prior to performing urgent laparoscopy and appendectomy.

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