Taking the itis out of Appendicitis

39 th National Conference on Pediatric Health Care March 19-22, 2018 CHICAGO Disclosures Taking the itis out of Appendicitis Sarah A. Martin Sarah has no disclosures Kelly S. Finkbeiner Kelly has no disclosures Sarah A. Martin, MS, CPNP AC/PC, CCRN Pediatric Surgery, Ann & Robert H. Lurie Children s Hospital of Chicago Associate Editor, Journal of Pediatric Health Care Kelly S. Finkbeiner, MSN, CPNP AC/PC Pediatric Surgery, Ann & Robert H. Lurie Children s Hospital of Chicago Learning Objectives State an understanding of this disease including pertinent anatomy, etiology, and pathophysiology of acute and perforated appendicitis. Describe consideration for diagnosing appendicitis including:, signs and symptoms, physical exam findings, laboratory results, radiographic findings, and differential diagnoses. Describe surgical, non operative with drain placement for complicated appendicitis, and preliminary findings for a clinical trial for non operative management of acute appendicitis. NSQIP Peds What is NSQIP? Started with the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) for adults 1980s Congress needed a program to allow for data collection and quality improvement initiatives in the VA system ACS in collaboration with the American Pediatric Surgical Association developed ACS NSQIP Peds for specialties in children s surgery which began in 2008 with four pilot hospitals Challenging as pediatric occurrence rates are low and the patients are variable Focus on a smaller number of surgeries as for hernias etc. not having large number of complications NSQIP Peds Enrollment open to free standing children s hospitals, children s hospitals within larger hospitals, specialty children s hospitals, general hospitals with a pediatric wing Hospitals pay a fee and employee a surgical clinical reviewer to collect reliable date on and compare their outcomes to other participating program Every 8 days a report for ORs based on CPT codes Can this help with standardization and protocolization? Provides a national database to measure outcomes Allows clinicians to act on data to improve care (e.g., minimize PIC use in the appendicitis population) How did I just learn of this? ~15% 6 1

Appendicitis Most common emergent surgical condition Incidence is increasing, approximately 1 per 1,000 Increasing in Hispanics, Asians and Native Americans; decreasing in Caucasian and African Americans Peak incidence 10 to 19 years of age Males > Females The Appendix Pathophysiology Occurs from occlusion of the appendiceal lumen Occlusion blocks mucus and bacterial drainage, raising appendiceal luminal pressure Increased pressure impairs perfusion with eventual gangrene and perforation 9 10 Diagnosis Can this disease be identified in a cost effective and time efficient manner with minimal radiation? Negative appendectomy rates in the U.S. at approximately 5% Estimated that a seasoned clinician should be able to diagnose in 90% of the cases clinically Clinical score + Lab + Radiologic Findings ~3% 12 2

Physical Exam Nearly 1/2 of children have an atypical presentation Classic presentation Dull periumbilical pain migrating to the right lower quadrant over 24 hours McBurney s point: Located 1/3 of the distance along a line from the front of the right pelvic bone and the umbilicus Fever Anorexia Physical Exam Common signs & symptoms Other signs Rovsing s sign right sided pain with lower left palpation Psoas sign pain with flexion and internal rotation of the right hip Obturator sign pain with left side down right hip extension Dunphy pain with coughing Markle test pain with heel drop Stethoscope test Findings that increase the likelihood Fever, pain migration to the RLQ, and rebound tenderness 13 CBC CMP CRP Urinalysis Pregnancy test Laboratory Tests Which signs & symptoms is/are the most useful in making the diagnosis of appendicitis according to a classic systematic review of the literature (Bundy et al., 2007)? A. Fever B. Fever and WBC count > 10,000/µL C. Rebound tenderness and RLQ pain D. Fever and rebound tenderness 15 Which signs & symptoms is/are the most useful in making the diagnosis of appendicitis according to a classic systematic review of the literature (Bundy et al., 2007)? A. Fever B. Fever and WBC count > 10,000/µL C. Rebound tenderness and RLQ pain D. Fever and rebound tenderness Pediatric Appendicitis Risk Scores Can help protocolize Pediatric Appendicitis Score (PAS) Children 4 to 15 years old 10 point score Diagnosis unlikely with score < 5 Alvarado 10 point score Diagnosis unlikely with score < 5 Appendicitis Inflammatory Response Score (AIR) 8 variables on weighted ordered logistic regression analysis Includes CRP 3

Pediatric Appendicitis Risk Scores PAS score Alvarado score AIR score Symptoms Nausea or vomiting 1 1 Vomiting 1 Anorexia 1 1 Migration of pain to the 2 1 right lower quadrant Signs Pain in the right lower 2 2 1 quadrant Rebound tenderness 1 1 Light 1 Medium 2 Strong 3 Body 1 temperature >37.5 C Body 1 1 temperature >38.5 C Laboratory Tests Leukocytosis shift 1 Polymorphonuclear 1 leukocytes (>75%) 70% 84% 1 >85% 2 WBC >10 10 9 /L 1 2 10.0 14.9 10 9 /L 1 >15.0 10 9 /L 2 CRP Concentration 10 49 g/l 1 >50 g/l 2 Total Score 10 10 12 Alvarado score 1 4 Alvarado score 5 6 Alvarado score 7 10 AIR score 0 4 AIR score 5 8 AIR score 9 10 Risk of appendicitis PAS score 1 4 PAS score 5 7 PAS score 8 10 Low risk Intermediate risk High risk From: Rentea, R.M., & St. Peter, S.D. (2017). Contemporary management of appendicitis in children, Advances in Pediatrics, 64(1), 225 251. doi: http://dx.doi.org/10.1016/j.yapd.2017.03.008 Case of PAS Clinical Decision Rule to Identify Children at Low Risk for Appendicitis Eight weighted criteria for total of 12 points 1. WBC > 10 X 10 9 /L= 1 point 2. Polymorphonuclear leukocytes (>75%) = 1 point 3. Nausea or vomiting = 1 point 4. Anorexia = 1 point 5. Rebound pain = 1 point 6. History of migration of pain to RLQ = 2 points 7. Focal RLQ pain = 2 points 8. Temperature > 38.5 degrees Celsius = 1 point Higher the score higher the chance of having appendicitis Score 1 4 Low risk of having appendicitis Case of PAS 1. WBC 15 X 10 9 /L = 1 point 2. Polys 85% = 1 points 3. Nausea =1 point 4. Rebound pain = 1 point 5. History of migration of pain to RLQ = 2 points 6. Focal RLQ pain=2 points 7. Temperature 38.6 degrees Celsius = 1 point Total Points: 9 Probability of Appendicitis: High risk Pediatric Appendicitis Risk Scores Can help to protocolize care Some organizations use as part of protocols Think rule out v. rule in Case of SDS 12 yo Asian female presents to the ED CC: Abdominal pain HPI: 1 day of abdominal pain Location of pain: Initially at umbilicus and now RLQ Increasing intensity Nausea, no vomiting PMH: Healthy female, No previous hospitalizations, no previous surgeries Immunizations UTD, NKDA, Meds: None VS: T 38.5 PO, HR 98, RR 14, BP 110/60 Wt: 45 kg (50 th %ile), 155 cm HT (75 th %ile) General: Quiet child holding her cell phone Chest: BS clear and equal, RRR, no murmur Abdomen: Soft, distended, + stethoscope sign RLQ Labs: WBC 12, Neutrophils 86%, Electrolytes low CO 2, Urinalysis WNL, Urine HCG neg Radiologic: US 8 mm, non compressible, no appendicolith Question What differential diagnoses are you considering? A. Appendicitis B. Urinary Tract Infection C. Ovarian Torsion D. Gastroenteritis 4

Question What differential diagnoses are you considering? A. Appendicitis B. Urinary Tract Infection C. Ovarian Torsion D. Gastroenteritis Question What are treatment options? A. IV Antibiotics B. Appendectomy C. IV Antibiotics and Appendectomy D. IV Antibiotics and Interval Appendectomy No Surgery for Acute Appendicitis 10 studies to date have been reported evaluating nonoperative management in children Success rates range from 75 80% for antibiotics alone Increased rates of perforated appendix for failure subgroup No Surgery for Appendicitis Inclusion Criteria 7 17 years old Abdominal pain less than 48 hours with no history of chronic AP Labs WBC 5 18 Imaging Hyperemia < 1.1 cm in diameter, compressible or non compressible, no abscess, no fecalith/appendicolith, no phlegmon No preoperative concern for perforation No diffuse peritonitis Not pregnant None study: No malignancy, not currently taking antibiotics No Surgery for Appendicitis Study treatment includes 10 days of antibiotics 2 days in the hospital Feed after 12 hours of symptoms stable or improving Lurie No Surgery for Appendicitis Participated in the study for 1 year as part of the Midwestern Pediatric Surgery Consortium N=36 (25% of subjects have received IV antibiotics and no OR) Phone follow up for antibiotic subjects at 2 to 5 days after discharge and at 2 weeks and by Nationwide Children s at 1 month, 6 month and a year To date, no antibiotic subjects have failed at Lurie 1 in 4 will fail 5

Case of SDS Parents elect to have an appendectomy Child noted to have acute appendicitis Post op care No more antibiotics IV fluids until drinking well and have voided OOB and ambulate ASAP Lots of pain meds Same Day Discharge Current evolving standard for acute appendicitis Lurie LOS 20 hours Goal per standards 6 hours Strive for earlier OR times Can be all about patient and family expectations Pain management SAM s strategy give lots IV and discharge with some PO opioid (Hycet and Norco, NEVER Codeine, and rarely Ultram) Get opioid in hand early in the post op trajectory Others should be comfortable on PO before discharge Follow up Often now by phone Case of PA: When things get tricky 4 yo Hispanic male presents to the ED CC: Abdominal pain HPI: 3 days of abdominal pain Increasing intensity Increase pain with walking Location of pain: RLQ Nausea, no vomiting PMH: Healthy male with exercise induced asthma, No previous hospitalizations, no previous surgeries Immunizations UTD, NKDA, Meds: Albuterol prn wheezing last dosed three months ago VS: T 39, HR 122, RR 28, BP 110/60 Wt: 13.8 kg (60 th %ile), HT 96.5 cm (90 th %ile) General: Tired appearing male Chest: BBS clear, RRR, no murmur Abdomen: Soft, distended, diffusely tender Labs: WBC 17, Neutrophils 86%, Lymphs 10%, ANC 14.45, Electrolytes WNL, Urinalysis WNL 34 Perforated (Complicated) Appendicitis Complicated Appendicitis is defined as the presence of an abscess, phlegmon or free fluid on radiologic imaging or noted at the time of operation Time from start of symptoms till perforation is 24 36 hours Research efforts on complicated appendicitis are focusing on reducing antibiotic duration The rates of perforation have been nearly the same in the past 10 15 years Factors Increasing Risk of Perforation Age Gender Socioeconomic status Ethnic and racial background 6

Trajectory of Appendicitis Question What would be the next step in making an appropriate diagnosis? A. STAT surgical consult B. Abdominal Ultrasound C. Abdomen and Pelvis CT scan D. Observation Imaging Options Ultrasound Abdomen US abdomen CT scan Appy Abdomen Abdomen and pelvis MR abdomen CT Scan 41 7

MR Abdomen 44 MR Abdomen + No ionizing radiation + High sensitivity and specificity Lack of availability in many hospitals High cost Motion sensitivity (may require sedation for younger children) Treatment Plan Antibiotics only Antibiotics followed by interval appendectomy OR for laparoscopic appendectomy IR for drainage of abdominal abscess followed by interval appendectomy Antibiotics only Daily Ceftriaxone and Flagyl (24 hour dosing) Transition to oral antibiotics when afebrile, tolerating a diet, pain improved Oral antibiotics: Augmentin X 7 10 days No surgical removal of the appendix Antibiotics followed by interval appendectomy Daily Ceftriaxone and Flagyl Transition to oral antibiotics when afebrile, tolerating a general diet and pain improved Oral antibiotics: Augmentin to complete a 7 day course Laparoscopic interval appendectomy in 6 8 weeks 8

Appendectomy at time of presentation Daily Ceftriaxone and Flagyl x 3 5 days Laparoscopic appendectomy Post operative pain control with Tylenol, Toradol, Morphine Advance diet as tolerated Discharge home when afebrile, pain well controlled with oral pain medication and tolerating a diet Transition to oral antibiotics for discharge home to complete a 5 7 day course IR drainage of abscess Daily Ceftriaxone and Flagyl IR drainage of abscess TPA to drain if concerns for retained abscess Drain remains in place approximately 2 4 days Home on oral antibiotics when drain is removed, afebrile, eating a general diet and pain improved Oral antibiotics: Augmentin to complete a 5 7 day course +/ interval appendectomy in 6 8 weeks Back to the Case of PA Underwent an immediate laparoscopic appendectomy for perforated appendicitis Ceftriaxone and Flagyl daily dosing POD #3 Afebrile, vomiting, diarrhea, continuing to have abdominal pain POD #5 CT scan with IV and PO contrast POD #6 IR drainage of an intraabdominal abscess POD # 8 IR drain removed and was transitioned to oral Augmentin POD #9 Discharged home to complete a 7 days course of Augmentin from time of IR drainage Post perforated Appendicitis Complications Complications rates for perforated appendicitis is approximately 10 20% Abscess formation Bowel obstruction Bowel fistula formation Wound infection WHEN TO IMAGE, THAT IS THE QUESTION?? Onset of new fever Not tolerating a diet on POD #3 image on POD #5 POD #5 if still having fever, abdominal pain, decreased PO intake POD #7 if still having fever, abdominal pain, decreased PO intake No need to image POD #5 if elevated CBC and no other symptoms POD #7 if elevated CBC and no other symptoms 54 9

Post operative Appendectomy CT Scan ~ 35% 55 Post operative IR Drainage of Intraabdominal Abscess US guided drain placement Anaerobic and aerobic cultures obtained E. coli Bacteroides Klebsiella C. difficile Enterobacter Pseudomonas Drain remains in place till output decreases Occasional TPA instillation A lot of Work to be Done! References No consensus exists on optimal management of complicated appendicitis Decrease the rate of perforated appendicitis Develop standard treatment protocols Initial imaging Antibiotics Length of antibiotics Repeat imaging Aguayo, P., Alemayehu, H., Desai, A.A., Fraser, J.D., & St. Peter. (2014). Initial experience with same day discharge after laparoscopic appendectomy for perforated appendix. Journal of Surgical Research, 186(2), 535. Bundy, D.G., Byerley, J.S., Liles, E.A., Perrin, E.M., Katznelson, J., & Rice, H.E. (2007). Does this child have appendicitis? Journal of the American Medical Association, 298, 438 451. Caruso, A.M., Pane, A., Garau, R., Atzori, P., Podda, M., Casuccio, A., & Mascia, L. (2017). Acute appendicitis in children: not only surgical treatment, Journal of Pediatric Surgery, 52(3), 444 448. doi: https://doi.org/10.1016/j.jpedsurg.2016.08.007 Helling, T.S., Soltys, D.F., & Seals, S. (2017). Operative versus non operative management in the care of patients with complicated appendicitis. The American Journal of Surgery, 214, 1195 1200. Nielsen, J.W., Kurtovic, K.J., Kenney, B.D., & Diefenbach, K.A. (2016). Postoperative timing of computed tomography scans for abscess in pediatric appendicitis. Journal of Surgical Research, 200, 1 7. Otero H.J., & Crowder, L. (2017). Imaging utilization for the diagnosis of appendicitis in stand alone Children s Hospitals in the United States: Trends and costs, Journal of the American College of Radiology, 14(5), 603 608. doi: http://dx.doi.org/10.1016/j.jacr.2016.12.013. Podevin, G., De Vries, P., Lardy, H., Garignon, C., Petit, T., Azzis, O., Mcheik, J., & Roze, J.C. (2017). An easy tofollow algorithm to improve pre operative diagnosis for appendicitis in children, Journal of Visceral Surgery, 154(4), 245 251. doi: http://dx.doi.org/10.1016/j.jviscsurg.2016.08.011 10

References Rentea, R.M., & St. Peter, S.D. (2017). Contemporary management of appendicitis in children, Advances in Pediatrics, 64(1), 225 251. doi: http://dx.doi.org/10.1016/j.yapd.2017.03.008 Saluja, S., Sun, T., Mao, J., Steigman, S.A., Oh, P.S., Yeo, H.L., Sedrakyan, A., & Merianos, D.J. (2017). Early versus late surgical management of complicated appendicitis in children: A statewide database analysis with one year followup. Journal of Pediatric Surgery. Doi: https://doi.org/1.1016/j.ped.surg.2017.09.012 Wu, J.X., Sacks, G.D., Dawes, DeUgarte, D., & Lee, S.L. (2017). The cost effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children. Journal of Pediatric Surgery, 52(7), 1135 1140. doi: http://dx.doi.org/10.1016/j.jpedsurg.2016.10.009. Xu, J., Adams, S., Liu, Y.C., & Karpelowsky, J. (2017). Nonoperative management in children with early acute appendicitis: A systematic review, Journal of Pediatric Surgery, 52(9), 1409 1415. doi: http://dx.doi.org/10.1016/j.jpedsurg.2017.05.003 Yu, Y.R., Smith, C.M., Ceyanes, K.K., Naik Mathuria, B.J., Shah, S.R., Vogel, A.M., Carberry, K.E., Nuchtern, J.G., & Lopez, M.A. (2018). A prospective same day discharge protocol for pediatric appendicitis: Adding value to a common surgical condition. Journal of Pediatric Surgery, 53(1), 36 41. doi: https://doi.org/10.1016/j.jpedsurg.2017.10.011 Sarah smartin@luriechildrens.org Kelly kfinkbei@luriechildrens.org Speaker Contact Information 11