Appendicitis

The history and physical exam, including rectal (and pelvic exam in females), are diagnostic of appendicitis in 80% of the cases. Perforation often follows the onset of symptoms in 24-48 hours. Beyond the neonatal period, but <2 years old, gastroenteritis and intussusception are also part of the differential diagnosis of abdominal pain.

Fever, vomiting, irritability, lethargy with right lower quadrant (RLQ) tenderness and guarding are diagnostic of appendicitis in the very young patient until proven otherwise.
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Masses may be felt on rectal exam in 2-7% of younger patients with appendicitis.

Children Older than 2 years old present with a perforated appendix about 30-60% of the time. This incidence declines as the age of the child increases.

Lower abdominal pain in the adolescent female may be caused by pelvic inflammatory disease (PID), ovarian cysts, ovarian torsion, ectopic pregnancy, or mittelschmerz (pain with ovulation).

A WBC >15,000 supports the need for surgery, but a normal WBC and differential does not exclude appendicitis.
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Intussusception
Intussusception is the most common cause of bowel obstruction between 2 months and 5 years of age. The most vulnerable age group is 4-10 months old, but children up to 7 years old may be at risk.

Intussusception is characterized by vomiting, colicky abdominal pain (85%) with drawing up of the legs, and currant jelly stools (60%). Fever is common. Lethargy, dehydration, obtundation and/or coma may occur in younger infants.

The abdomen may be soft and nontender between episodes of colicky pain, but eventually it becomes distended. A sausage-shaped mass in the right upper quadrant (RUQ) may be palpable.

Intussusception may sometimes be palpated during rectal examination, and three percent of intussusceptions may prolapse.

Ninety-five percent of intussusceptions are located at the ileocecal junction, 5% are found elsewhere in the GI tract.
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Abdominal X-ray

The leading edge of the intussusception is usually outlined with air, which will establish the diagnosis. Often there are radiographic signs of bowel obstruction.

When the plain abdominal x-ray is normal, intussusception cannot be excluded without a barium enema.
Treatment usually consists of radiologic reduction using air and fluoroscopy, which is effective in 80-90%. Radiographic reduction is contraindicated if the patient has evidence of peritoneal irritation or toxicity. Under these conditions, surgery must be considered.
Abdominal pain

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