Appendicitis and surgical abdomen — formative SAQs

SAQ 1 — The school-aged child with migratory pain (10 marks, 15 minutes)

A previously well nine-year-old boy has eighteen hours of peri-umbilical pain that has moved to the right iliac fossa, with anorexia, nausea and a temperature of 38.4 degrees. He is tender at McBurney point with rebound and wince on hopping. His white cell count is 13 with a neutrophilia. [1]

a) Calculate his Pediatric Appendicitis Score, stating how many points each feature earns, and interpret the result. (3 marks) [1]

b) Name the most appropriate first-line investigation and the diagnostic finding you expect, and state the next investigation if it is non-diagnostic. (3 marks) [6]

c) Outline your resuscitation and analgesia before any operation, including the fluid you would give. (2 marks) [3]

d) Describe the definitive treatment options for his uncomplicated appendicitis, the evidence that frames the choice, and how you would involve the family in the decision. (2 marks) [5]

SAQ 2 — The young child, perforation and the bilious vomit (10 marks, 15 minutes)

A previously well, irritable three-year-old has twenty-four hours of crying, refusing to walk and a low-grade fever, and is now diffusely tender with guarding. Separately, a four-month-old is brought in with a single green-coloured vomit, and a colleague plans to manage it as gastroenteritis. [3]

a) Why is this three-year-old likely to be perforated at presentation, and how does the perforation rate vary with age? (3 marks) [3]

b) Outline the management of a child with perforated appendicitis, including surgery and the antibiotic strategy. (3 marks) [3]

c) Explain why a bilious vomit in a previously well infant must not be reassured as gastroenteritis, and outline your immediate approach. (4 marks) [3]