Appendicitis and surgical abdomen — branching viva

Opening — framing the problem

The examiner begins: a previously well nine-year-old 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, and is tender at McBurney point with a wince on hopping. Talk me through your approach. [1]

I would frame this as acute appendicitis, the commonest abdominal surgical emergency of childhood, and recognise the migratory pain with anorexia and localised tenderness as itself the key clue. My priorities would be to assess and resuscitate, to score with the Pediatric Appendicitis Score, to confirm with ultrasound first, and to involve the paediatric surgeon early, because timely appendicectomy prevents perforation and a missed surgical abdomen costs bowel. [1] [3]

Branch A — scoring and stratifying risk

How would you score him, and what does the score tell you? [2]

I would apply the ten-point Pediatric Appendicitis Score. He earns one point each for nausea, migration of pain, anorexia, fever of 38 degrees or more and a left-shifted white cell count, and two points each for right iliac fossa tenderness and for cough, percussion or hopping tenderness. A score of 7 or above is high probability, 2 or below is low, and the broad middle needs imaging or active observation, though the score never rules out appendicitis on its own. [1] [2]

Branch B — the imaging pathway

How would you confirm it, and what if the first test is not diagnostic? [6]

I would arrange an abdominal ultrasound as the first-line investigation and expect a non-compressible blind-ending tube over 6 millimetres with wall thickening. If the ultrasound is equivocal or non-diagnostic and clinical concern persists, magnetic resonance imaging is the preferred second-line test in children because it avoids ionising radiation and achieves sensitivity and specificity in the high nineties, matching computed tomography. [6] [3]

Branch C — resuscitation and the myth that analgesia hides the abdomen

What would you do before any operation, and does analgesia delay the diagnosis? [3]

I would keep him nil by mouth, secure intravenous access, and give effective analgesia because the evidence is clear that opioid analgesia does not obscure the examination or delay the diagnosis. I would correct dehydration with a 10 to 20 mL per kilogram isotonic crystalloid bolus reassessed for response, check the glucose, and have the surgeon involved early, starting broad-spectrum antibiotics if perforation is suspected. [3] [1]

Branch D — the definitive treatment and the shared decision

The ultrasound confirms appendicitis. What are the options, and how do you choose? [5]

For confirmed uncomplicated appendicitis, laparoscopic appendicectomy is the standard definitive treatment with a short stay and a low wound infection rate. The alternative is non-operative antibiotics, which the landmark trial showed resolves about three-quarters of uncomplicated cases at one year, though long-term follow-up shows recurrence accumulates to a substantial minority. The choice is a shared decision, and a fecalith makes non-operative failure more likely, so an informed family decides between surgery and antibiotics with the trade-off made explicit. [5] [9]

Closing — the pivot to the young child and the bilious vomit

Now an irritable three-year-old refuses to walk and is guarded, and separately a four-month-old brings up a green vomit. What changes? [3]

The three-year-old is likely perforated at presentation, because the under-five child has a short, atypical history and presents late, with perforation in roughly half to two-thirds. I would resuscitate, give broad-spectrum antibiotics, and arrange laparoscopic or open appendicectomy with washout and a prolonged antibiotic course. For the bilious vomit, I would treat it as malrotation with midgut volvulus until proven otherwise, arrange urgent upper gastrointestinal contrast imaging, and call the surgeon at once, because the midgut can ischaeme within hours and a bilious vomit must never be reassured as gastroenteritis. [3] [2]