Rebound Tenderness in Diagnosis of Appendicitis in Children

Rebound Tenderness in Diagnosis of Appendicitis in ChildrenAbdominal wo(e) in the ass is a common turn ination within the accident and fatality section A+E and specialist obtains working in this environment need to be long-familiar and confident in dealing with this getation (Hibberts and Bushell 2007, Pines, Pines, Hall, Hunter, Srinivasan and Ghaemmaghami 2005). Abdominal pain basin be associated with a wide variety of surgical and nonsurgical conditions, with the virtually prevalent cause being subtile appendicitis (Lin, Chen, Chung, Ho, and Lin, 2009). The diagnosing of appendicitis is formulated from unverifiable and objective data including a patients memoir, type AB examination, science laboratory investigations and contracts and symptoms. This appellative result critically analyse the clinical skill of testing for summon warmness and its relevance to diagnosing appendicitis in children.The clinical diagnosis of crafty appendicitis in children is difficul t for many practiti starrs (Broek, Ende, Bijnen, Breslau and Alkmaar, 2004). Between the years 2008 and 2009 the number of patients presenting to A+E within the UK who were diagnosed with appendicitis was 44,244 (NHS Information Centre, 2009). This equates to almost 0.3% of all presentations in A+E everyplace one year. Approximately 9,300 of this population were amidst the ages of 0 and 14 years senior (NHS Information Centre, 2009). However up to 25% of these 9,300 children with hazard appendicitis have a normal appendix at operation (Smink, Finkelstein, Garcia-Pena, Shannon, Taylor, and Fishman, 2004). Furthermore, the 25% of paediatric negative appendectomies now result in considerable clinical and economic costs to the NHS (Koepsell, 2002). These substantial figures are one of the primary reasons for specifying this assignment on children. In addition, the scope of practice within A+E covers paediatrics for many adult qualified nurses and adult trained nurse practitioners. It is thitherfore imperative that the companionship base for all A+E staff encompasses paediatrics at an advanced level as hygienic (Cleaver, 2003).The overall the true for the clinical examination in diagnosing sharp appendicitis has been reported to be between 54% and 70% in children (Birkhahn, Briggs, Datillo, avant-garde Deusen and Gaeta, 2006). In addition Whisker, Luke, Hendrickse, Bowley and Lander (2009) indicate that sole(prenominal) 4% of children have a miss-diagnosis of appendicitis in specialist paediatric centres, compared to 20% in partition usual hospitals. Despite the uncertainty of the diagnosis and the cost of miss-diagnosis to the NHS, appendicitis requires urgent treatment (Williams, et al., 2009). This is aside-of-pocket to the risk of perforation, which occurs in approximately one third of cases in children (Neilson, et al., 1990). therefore the need for a good clinical assessment at stolon contact in A+E is needed to provide a correct management plan and reduce on costs for the NHS.An ab examination should be performed where possible in a warm, well illumine room with the patient well-draped and relaxed (Bickley, 2009). Initially the practitioner should undertake inspection, auscultation and percussion of the consentaneous nine sections of the abdomen (Lippincott Williams and Wilkins, 2008). The final aspect of the type AB examination should be palpation as this has the likely to be the most painful (Allan, 2008). t effective exploration is a process which should always be commenced away from the site of pain, as this will supply the patient to gain some reassurance from the practitioner and military service them to relax (Bickley, 2009, Hibberts and Bushell, 2007). The practitioner should utilise the palmer surfaces of the fingers to identify any abnormal signs (Bickley, 2009). much special palpation techniques layabout help to diagnose appendicitis, such as backfire warmness (Bickley, 2009). This is performe d by pressing s down in the mouthly and firmly to a detail area and then withdrawing them quickly (Bickley, 2009). Practitioners should observe the patient and require if pain was worse on pressing or letting go (Hibberts and Bushell, 2007). However, Bickley (2009) suggests that if any of the previous examinations such as light or productive palpation are positive then this should non be undertaken as it will cause un cod pain for the patient.The whole process of abdominal examination in children follows the same arranging as in adults. However, the causes of abdominal pain in children are often different, encompassing a unsubtle range of lancinating and chronic diseases (Bickley, 2009). Therefore it maybe pertinent to suggest that more emphasis should be placed special techniques such as checking for rebound essence rather than abdominal palpation and testing for rebound.The initial discovery and accreditation of rebound tenderness (also known as Blumbergs sign) is credited to a German surgeon called Jacob Moritz Blumberg (1873 1955). Many articles make reference to Blumbergs sign just there appears to be no relevant literature, research or deduction base to bide this surgeon was the gentleman who discovered this sign (Mantzaris, Anastassopoulos, Adamopoulos and Gardikis, 2008).A report card undertaken by (Williams, et al., 2009) showed that out of 98 children who had acute appendicitis 91% had right on lower quarter-circle tenderness on palpation however only 30% had rebound tenderness. another(prenominal) consume by Lin, Chen, Chung, Ho, and Lin (2009) also suggested that 43.4% of the 53 children examined with appendicitis had rebound tenderness. So both these studies suggest that positive rebound tenderness is an indication of an acute appendicitis in children and and so cannot be ruled out of an initial differential diagnosis.Golledge, Toms, Franklin, Scriven and Galland (1996) specifically evaluated the cats eye symptom (pain going over a bump in the road), the cough sign, right lower quadrant pain to percussion, rebound tenderness and guarding. The data from this evaluation suggested that rebound tenderness had a likelihood ratio of 7.4 compared to the other signs which had likelihood ratios of between 1.1 and 4.1. This data accordingly suggests that rebound tenderness is a very useful sign in the diagnosis of acute appendicitis, but that the other signs and symptoms are not (Moyer, et al., 2001). Overall rebound tenderness is useful sign for diagnosing appendicitis when there is a high suspicion of appendicitis and is accompanied with other diagnostic indicators (Moyer, et al., 2001).Another presentation to be considered in relation to abdominal pain and rebound tenderness is the succession of the pain experienced by the child. A line of business undertaken by Oshea, Bishop, Alario and Cooper (1988) involved 246 children from 13 to 18 years old who presented to the emergency department with a history of less th an one week of abdominal pain. Results showed that the likelihood ratio of pain was greater when the child had the pain for more than 12 hours (Likelihood ratio 1.3) compared to less than 12 hours (Likelihood ratio 0.64). by and by in the take aim pain distance was evaluated at less than 24 hours and more than 24 hours, with their likelihood ratios being 0.83 and 1.2 respectively. When compared to Andersson, et al. (1999) study of 502 patients aged 10 to 86 the greatest likelihood ratio was 1.7 at 7-12 hours after aggression of pain. establish on both studies it is very difficult to see how duration of pain can lead to the diagnosis of appendicitis. Therefore, practitioners essential not allow the duration of pain to prevent any further investigation into the diagnosis (Moyer, et al., 2001).Another symptom which could possibly indicate the diagnosis of appendicitis is fever (Gwynn, 2001). Cardall, Glasser and Gusss (2004) study evaluated both hundred and ninety three people a ged between 7 and 75 who presented to the emergency department with suspected appendicitis. Temperatures were classed at greater than 99oF or less than 99oF. The study showed that 27% of patients whos temperature was 99oF. When the results were analysed in terms of specific temperature intervals, the highest likelihood ratio (3.18) was found in patients with temperatures greater than 102 F. However, Bergerons (2006) study on clinical judgement suggests there is no clinical treasure with temperature as there is minimal sensitivity and specificity in the diagnosis of appendicitis. Therefore, as with duration of pain duration and levels of WBCC, temperature as a wiz entity has little diagnostic utility in the diagnosis of appendicitis unless it is combined with other signs and symptoms such as rebound tenderness (Cardall, Glasser and Guss, 2004).For many years laboratory tests such as white stemma cell look (WBCC) leukocytes and C-reactive protein (CRP) have been used to support a diagnosis, but the considerable overlap with other inflammatory conditions accounts for the low specificity and positive predictive value of these tests (Stefanutti, Ghirardo and Gamba, 2007). Recent studies on adult patients who present with clinical signs and symptoms indicating acute appendicitis, show that appendicitis can be excluded if both leukocyte count and C-reactive protein value are normal (Gronroos, 2001). However, Stefanutti, Ghirardo and Gamba, (2007) suggest that only a fewer studies have been reported in paediatric patients and the role of WBCC and CRP in excluding acute appendicitis in children has not been confirmed. According to Andersson et al. (1999) children who present with signs and symptoms of appendicitis such as rebound tenderness and have a WBCC of 15000 only moderately increases the estimated risk of appendicitis. This therefore shows that only at the extremes of the WBCC does this diagnostic indicator appear useful (Moyer, et al., 2001). Therefore, w ayward to adult patients, normal leukocyte count, WBCC and CRP value cannot effectively exclude acute appendicitis in children.Another usual predictor of appendicitis is vomiting (Bergeron, Richer, Gharib and Giard, 1999). The study by Andersson et al. (1999) measured the likelihood ratio for appendicitis in a patient with vomiting compared to one with no vomiting to be 1.8. In addition Reynolds and Jaffe (1992) study suggests that a combination of four predictors including vomiting right lower quadrant pain, abdominal tenderness, and abdominal guarding. More specifically 97% of the 377 children studied who were diagnosed with appendicitis had two or more of these predictors. Therefore, a patient who presents to A+E with less than two of the above predictors is quite unlikely to have appendicitis.Alvarado (1986) conducted a retrospective study of 305 patients hospitalised with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analysed fo r specificity, sensitivity, predictive value, and interchangeable probability.Their importance, according to their diagnostic weight, was take rootd as follows localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain (Alvarado, 1986). This make headway system shown below is deemed by many surgeons as an easy supporter for supporting the diagnosis of acute appendicitis ( khan and Rehman, 2005).A study undertaken by Baidya, Rodrigues, Rao and Khan (2007) investigated the diagnostic accuracy of Alvarado marker system. The results showed that a gradation of 7 for an appendicitis was 88.2% correct in diagnosis. However, the diagnostic accuracy of an Alvarado score Despite recent advances in knowledge and diagnostic investigations, a population-based analysis in the United States found that the incidence of unnecessary appendectomy has not changed (Flum, Mo rris and Koepsell, 2001). Therefore to increase diagnostic accuracy, modernistic modalities such as ultrasound descrys have been tuckd (Broek, Ende, Bijnen, Breslau and Alkmaar, 2004). Kaneko and Tsuda (2004) conducted a 10-year study use ultrasound scans to diagnose appendicitis in children and are convinced that ultrasound scans can identify inflamed appendices with 100% sensitivity and can also determine the severity as well. However Smink, Finkelstein, Garcia-Pena, Shannon, Taylor and Fishman (2004) suggest that the use of ultrasound has not rock-bottom negative appendectomies as similar negative rates were present over a decade ago. Therefore on the basis of the operational evidence, patients presenting to A+E with a strong clinical case of appendicitis should be referred direct to the surgeon without an ultrasound.In addition to the use of ultrasound scan the use of computed tomography (CT) has been recently studied and evaluated. There are presently two perspectives in the literature regarding the use of CT scan for the diagnosis of acute appendicitis one supporting its routine use due to the decreased incidence of negative appendectomies, and the other one against its routine use due to the increased cost and delay in surgical management (Ceydel, Lavotshkin, Yu and Wise, 2006). In addition the benefits of imaging eliminating inpatient observation and unnecessary surgery must be weighed against the malignancy risk from radiation, as well as excitation of rectal contrast administration (Smink, Finkelstein, Garcia-Pena, Shannon, Taylor and Fishman, 2004). Ceydel, Lavotshkin, Yu and Wises (2006) retrospective study showed that the negative appendectomy rate was much less in patients who had CT scans (7.6%) compared to the non CT scan group (24%). Therefore clinicians within A+E use their clinical judgement and place emphasis on the importance of routine history and an exact forcible examination utilising CT scans for atypical cases of acute appen dicitis (Gwynn, 2001).shortly within the A+E department there is no specific pathway or tool for ruling in acute appendicitis in paediatrics. In addition Birkhahn, Briggs, Datillo, Van Deusen and Gaeta (2006) suggest that no major medical exam association or professional organisation currently endorses a exchangeable pathway for the evaluation of patients with suspected appendicitis. With up to 25 % of children having negative appendectomies it is therefore of clinical and financial value to consider the use of a scoring system to admit or discharge children who present with a possible acute appendicitis. Current systems are in place for other potential conditions such as myocardial infarctions, pancreatitis and pneumonia. These other systems have been audited locally and nationally and are currently working well within the trust, therefore the plans to introduce the Alvarado scoring system will be put forward in the next review of clinical practice meeting between nursing and m edical staff.To conclude, this assignment demonstrates that for an emergency department practitioner in a fast paced A+E setting, the accurate diagnosis of acute appendicitis system a challenge for the paediatric age group. An accurate history and physical examination, which as highlighted can be challenge in younger patients plays an meaning(a) role in the diagnosis of early acute appendicitis (Mallick, 2008). Physical clinical signs elicited upon examination provide the practitioner with a good taste to expected diagnosis. However, the usefulness of rebound tenderness as a single examination has minimal clinical value. The whole patient picture which encompasses an accurate history, clinical examination, laboratory investigations and possible diagnostic imaging is therefore life-sustaining to providing a correct diagnosis.The use of clinical scoring systems like the Alvarado score can be a cheap and quick tool to restrain in emergency departments to rule in acute appendicitis . This scoring system includes many aspects such as clinical history, rebound tenderness and laboratory investigations. This allows for observation and critical re-evaluation of the evolving clinical picture. Its application improves the overall diagnostic accuracy and consequently reduces negative appendectomies (Khan and Rehman, 2005). In clinical cases where the practitioner is unsure if the actual diagnosis is acute appendicitis other diagnostic imaging studies such as ultrasound and CT may be undertaken. This must only then be considered once a thorough clinical examination has not provided any indication for acute appendicitis and the benefits out way the risks.ReferencesNHS Information Centre. (2009). chief(a) diagnosis summary. Retrieved November 21, 2009, from Hospital Episode Online http//www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937categoryID=202Allan, B. (2008). History and examination (3rd ed.). Philadelphia Mosby.Alvarado, A. (1986). A practical score fo r the early diagnosis of acute appendicitis. Annals of necessity Medicine, 15 (5), 557-564.Andersson, R., Hugander, A., Ghazi, S., Ravn, H., Offenbartl, S., Nystrm, P., et al. (1999). 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