Appendicitis is the most common cause of an acute surgical abdomen in children.
It occurs when the appendix, a small tube which protrudes from the large intestine,
becomes acutely inflamed.
Appendicitis is usually caused by some sort of obstruction of the appendix or it’s
opening (appendiceal lumen) by feces, any foreign object or body, or, in a few cases,
a tumor. It can also be caused by a twist of the appendix, which can result in ischemic
necrosis, a disease in which blood vessels are blocked by this twist so blood supply
to the organs decreases and many cells die.
Though appendicitis usually occurs in children over the age of two years and peaks
during the teen and young adult years, it can occur in infants and toddlers. The
disease is more commonly found in males than in females. The exact incidence of
appendicitis is unknown. In terms of genetics, appendicitis has been found to show
a familial tendency.
The typical first warning sign of appendicitis is dull pain around the navel. The
pain continues and often becomes more localized at the site of the appendix, downward
and to the right side of the navel. Usually, pressure applied to this area will
cause tenderness and pain. It is important to note that there is variability in
the location of the appendix and so the location of the pain may also vary. A loss
of or reduction in appetite is always present. Other symptoms may include: nausea,
vomiting, and a low-grade fever, however, the vomiting never precedes the pain.
The differential diagnosis for appendicitis is extensive. In the case of gastroenteritis
(commonly called the stomach flu), vomiting and diarrhea usually occur before the
onset of pain. Constipation can often be confused for appendicitis however this
its pain pattern is not located in the lower right quadrant of the abdomen. A pneumonia
in the right lower lobe of the lung can present with symptoms similar to appendicitis.
Other conditions that may mimic appendicitis are: Urinary tract infection, inflammatory
bowel disease, sickle cell crisis, diabetic ketoacidosis, ovarian torsion, ectopic
pregnancy, dysmenorrhea, Mittelschmerz, intussusception, Meckel’s diverticulitis
or post-surgical adhesions in the abdomen.
If symptoms are present, the health care provider may perform tests while the patient
is lying on his or her back to determine the severity and proximity of the pain
such as: extending the right leg or rotating a flexed leg. A rectal exam may show
right-sided tenderness. He or she may also choose to perform an abdominal ultrasound,
an abdominal CT scan, or an exploratory laparotomy, a procedure using a small camera
and an incision. Your health care provider may also choose to perform a chest x-ray,
a complete blood count (CBC) and/or a urinalysis and urine culture. A pelvic examination
may be indicated in a female adolescent with abdominal pain.
Most commonly, appendicitis is treated by a surgery called an appendectomy whereby
the appendix is removed (open surgery). More recently, surgeons have performed
laparascopic surgery whereby smaller incisions are made to pass a camera and surgical
instruments. A systematic review of 5 studies in 436 children aged 1 to 16 years
found that laparoscopic surgery significantly reduced the number of wound infections
and the length of hospital stay compared with open surgery. The review did not find
any significant difference between laparoscopic surgery and open surgery for intra-abdominal
abscesses, in postoperative pain, and in the time to mobilization.
Another systematic review of several studies found that prophylactic antibiotics
reduce the number of wound infections in children with complicated appendicitis
compared with no antibiotics. Further studies are under way to determine whether
antibiotics in children with simple appendicitis are indicated.
Due to the variability in symptoms upon presentation and the subsequent progression
of symptoms in young children appendicitis sometimes is not diagnosed in time, causing
the intestines to perforate before surgery can be performed. Other complications
of the disease include peritonitis (an infection in the intra-abdominal fluid and
tissues, and/or decay of the intestines (gangrene).
Studies have been done in adults whereby antibiotics were given to try to avoid
surgery, but the recurrence rate was too high to make this a viable option. At the
present time, there is no evidence that dietary or lifestyle regimens will help
to prevent appendicitis.
Hoekelman RA, Blatman S, Friedman SB, Nelson NM, Seidel HM. Primary Pediatric Care 1987 C.V. Mosby
Suerland SR, Lefering R, Neugebauer EAM. Laparoscopic vs. open surgery for suspected appendicitis. The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley and Sons
Milewczyk M, Michalik M, Ciesielski M. A prospective, randomized, unicenter study comparing laparoscopic and open treatments of acute appendicitis. SURG Endosc 2003; 37: 1317-1320
Copyright 2012 Daniel Feiten M.D., All Rights Reserved
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