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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