Appendicitis in Children
What is appendicitis?
Appendicitis is a painful swelling and infection of the appendix (a narrow, finger-like pouch that branches off the large intestine). Doctors are not really sure what the appendix does, but removing it is not harmful. Appendicitis is the most common cause of emergency surgery in childhood.
What causes appendicitis?
Appendicitis occurs when the interior of the appendix becomes filled with something that causes it to swell, such as mucus, stool, or parasites. The appendix then becomes irritated and inflamed. The blood supply to the appendix is cut off as the swelling and irritation increase. Adequate blood flow is necessary for a body part to remain healthy. When the blood flow is reduced, the appendix starts to die. Rupture (or perforation) occurs as holes develop in the walls of the appendix, allowing stool, mucus, and other substances to leak through and get inside the abdomen. An infection inside the abdomen known as peritonitis occurs when the appendix perforates.
What are the risk factors for appendicitis?
Appendicitis affects 1 in 1,000 people living in the U.S. and is a common reason for a child to need emergency abdominal surgery. Most cases of appendicitis occur between the ages of 10 and 30 years.
Why is appendicitis a concern?
An irritated appendix can rapidly turn into an infected and ruptured appendix, sometimes within hours. A ruptured appendix can be life-threatening. When the appendix ruptures, bacteria infect the organs inside the abdominal cavity, causing peritonitis. The bacterial infection can spread very quickly and be difficult to treat if diagnosis is delayed.
What are the symptoms of appendicitis?
The following are the most common symptoms of appendicitis. However, each child may experience symptoms differently. Symptoms may include:
Pain in the abdomen which:
May start in the area around the belly button, and move over to the lower right-hand side of the abdomen, but may also start in the lower right-hand side of the abdomen.
Usually increases in severity as time passes.
May be worse with moving, taking deep breaths, being touched, and coughing or sneezing.
May spread throughout the abdomen if the appendix ruptures.
Nausea and vomiting
Loss of appetite
Fever and chills
Changes in behavior
Diarrhea or constipation
When should your child's health care provider be called?
Since an infected appendix can rupture and be a life-threatening problem, please call your health care provider or go to the emergency room immediately if you think your child has appendicitis.
How is appendicitis diagnosed?
In addition to a complete medical history and physical examination, diagnostic procedures for appendicitis may include:
Abdominal ultrasound. A diagnostic imaging technique which uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels.
Computed tomography scan of the abdomen, with or without contrast (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
Other tests may include:
Blood tests. These tests evaluate the infection, or to determine if there are any problems with other abdominal organs, such as the liver or pancreas.
Urinalysis. This test detects a bladder or kidney infection, which may mimic the symptoms of appendicitis.
Symptoms of appendicitis may resemble other conditions or medical problems. Consult your health care provider for a diagnosis.
Treatment for appendicitis
Specific treatment for appendicitis will be determined by your child's health care provider based on the following:
The extent of the problem
Your child's age, overall health, and medical history
The opinion of the surgeon and other health care providers involved in the child's care
Your child's tolerance for specific medications, procedures, or therapies
Expectations for the course of the problem
Your opinion and preference
Because of the likelihood of the appendix rupturing and causing a severe, life-threatening infection, health care providers will recommend that the appendix be removed with an operation.
The appendix may be removed in two ways:
Open method. Under anesthesia, an incision is made in the lower right-hand side of the abdomen. The surgeon finds the appendix and removes it. If the appendix has ruptured, a small drainage tube may be placed to allow pus and other fluids that are in the abdomen to drain out. The tube will be removed in a few days, when the surgeon feels the abdominal infection has subsided.
Laparoscopic method. This procedure uses several small incisions and a camera called a laparoscope to look inside the abdomen during the operation. Under anesthesia, the instruments the surgeon uses to remove the appendix are placed through a single or several small incisions, and the laparoscope is placed through another incision. This method is not usually performed if the appendix has ruptured.
After surgery, children are not allowed to eat or drink anything for a specified period of time so the intestine can heal. Fluids are given into the bloodstream through small plastic tubes called IVs until your child is allowed to begin drinking liquids. Your child will also receive antibiotics and medications to help him or her feel comfortable through the IV. Eventually, children will be allowed to drink clear liquids (such as water, sports drinks like Gatorade or PowerAde, or apple juice), and then gradually advance to solid foods.
Health care providers may recommend nonoperative treatment of a ruptured appendix if there is a contained abscess and the child is stable. In some cases in which the appendix has ruptured and formed a localized abscess, a health care provider may recommend that the appendix not be removed right away. Instead, your child may receive treatment with intravenous antibiotics given through a intravenous catheter called a peripherally inserted central catheter or PICC line for about 10 to 14 days. This may be done along with CT or ultrasound-guided drainage of the abscess. This allows the infection and inflammatory process to resolve. Your child will then undergo an elective (planned) interval appendectomy 6 to 8 weeks after.
A child whose appendix ruptured will have to stay in the hospital longer than the child whose appendix was removed before it ruptured. Some children will need to take antibiotics by mouth for a period of time specified by the health care provider after they go home.
What happens after my child leaves the hospital?
Your health care provider will generally recommend that your child not do any heavy lifting, play contact sports, or "rough-house" for several weeks after the operation. If a drain is still in place when your child goes home, he or she should not take a tub bath or go swimming until the drain is removed.
Your child may need to take antibiotics at home to help fight the infection in the abdomen.
You will be given a prescription for pain medication for your child to take at home to help him or her feel comfortable. Some pain medications can make a child constipated, so ask your health care provider or pharmacist about any side effects the medication might have. Moving around after surgery rather than lying in bed can help prevent constipation. Drinking fruit juices and eating fruits, whole grain cereals and breads, and vegetables after being advanced to solid foods can help with constipation as well.
Most children who have their appendix removed will have no long-term problems.