Appendicitis

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The appendix is a blind –ended tube connected to the cecum (a pouch like structure of the colon). The cecum is located at the junction where the ileum (last part of the small intestines) and the ascending colon (the first part of the large intestine) connect to one another. Appendicitis is an inflammation of the appendix. Statistically, it is the most common emergency abdominal surgery in children, with up to 80,000 cases diagnosed in our country each year. It affects males and females equally with the median age of diagnosis being 10 years old.

Symptoms

The initial presentation is pain in the mid-section of the abdomen, followed by nausea, pain in the right lower quadrant of the abdomen, vomiting and fever. Appendix perforation is known to occur within 48 hours of the complaint of pain. Complication that can arise from a perforated appendix includes, abscess, enterocutaneous fistula (which is an abnormal passageway between two organs), peritonitis, partial bowel obstruction / ileus and phlegmon. A phlegmon, as defined by Wikipedia, is a spreading diffuse inflammatory process with formation of purulent exudate or pus. Other symptoms you might see includes stooped posture, loss of appetite, constipation or diarrhea, pallor, fast heart rate and fast breathing, rigid abdomen, irritability and lethargy.

The cause of appendicitis is obstruction of the lumen of the appendix. This can be the result of hardened fecal material (fecalith) getting stuck in the appendix. Sometimes swollen lymphoid tissue, resulting from a viral infection, may also obstruct the appendix. Pinworms have also been known to obstruct the appendix, however, this is a rare occurrence. What tends to happen afterwards is the outward flow of secretions produced by the appendix becomes blocked and then pressure builds up within the lumen. The blood vessels within the appendix become compressed due to the pressure. This leads to ischemia and necrosis with the end results being perforation and rupture, and then, bacteria escaping into the peritoneal cavity.

Diagnosis

Diagnosing appendicitis is not always easy because the symptoms associated with the disease also mimic symptoms associated with other disease processes such as pelvic inflammatory disease, irritable bowel disease, and urinary tract infections, just to name a few. The diagnosis is based, for the most part, on a history and physical exam. Laboratory studies can be helpful in differentiating the cause of symptoms, particularly the CBC or complete blood cell count. An elevated white blood cell count is often seen with appendicitis but it not necessarily specific to the disease. Imaging studies, such as a CT (computed tomography) and ultrasonography (an ultrasound) of the abdomen is often employed.

Treatment

Treatment for appendicitis will vary depending on whether or not, the appendix has perforated or not. If it has not been perforated or ruptured, then rehydration, antibiotics and surgical removal or an appendectomy is indicated. The appendix can be removed using a laparoscope in this case. The advantage to this approach is a shorter hospital stay, recovery time is rapid and a one-time dose of antibiotics are indicated.

If, the appendix is ruptured, additional treatment modalities has to be employed to avoid complications. IV antibiotics are given preoperatively as well as postoperatively for several days. Your child will be given IV fluids and electrolytes to facilitate rehydration. A nasogastric tube (NG tube) will be inserted to facilitate gastric decompression because usually peristalsis or the normal passage of stomach content through the gastrointestinal tract is very slow and in many cases, completely stops. This tube, which is inserted through the nasal passage down to the stomach, may in place for several days depending on how well your child progresses. Resuming normal activities such as moving around in bed and walking will help facilitate the return of peristalsis. Typically, the conventional incision in the lower right quadrant of the abdomen is the approach taken, however, some surgeons will use the laparoscopic approach. Some doctors will close the incision after irrigating the peritoneal cavity. Sometimes the incision is left open. This is done to allow the wound to drain secretions into the gauze dressing which helps to prevent wound infection. Also, you might see the incision partially closed with a drain extending out from it to facilitate the draining process.

Prognosis

Complications are rare after a routine, non-perforated appendectomy is performed. The mortality rate for an appendix, which has ruptured, is very low (less than 0.3%). As usual, the sooner the diagnosis is made and treatment is performed the likelier the complications will be avoided.

Pearls of wisdom: whenever appendicitis may be suspected, you want to avoid using enemas, laxatives, or applying heat to the area for employing these measures increases the chances of an appendix rupture.

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