Tonsillitis / Tonsillectomy

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The tonsils are a part of the body’s Lymphatic system. These masses of lymphoid tissue are located in the upper back of the mouth (oral cavity) and function to filter and protect the respiratory and alimentary tract from harmful bacteria. They also play a role in antibody formation. Children typically have larger tonsils than adults because it is thought to be a protective mechanism since younger children are prone to get upper respiratory infections. There are several types of tonsils located in the human body. The type that is visible during an oral examination is known as the palatine tonsils. The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the back (posterior) wall of the nasal-oral cavity. Tonsillitis is the inflammation (swelling) and infection of the tonsils. The agent responsible for the infection may be a virus or a bacteria.

Clinical Manifestation

As the palatine tonsils become enlarged, they meet in the midline which results in the obstruction of the passageway for air and food. The child may have difficulty swallowing and breathing. As the adenoids become enlarged, the space behind the back nasal passageway becomes blocked, which also makes it extremely difficult for air to pass from the nose to the back of the throat.

Therapeutic Management

With tonsillitis, it is important to differentiate between viral and bacterial infection. A throat cultures is done and if positive for bacteria, then the infection is treated with antibiotics. Most infections are caused by a virus, and since antibiotics are useless against a virus, you basically treat the symptoms.

A tonsillectomy is the surgical removal of the palatine tonsils. The procedure is an absolute essential if there is recurrent infections and abscesses, airway obstruction involvement or if the infection results in fever leading to convulsions. Others indications for the procedure includes tonsillitis that doesn’t respond to the antibiotics.

An adenoidectomy is the surgical removal of the pharyngeal tonsils. The surgery is recommended for children whose tonsils obstruct their nasal breathing and for those who experience recurrent adenoid, sinus and ear infections.

After Surgery Care

The goal of after care is to minimize discomfort and minimize activity in order to avoid bleeding. Those children who have a sleep-disordered breathing will require close monitoring of their airway and breathing. This may include an overnight stay in the hospital.

Any oral intake is avoided until your child is fully awake. Initially, you will want to start with cool, clear liquids. Cold water, popsicles, gelatin, and diluted fruit juice is recommended to start. Avoid citrus juice because they may cause discomfort to the surgical site and avoid red or brown colored beverages so that you can distinguish fresh or old blood in vomitus from the ingested liquid. Avoid straws as well. Fluids are strongly encouraged to avoid dehydration because the pain from the surgery may cause your child to be reluctant to drink anything. Soft foods are started the next day, if your child is tolerating the liquids. Items such as gelatin, sherbet, mashed potatoes, and soups are foods to consider. Some doctors will have you avoid some milk product such as ice cream, pudding, and milk because these items will coat the throat and may cause your child to cough in order to clear the throat, which can cause the surgical site to bleed.

Your child will be instructed to engage in light activity only for a few weeks. They are to avoid frequent coughing, clearing the throat, blowing their nose or any activity that may cause tension to the surgical site. NO RUNNING / NO JUMPING. Normal activity may be resumed after you are cleared by your doctor.

Pain control is vitally important in order to avoid malnourishment and dehydration. An ice collar should be used for the first 48 hours to minimize swelling. Pain medication should be given regularly, even during the night for the first few days, because the pain from the surgery is continuous. Afterwards, you will need to assess for pain and give it as needed. Combination non-opioids and opioid elixirs are usually prescribed. Eventually, over the counter acetaminophen will be effective in controlling the pain. Other measures for you to consider include, warm salt water gargles and throat lozenges.

Active bleeding from the surgical site is uncommon but has been recognized in 5% of patients and as far as 14 days after the procedure. You will want to observe the site directly to assess for bleeding and you will need to have a good source of light to do that. So, be sure to have a good flashlight available. You want to be observing your child for frequent swallowing, particularly in the toddler age child who may not be able to verbalize or who may not be aware of the fact that they are bleeding. Other signs that they may be bleeding includes a fast heart rate, pallor, frequently clearing of the throat and vomiting of bright red blood. Surgery may be required to cauterize the bleeding vessel. Some secretions are common and may present in the form of blood tinged saliva. Their vomit content may include some dark brown (old blood) and this may also be present in nose secretions and around their gum and teeth.

Airway obstruction is a potential complication as well. This is a result of swelling (or edema) and / or accumulated secretions that may have occurred. You will know this if you observe signs of respiratory distress which will present itself in the form of labored breathing, restlessness, agitation, fast breathing rate, stridor, and cyanosis (turning blue). Suctioning equipment and oxygen needs to be available if this occurs.

Pyloric Stenosis

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The pyloric canal is the opening between the stomach and the duodenum, which is the first section of the small intestine. In pyloric stenosis, the circumferential muscle of the sphincter becomes thickened, resulting in elongation and narrowing of the pyloric canal. This produces an outlet obstruction which leads to projectile vomiting, dehydration, metabolic alkalosis and growth failure. The precise etiology is unknown.

This condition usually develops in the first 2 to 5 weeks of life. The reported incidence is 1 to 3 per 1000 live births with a male-to-female ratio of 4 to 6: 1. There is a genetic predisposition, so many times the siblings and offsprings of the affected child are at increased risk of developing hypertrophic pyloric stenosis. It is more common in full term than in preterm infants. It is not seen as often in African-American and Asian infants, than in white infants.

Diagnostic Evaluation

The diagnosis is usually made after a history and physical examination. The olive-like mass is easily palpated when the stomach is empty (usually the result of persistent vomiting), the infant is quiet, and the abdominal muscles are relaxed. Vomiting occurs within 30 to 60 minutes of feeding and will become projectile in nature as the obstruction progresses. The emesis consists of stale formula / milk and is non-bilious (doesn’t consist of bile or the green colored contents of the stomach). If this condition is not diagnosed early, the infant may become dehydrated and appear malnourished.

If the diagnosis is inconclusive from the history and physical exam, and ultrasound may be in order. The ultrasound will reveal an elongated, sausage-shaped mass with an elongated pyloric canal. If ultrasonography doesn’t produce a conclusive diagnosis, then and upper Gastrointestinal radiography should be done. Laboratory findings (i.e., blood sample analysis) usually supports the diagnosis in revealing the metabolic alteration (low blood chloride levels / elevated blood carbon dioxide level) created by depletion of fluid and electrolytes and hydrogen ions from the prolonged vomiting.

Therapeutic Management and Prognosis

Relief of the pyloric obstruction is achieved through surgical intervention, known as a pyloromyotomy. This procedure is often performed by laparoscope. The procedure consists of making a longitudinal incision through the circular muscle fibers of the pylorus down to, but not including the sub-mucosa layer. The procedure has a high success rate. The infant is kept NPO (nothing by mouth) for a 4-6 hours, postoperatively. When feedings are re-introduced, it will began with an electrolyte replenishing solution, such as Pedialyte. The amount will be small and frequent. If the child is able to retained the Pedialyte after a few feedings, then formula or breast milk may be re-introduced into the diet. The amount, type and the frequency of the feedings will be determined by the surgeon. The amount and the interval between feedings are gradually increased. The parent is also instructed to burp the infant frequently during the feedings and keep the child upright for 30 minutes after the feedings.

Intussusception

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Intussusception is a condition in which one segment of the bowel (intestine) will telescope into another segment of the bowel. A model of the defect can easily be demonstrated by taking a rubber glove and pushing the end of one of the fingers back into itself. It is the most common cause of intestinal obstruction. It typically will occur in children between the ages of 3 months to 3 years. It tends to occur in boys more frequently than in girls, and can be found more commonly in children with cystic fibrosis. Over 90% of the cases do have a pathological cause stemming from such conditions as polyps (an abnormal growth in the intestine) in the colon, lymphoma (cancer of lymphoid tissue) or Meckels diverticulum (small out pouching of the small intestine). As the bowel is compressed resulting from this telescoping, the blood vessels and the lymphatic system becomes obstructed. This leads to disruption in blood supply (and oxygen) to the bowel which ultimately will lead to death of the bowel tissue involved.

Symptoms

Symptoms you can see with this condition includes sudden acute abdominal pain and abdominal distention, vomiting , lethargy, passage of red, currant jelly –like stool (stool mixed with blood and mucus) and a palpable sausage shaped mass in the right upper quadrant of the abdomen. You may see your child experiencing episodes of pain, manifested by screaming and drawing up their knees to the chest alternating with periods of normalcy and no pain. Eventually fever, extreme physical weakness and exhaustion will ensue.

Diagnostic Evaluation and Treatment

In conjunction with the subjective findings, the diagnosis can be confirmed with an ultrasound. Statistically, spontaneous reduction of this condition has occurred in approximately 10% of cases.

Medical correction includes the following. A Radiologist guided pneumo-enema (air enema) with or without water-soluble contrast. Your doctor may choose to try an ultrasound guided hydrostatic (saline) enema. The principle of hydrostatic reduction can be demonstrated taking that same glove and filling it with water. This pushes that telescoping finger back into a fully extended position. The advantage to using the latter approach is the absence of exposure to radiation. A reoccurrence of the intussusception, after these interventions, is fairly uncommon. Prior to the reduction procedure, your child may receive IV fluids and antibiotic therapy. An NG (nasogastric) tube may be inserted to allow for stomach decompression. If the medical procedures are unsuccessful, the condition may require surgical correction. Surgery involves an incision into the abdomen and manually reducing the telescoping of the bowels. Surgery may also require resecting (or cutting out) any intestine that has died due to the lack of blood supply (along with the life sustaining oxygen that goes along with that blood). The two ends of the viable (living portion of intestine) are connected after the resection. After either approach for correction, your child may be required to maintain an NPO (nothing by mouth status), NG tube decompression ( if surgery was performed), IV fluids and antibiotics.

Prognosis

With early diagnosis and treatment, any serious complications are very rare. Statistically, approximately 80% of non-operative reductions are successful and surgery is required if the reduction is not successful.

Hydrocephalus

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Hydrocephalus (a.k.a., water on the brain) is a condition of the brain where there is an imbalance in the production and the absorption of cerebral spinal fluid (CSF) in the ventricle system. CSF is the clear, water-like fluid that surrounds the brain and the spinal cord. It also cushions these two organs. An imbalance in the production / secretion and / or the absorption of the CSF causes this fluid to accumulate in the ventricles. The ventricles of the brain become dilated and this increase in volume causes the surrounding brain tissue to become compressed against the skull. If this occurs before the skull sutures are fused (fixed and closed), it will cause the head to swell. The sutures fuse at around 12 years of age. Below that age, when the sutures are partially fused, they can become diastatic or opened.

Causes for Hydrocephalus

The purpose of CSF is to deliver vital nutrients to the brain and to rid the brain of waste products. In the perfect world, CSF will flow through its typical narrow passageways and exit the brain through a reservoir at the base of the brain, called the cistern. If a blockage occurs in any of the passageways (including the ventricles), the CSF will back up and cause an excess of fluid in the brain. The excess fluid leads to increase pressure under the skull. With that increased pressure the brain tissues will move to the area of least resistance which ultimately will be the base of the skull. This will lead to brain herniation, which is a medical, life threatening emergency.

Signs/Symptoms

Early Infancy: rapid head growth, bulging fontanel (soft spot on the top of head), separating sutures, dilated scalp veins, and Macewen sign which is a cracked-pot sound on percussion.

Later Infancy: bulging fontanels, forehead enlargement (known as bossing), depressed eyes / setting sun eyes, pupils sluggish with unequal response to light.

Infancy in general: fussiness, lethargy (sluggish and inactive), change in level of consciousness, vomiting, spasticity in the legs, difficulty sucking and feeding, and high pitched cry.

Childhood: headache, vomiting, irritability, lethargy, confusion, loss of coordination, cross-eyed (strabismus) and inability to concentrate.

Diagnostic Evaluation

In addition to the subjective findings seen by the physician, the gold standard for diagnosing hydrocephalus is a CT (computed tomography) scan, also known as a “cat scan” or an MRI (magnetic resonance imaging).

Treatment

Treatment for hydrocephalus is geared towards relieving the condition. This can be done by surgical intervention, which involves removal of the obstruction, as in the case of a tumor. Or it can be accomplished by placing a device known as a shunt (ventriculoperitoneal or VP shunt), which will drain the excess fluid. This shunt system consists of a catheter placed in the ventricle of the brain, a flush pump, a unidirectional flow valve, and a distal catheter. The distal catheter usually terminates in the peritoneum (the area that houses the abdominal organs, i.e., the stomach, liver, etc.).

Complications/Prognosis

The main complications of the VP shunts are malfunction and infection. All shunts are capable of having some mechanical issues such as catheter kinking, plugging, separation or migration of the tubing. If this occurs, a revision by the doctor may be warranted. Infections are treated with antibiotics. Reoccurring infections may require removal of the shunt and placement of a new shunt. When hydrocephalus is treated medically and surgically, there is an 80% survival rate, with the highest incidence of mortality occurring within the first year of obtaining diagnosis and treatment.

Hirschsprung Disease

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Hirschsprung disease (hd) is a congenital disease involving the large intestine whereas there is inadequate motility of a part, or in rare cases (5%), all of the intestine. During the normal, development of the fetus, nerve cells known as ganglion cells migrate from the neural crest to the large intestine (colon). In hd, the migration is not complete resulting in the absence of these ganglion cell and inadequate motility of that part of the colon. The absence of ganglion cells results in a persistent over-stimulation of nerves in the affected portion of the colon, resulting in contraction and lack of (food propelling motion). In most cases of hd, the affected segment of the colon includes the distal colon and the rectum. This results in the inability of the rectum internal sphincter to relax. When the rectal sphincter can’t relax, stool cannot pass through to the outside of the body. This disorder is four times more common in males, than in females. The incidence is 1 in 5000 live births. This condition can be problematic in that it results in mechanical obstruction, constipation, vomiting, and a distended abdomen (stomach / intestine swelling), to name a few.

Clinical Manifestations

Newborn period: failure to pass meconium stool within 24-48 hours after birth, refusal to eat, bilious (green-colored) vomitus, and abdominal distention.

Infancy: failure to thrive, constipation, explosive, watery diarrhea and vomiting, fever, and ill in appearance.

Childhood: constipation, malnourished appearance, ribbon-like, foul smelling stools, a palpable, fecal mass, and visible persistalsis.

Diagnosis

In addition to the subjective findings, diagnosis is verified with the assistance of a barium enema and anus -rectum manometric (pressure measuring) exam. The diagnosis is ultimately confirmed by the finding of a rectal biopsy, which will reveal the absence of the ganglion cell.

Treatment

Most cases of hd will require surgical intervention in contrast to medical management with frequent enemas. Surgery consists of removing the portion of the intestine that lacks the ganglion cells. The procedure known as the soave endorectal pull-through consists of pulling the end of the normal colon through the muscular sleeve of the rectum and connecting them. This will relieve the obstruction, restore normal intestine motility and preserve the function of the external anal sphincter. If only a small portion of the intestine is involved a procedure known as an anal-rectal myomectomy may be performed. If the disease is not diagnosed early, a portion of the intestine may become enlarged due to the constipation and obstruction. If this is the case, the condition may have to be corrected in two stages with stage one involving a colostomyand the removal of the diseased portion of the colon. Stage two would involve reconnecting the two ends of the colon.

Prognosis

After the surgical procedure, some children may experience incontinence (loss of bowel control) and anal stricture (narrowing). Further treatment may include bowel retraining and anal dilatation therapy. Constipation may continue to be a problem and will require management by your pediatrician.

GERD / Gastro-Esophageal Reflux

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Gastro-esophageal (GER) reflux is a condition that is defined as the transfer of gastric contents into the esophagus. Typically, it occurs throughout the day, most frequently after meals and at nights. This condition differs from gastro-esophageal reflux disease, a.k.a. GERD’s. GERD represents symptoms or tissue damage that result from GER. With “physiologic” GER, the condition usually resolves spontaneously by 1 year of age. The causes of GER is multifactorial, however, the primary mechanism likely involves an inappropriate relaxation of the lower esophageal sphincter. Factors that increase abdominal pressure such as coughing, sneezing, scoliosis and overeating, may contribute to GERD. There are certain conditions that may predispose a child to a higher likelihood of developing GERD. Those conditions include neurological impairment, hiatal hernia, obesity, trachea-esophageal and esophageal atresia repair, asthma, cystic fibrosis and cerebral palsy.

Diagnostic Evaluation

A simple history and physical may be sufficient in establishing a diagnosis of GER. However, in many cases, the physician may order an upper GI series. This is a radiological examination of the upper gastro-intestinal tract, which consists of the esophagus, stomach and duodenum (the first section of the small intestine). This test is also useful in determining the presence of anatomical abnormalities which may contribute to GER. Another test, which is considered the gold standard for diagnosing GER, is the pH monitoring study. This test allows direct, physiological measurement of acid in the esophagus. It consists of a probe being placed by a physician to the distal end of the esophagus. The probe is connected to a machine which measures the pH of the esophagus. A continuous measurement of the acidity of that area is recorded for up to 24 hours depending upon the length of time the physician requires. Upon completion of the monitoring process, the physician will download and analyze the data. A reflux episode is defined as esophageal pH drop below a four. Components of the pH study include the following:

  • Percent total time pH < 4
  • Percent Upright time pH < 4
  • Percent Supine (lying on your back) time pH < 4
  • Number of reflux episodes
  • Number of reflux episodes ≥ 5 min
  • Longest reflux episode (minutes)

His findings will determine whether the physician will treat this condition medically (with medication / diet / activity) or whether to treat it surgically, with a procedure known as a fundoplication.

Therapeutic Management

The severity of GER varies from individual to individual. Therefore, its therapeutic management will vary as well. For example, an infant who is not experiencing respiratory complications and who continues to plot favorably on the growth chart, may not need therapeutic management. For others, it may involve the aversion of certain foods with exacerbates the reflux, such as citrus, caffeine, tomatoes, peppermint, alcohol, spicy or fried foods. Therapy may involve lifestyle modifications, such as smaller portions and shorter intervals between feedings, thickened feedings and upright position may prove to be helpful. Continuous, nasogastric tube feedings may be necessary for those with severe reflux and growth failure until surgery can be performed. Elevating the head of the bed 30 degrees or placing the child in an infant seat for 1 hour after feeding may decrease GER.

Pharmacological Therapy Medication used to treat GERD fall into two classifications. The H2-receptor antagonist includes Zantac (Ranitidine), Tagamet (cimetidine) and Pepcid (famotidine). The proton pump inhibitors are Nexium (esomeprazole), Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole) and Aciphex (rabeprazole). Their mechanism of action is by reducing the amount of hydrochloric acid secreted and also may stimulate an increase in lower esophageal sphincter tone.

Surgical Management

The medical community is typically very, conservative when it comes to recommending surgery. Surgery is usually recommended for the child with severe complications, such as recurrent aspiration pneumonia, apnea, severe esophagitis, or growth failure. It also may be recommended for the child who fails to respond to medication and non-pharmacological treatment. The Nissen fundoplication is the most common surgical procedure and there are different variations of fundoplication performed. This procedure is now commonly performed using a laparoscope, which results in less recovery time, less pain, better cosmetic results and fewer complications. This procedure involves passage of the gastric fundus (the upper, left portion of the stomach) behind the esophagus to encircle the distal (lower end of) portion of the esophagus. This results in preventing the reflux by reinforcing the closing function of the lower esophageal sphincter.

Clubfeet

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Clubfeet or club foot is a congenital, deformity of one foot or both, as well as, the ankle. The most common positions include the following variations:

  1. A bending inward of the foot, 2) A bending outward of the foot, 3) A plantar flexion, in which the front of the foot is bending downward (toes are lower than the heel) and 4) A dorsiflexion, in which the front of the foot is bending upward and 5) Toes lower than the heel and turning inward.

Most cases are a combination of these positions. This condition may occur as an isolated deformity or may be a part of a syndrome or other disorders, such as cerebral palsy or spina bifida. The incidence of occurrence in our population is 1 in 1000 live birth. It typically affects boys 2 times more than girls and 50% of the cases, it involves both feet. The cause of the deformity is not certain, but there are two schools of thought in what causes it. Some experts seem to believe this deformity it the result of abnormal positioning and restricted movement of the baby in the uterus. Others seem to believe in an abnormal development at the cellular level, while in utero.

Diagnostic Evaluation

This type of deformity is readily apparent and is sometimes diagnosed before birth via ultrasound. However, it does require classification in order to determine the treatment plan for correcting it, whether it is corrected with or without surgery.

Classification and Treatment

Clubfoot is divided into 3 subcategories. The positional clubfoot ( also known as, postural or transitional clubfoot), is the milder form of clubfoot and is believed to be the result of intrauterine crowding. This can sometimes be corrected by simple stretching and applying a cast (serial casting). There are cases where this type of clubfoot has corrected spontaneously (on its own). The clubfoot deformity associated with other birth defects or associated with a syndrome (syndromic or teratologic clubfoot), is a more severe form of clubfoot and is usually resistant to simple stretching exercises and casting. It will require surgery to correct it. And the third class of clubfoot, known as idiopathic clubfoot requires surgery to correct it because this type of clubfoot usually has some type of bone abnormality.

Therapeutic Management

Now, the goal of treatment is three pronged in nature. First of all you want it to be as painless, as possible. Secondly, you want a plantigrade or flat foot and lastly, you want a stable foot. It also involves three stages, as well: 1) Correcting the foot deformity, 2) maintaining that correctness, as well as, accomplishing normal muscle balance, and 3) follow-up examinations by the Doctor to prevent the deformity from coming back.

The most common method is to begin placing the leg and foot into a long leg cast, as soon as possible, after birth. It will involve periodic manipulation of the foot and reapplying another cast, otherwise known as, serial casting. Sometimes, cutting of the tendon at the heel, or tenotomy is required to achieve normal foot alignment. Sometimes, the child’s foot or feet, may be placed in specially made shoe or sandal for a period of time, determined by the Doctor, in order to prevent reoccurrence of the deformity. If the approach does not achieve the goal of normal foot alignment, then more extensive surgery may be required.

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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