Pediatric appendicitis
Pediatric appendicitis is an infection or inflammation of the appendix, a pinky-sized, tube-like structure part of the large intestine in children. The appendix is located in the right lower section of the abdomen in most children. Doctors are not really sure what the appendix does, but removing it is not harmful.
Appendicitis can be an emergency situation. Appendicitis is the most common childhood surgical emergency, but the diagnosis can be challenging, especially in children, often leading to either unnecessary surgery in children without appendicitis, or a ruptured appendix and serious complications when the condition is missed.
Appendicitis affects 1 in 1,000 people living in the U.S. Most cases of appendicitis occur between the ages of 10 and 30 years.
Since an infected appendix can rupture and be a life-threatening problem, call your health care provider or go to the emergency room immediately if your child has these symptoms:
- sudden, pronounced pain around the belly button area
- in a short period of time, the pain moves to the lower right-hand part of the abdomen and your child may have a difficult time breathing.
Symptoms of appendicitis may resemble other conditions or medical problems. Consult your health care provider for a diagnosis.
Figure 1. Appendix
Why is appendicitis in children 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.
Is immediate surgery always necessary if a child has appendicitis?
Health care providers may recommend non-operative 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 an 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 later.
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.
Pediatric appendicitis causes
Appendicitis is the result of a blockage of the appendix caused by hard mucus or stool, or swelling caused by a virus. The blockage causes the appendix to swell and become inflamed. If the swelling and infection are left untreated, the appendix can burst (perforate), causing the contents of the appendix to be released into the abdomen, spreading the infection.
Pediatric appendicitis is the most common cause of emergency abdominal surgery in children. Though it can happen at any age, appendicitis occurs more frequently in school-aged children, and rarely occurs under the age of 1.
Pediatric appendicitis symptoms
The signs and symptoms of appendicitis can vary from child to child. The most common symptoms of appendicitis in children are:
- Abdominal pain that begins around the belly button and moves to the right lower side of the abdomen. The pain typically increases when walking, jumping or coughing, and usually worsens as time goes on.
- Low fever, beginning after other symptoms
- Nausea and/or vomiting
- Loss of appetite
- Diarrhea
- Constipation
- Gas pain
- Tenderness in the right lower abdomen
- Abdominal swelling
- Elevated white blood cell count
- Appetite loss
The distinctive symptom should be treated very seriously; should the appendix rupture, it may infect the double-layer peritoneal membrane that lines the abdominal cavity. The medical term for this is peritonitis. Notify your child’s doctor at once or contact a local hospital emergency department. While you wait to see the doctor, instruct your child to lie down and be still. Any kind of movement, including coughing or taking a deep breath, can exacerbate the pain. Don’t offer water, food, laxatives, aspirin or a heating pad.
Pediatric appendicitis diagnosis
Appendicitis can be difficult to diagnose definitely. Pediatric appendicitis is diagnosed with a thorough health history and physical examination. Your child may need to have an imaging study completed, such as an ultrasound, MRI or CT scan, to see the appendix. Your child may also have laboratory studies completed, such as a complete blood count (CBC), to determine the extent of the infection.
Pediatric appendicitis treatment
Immediately following diagnosis, patients with appendicitis will receive antibiotics to treat the infection.
Ultimately, the treatment for appendicitis is a surgery to remove the appendix, called an appendectomy. Your child’s surgeon will help determine the best treatment for your child. Conventional “open” surgery usually requires a two day hospital stay, barring complications, and leaves youngsters with a small scar, but completely cured.
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 the 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 through the IV to help her feel comfortable. Eventually, children will be allowed to drink clear liquids (such as water, sports drinks or apple juice), and then gradually advance to solid foods.
What happens after my child leaves the hospital?
Your physician 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, 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 her feel comfortable. Some pain medications can make your child constipated, so ask your physician 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.
