APPENDICITIS

Definition: Inflammation of the appendix in the large intestine.

Note: Whenever a child complains of severe abdominal pains, it is likely that the parent is concerned that the child may have appendicitis. If abdominal pain develops suddenly and the child continues to complain, the doctor should be contacted. It is impor- tant that the diagnosis of this condition be established early to avoid having the appendix rupture, which causes more serious problems for the child.

1. How did this condition develop in my child?

The appendix is a leftover of development where the small and large bowel are joined in the right lower quadrant of the child’s abdomen. It is hollow, and it opens into the large bowel. The opening is small and susceptible to being clogged by a stool ball (called a fecalith), or it can swell shut when the child has a viral illness somewhere else in the body. The opening of the appendix is surrounded with the same lymphoid tissue that swells in your child’s neck when he or she gets a viral illness. The appendix normally has bacteria in its hollow center that are evacuated with the stool. If the opening is blocked, however, the bacteria continue to grow but cannot escape. Pressure builds up, and the bacteria can invade the wall of the appendix, weakening it. If left untreated, the appendix can “rupture,” spilling the infection into the wider abdomen.

2. Are there further tests to be done to more fully establish the diagnosis?

The most common test is a CT scan of the abdomen and pelvis. Sometimes a sonogram can also identify appendicitis. There is no single test (or combination of tests) that is 100 percent accurate, so the decision to perform an appendectomy is based on a combination of blood and urine tests, radiology images like a CT scan, and examination by an experienced surgeon. Sometimes, if the diagnosis is in doubt, your child may be admitted to the hospital for a period of observation and/or repeat testing.

3. What is the treatment for this condition?

The definitive treatment is to remove the appendix with an operation. This may be done through an incision in the right lower quad- rant of the abdomen or with a laparoscope (which uses three small incisions, one of which is in the belly button). If the appendix has already ruptured and a pus pocket (abscess) has formed around it, the best treatment may be to drain the pus and treat the child with antibiotics first and remove the appendix later (sometimes six weeks later). Many children require intravenous fluids and antibiotics for several hours prior to the operation so they tolerate the anesthesia better.

4. What complications can occur as a result of this condition if left untreated?

The complication that everyone worries about is rupture. If a child has a nonruptured appendix removed, he or she can usually be discharged home without antibiotics in one to two days after the operation. If the appendix has ruptured, however, the child will need five to seven days of intravenous antibiotics after the operation and additional oral antibiotics at home. Even then, children are at much higher risk for abscess formation (usually forms about a week after the appendectomy), which may require drainage with another procedure.

5. What, where, and by whom should the surgery to correct this condition be performed?

The appendectomy is usually performed by a pediatric surgeon in smaller children and by a pediatric or adult general surgeon in teenagers. It must be done in a full service hospital, not a day surgery center.

6. If surgery is necessary, what are the potential complications that can occur?

Local infections in the skin incisions can occur. This appears as bright redness extending more than one-half inch from the edges of the incision or pus draining from the incision. Local infection is treated by removing the outer layer of stitches to allow the area to drain and by antibiotics.

     An abscess (a pus pocket formed deep in the abdomen) can occur about a week after an appendectomy for ruptured appendicitis. Formation of an abscess is rare after an appendectomy for nonruptured appendicitis. The abscess is almost always discovered prior to the child going home. If the child still has fever, severe pain, and/or persistently abnormal blood tests greater than one week after the operation, a repeat CT scan of the abdomen and pelvis may be done to check for an abscess. If one is found, one of three treatments will likely be recommended: continued IV antibiotics (for smaller abscesses), drainage by the radiologist using a CT scan for guidance (with the child asleep, a small catheter is inserted into the abscess and left in place until it resolves), or (rarely) another operation for drainage of abscesses that cannot be reached safely by the radiologist.

7. When do you wish to see my child again regarding this condition?

If the appendix did not rupture, one visit to the surgeon two to three weeks after discharge home is sufficient. Most children will be allowed to return to sports or physical education classes after this visit. If the appendix ruptured, an additional visit may be necessary after all antibiotics have been completed. 

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