Appendicitis is by far the most common medical problem requiring abdominal surgery in childhood.  The appendix is a small thin pouch that is found on the outside of the colon.  The purpose of the appendix is not entirely known, although a leading theory is that the appendix stores "good bacteria" that can repopulate the colon after an infection.  Inflammation of the appendix is called appendicitis.  The goal of medical treatment is to remove an inflammed appendix surgically before it ruptures and spreads the infection.  The classic symptoms of appendicitis are right, lower abdominal pain, loss of appetite, and fever.  Unfortunately, the symptoms are not always "classic" and the diagnosis may be delayed, especially in young children.

 

What is appendix and what is it for?

The appendix is a small, thin, "worm-like" hollow pouch that hangs from the outside of the first part of this colon.  This is typically found in the right, lower part of the abdomen (but may be more towards the chest or belly button in some children).

The appendix is formed during development of the colon in the fetus.

The purpose of the appendix is a mystery, although one theory is that the appendix stores "good bacteria" during times of intestinal infection.  Once the infection clears, bacteria from the appendix can enter the colon, reproduce and replenish the supply of the "normal bacterial flora." 

What is appendicitis and why does it happen?

Nobody knows exactly why some people get appendicitis and others don't.  Appendicitis occurs when the appendix becomes inflammed.  The appendix, which is a pouch, becomes blocked and is unable to empty.  Bacteria infects the area, causing worsening inflammation and a collection of pus and debris.  If the appendix ruptures, the infection can spread into the abdomen and enter the bloodstream.

Who gets appendicitis?

Appendicitis can occur at any age, however it most commonly affects adolescents and pre-teenagers.  Children less than 3 years of age account for about 2% of cases and are often the most difficult to diagnose.  These young children are more likely to have ruptured appendicitis at the time of diagnosis.  The life-time risk of developing appendicitis is between 6 and 9% for all children (and adults).

What are the symptoms of appendicitis?

Some children have very mild symptoms, while others can present with sepsis and shock (very sick!).

• Abdominal pain - typically it begins around the belly button and then after several hours (or 1-2 days) the pain moves to the right, lower part of the abdomen.  The pain is constant and hurts worse with movement or when the belly is pressed.
• Fever - not always present and may be mild.
• Anorexia - refusal to eat, loss of appetite
• Nausea and vomiting - occurs AFTER the abdominal pain starts

How is appendicitis diagnosed?

Appendicitis, in some cases, can be diagnosed based on the symptoms and the physical exam (without any tests).

Abdominal exam - when pressed, the belly hurts!  Especially in the right, lower belly area. 

• Guarding - the abdominal muscles become tense in response to pressure from the doctor's hand
• Rebound - the abdomen hurts AFTER the abdomen is pressed and released quickly
• Peritoneal signs - if the inflammation has spread to the rest of the abdomen, the belly can become rigid and extremely painful.  Pain can be worsened by stretching certain abdominal muscles, jumping up and down, shaking the bed, or tapping on the bottom of the feet.
• Digital rectal exam - should be performed to help localize inflammation in the abdomen

Blood tests - sometimes helpful, but may be normal

• White blood count - elevated in cases of infection, but may be low in severe infections
• Platelet count - elevated in cases of infection, but may be low in severe infections
• ESR, CRP - these are markers of inflammation that may be elevated in cases of appendicitis
• Blood culture - may be positive if the infection has spread to the bloodstream

Urine tests - should be normal with appendicitis.  If abnormal, the child may have another problem (i.e., urinary tract infection)

Ultrasound of the abdomen

• May reveal the swollen appendix or a stone (if present) in the appendix. 
• If the appendix is not seen with ultrasound, appendicitis may still be present. 
• Difficult to see the appendix in overweight patients.
• May be helpful for ruling out other problems in females (i.e., ovarian cysts, ectopic pregnancy)

Computed tomography (CT scan)

• One of the best tests for appendicitis, however there is controversy on whether or not it is necessary to diagnose all cases. 
• CT scans take time to obtain, are not always available, and exposes the patient to a large amount of radiation.
• If appendicitis is present it may show a fluid-filled tube-like structure with a diameter more than 6mm.  There may also be bowel wall thickening, lines of inflammed fatty tissue, or a fluid collection (i.e., an abscess) around the appendix.

X-ray of the abdomen

• Usually x-rays are normal in appendicitis, so they may not be helpful
• In some cases, a stone in the appendix may be visible (8-10% of cases)

How is appendicitis treated?

• Surgery should be performed as soon as possible after diagnosis. Removing the appendix (appendectomy) cures the problem. 
• In cases where the diagnosis is uncertain, the patient may be hospitalized and monitored for changes in the symptoms over 12 or 24 hours.  The symptoms of appendicitis typically will worsen with time, making the diagnosis more obvious.
• If the appendix has ruptured, the child may be too sick to take to surgery immediately.
• Antibiotics should be given.  Often, more than one antibiotic is needed to cover all the possible bacteria types.
• Intravenous fluids are given since the patient is often dehydrated due to poor fluid intake.  A person with appendicitis should not eat until the appendix has been removed.

What if my child is found to NOT have appendicitis during surgery?

Most physicians agree that a "high suspicion of appendicitis" is enough to take the child to surgery.  This means that some children who undergo surgery will be found to NOT have appendicitis.  The risk of missing a case of appendicitis outweighs the risk of waiting for 100% certainty of appendicitis prior to surgery.  Some surgeons believe that between 2 to 20% of surgeries should show a NORMAL appendix to ensure the surgeon is aggressive enough not to miss any cases of appendicitis.

How is the appendix removed?

The patient is taken to an operating room, given anesthesia medicines, and a surgeon removes the appendix.  This is done with a small incision in the right, lower abdomen or by using a laparoscope, a stick-like device with a camera that allows for several much smaller incisions.

What is "perforation," and how common is it?

Perforation means the appendix has ruptured, leaking stool into the abdomen, outside the intestines.  This can lead to abdominal infection, abscesses, and/or sepsis.  Perforation of the appendix can be life-threatening in some cases.

Perforation is much more common in younger children with rates as high as 82% of children less than 5 years of age, and up to 100% in children less than 1 year old.

Rupture of the appendix typically occurs 24-36 hours after the beginning of symptoms.

What happens after the appendix is removed?

• Removal of the appendix (appendectomy) is a cure for appendicitis
• Recovery is typically rapid (i.e., a few days)
• Antibiotics may be given for a week or two to prevent spread of the infection