Acute Appendicitis

most common condition requiring emergency abdominal operation in childhood.

Diagnosis is difficult in children
The risk of perforation is greatest in 1- to 4-yr-old children
lowest in the adolescent age group

EPIDEMIOLOGY.

Appendicitis is rare if diets are high in fiber. However, no causal relationship has been
established between dietary fiber and appendicitis.

ETIOLOGY.

obstruction of the appendix results in a marked increase of intraluminal pressure, Æ

exceeds systolic blood pressure. - venous congestion progresses to thrombosis, necrosis,
and perforation. The obstruction is caused by inspissated fecal material (fecalith). The
inspissated material may calcify, leading to a radiographically visible appendicolith
Obstruction resulting from mucosal edema may be associated with systemic or enteric
viral or bacterial (Yersinia, Salmonella, Shigella) infections.
Carcinoid tumors, foreign bodies, and Ascaris are also causes of appendicitis.

PATHOLOGY.

three phases. 1. luminal obstruction, venous congestion progresses to mucosal ischemia,

necrosis, and ulceration. 2. Bacterial invasion 3. necrosis of the wall results in perforation
and contamination of the peritoneum. The perforation usually occurs at the tip of the
appendix

fecal contamination may be confined to the pelvis or the right iliac fossa by the omentum
and adjacent loops of small bowel, or it may spread throughout the peritoneal cavity.
Young children have a poorly developed omentum, and local perforation is not usually
confined. Bacterial invasion of the mesenteric veins may result in portal vein sepsis
(pylephlebitis) and subsequent liver abscess formation. The inflammatory process
associated with perforation may lead to intestinal obstruction or paralytic ileus.

CLINICAL MANIFESTATIONS.

The classic triad consists of pain, vomiting, and fever.

- pain is periumbilical. vomiting follows the onset of pain.
Anorexia is more common.
Fever is low grade – high if perforation with peritonitis.
The sequence of symptoms - pain, Æ vomiting, Æ fever .In infectious enteritis, Æ
vomiting Æcrampy pain of hyperperistalsis.
DiarrheaÆconsists of small, mucous stools caused by irritation of the sigmoid colon.
irritation of the bladder may produce urinary symptoms such as frequency and urgency.

pain migrates to the right lower quadrant.

If the appendix is retrocecal, the pain will be lateral or posterior and may mimic the
symptoms associated with septic arthritis of the hip or psoas abscess.
With perforation, the pain becomes generalized
If becomes abscess, localizes in right lower quadrant.
Palpation of an abdominal or rectal mass indicates abscess formation.

The progression from onset of symptoms to perforation usually occurs over 36–48 hr

Physical Examination.

History and physical examination

DD - viral gastroenteritis,
constipation,
urinary tract infection,
hemolytic-uremic syndrome,
Henoch-Schönlein purpura,
mesenteric adenitis
tubo-ovarian disease.

onset of pain before vomiting or diarrhea,

loss of appetite,
migration of pain from periumbilical to right lower quadrant,
aggravation of pain during the trip to office or hospital.

In excluding alternative diagnoses, it is essential to question

history of constipation,
urinary tract symptoms,
cough and fever suggesting lower lobe pneumonia,
profuse diarrhea,
headache, myalgias or other constitutional symptoms of viral syndromes, and similar
symptoms in other household members.
Untreated appendicitis proceeds to perforation within 48–72 hr;
duration of symptoms is important in the interpretation of physical findings and in the
determination of a treatment strategy.

Physical examination
inspection of
the child's behavior
the appearance of the abdomen.
The child with appendicitis frequently moves slowly, hunched forward, and often with a
slight limp.
The child may protect the right lower quadrant with a hand and may be reluctant to climb
onto the examining table.

Early in appendicitis, the abdomen is flat.

Discoloration or bruises should suggest abdominal trauma.

Abdominal distention indicates a complication such as perforation or obstruction.

Auscultation may reveal normal or hyperactive bowel sounds in early then - hypoactive
bowel sounds as it progresses to perforation.
Palpation -be gentle
The right lower quadrant (McBurney point) should be palpated last,
McBurney point is the junction of the lateral and middle thirds of the line joining the
right anterior superior ileac spine and the umbilicus.
The most important physical finding in appendicitis is persistent direct tenderness to
palpation and rigidity of the overlying rectus muscle
Gentle finger percussion in all four quadrants
rectal examination should be the final
- if the diagnosis is in doubt, particularly in the very young (younger than 4 yr) or in the
female adolescent, rectal examination often yields important information.

Examine - ears, mucous membranes, lungs, and skin, for signs of other diseases - identify
shock from sepsis, dehydration

Laboratory Findings.

complete blood count (CBC)

urinalysis.
leukocytosis or shift in differential,
The primary role of laboratory studies is to exclude alternative diagnoses such as
urinary tract infection,
hemolytic-uremic syndrome,
Henoch-Schönlein purpura
proximity of the appendix to the ureter may result in pus cells in the urine. Up to 30 white
cells per high-power field and 20 red cells have been reported in suppurative appendicitis.

The presence of bacteria or pyuria greater than 30 white cells per high-power field
suggests true urinary tract infection.
the presence of significant proteinuria or cast formation argues against appendicitis.

Review of the CBC is to diagnose microangiopathic anemia, thrombocytosis, or

thrombocytopenia

Imaging Studies.
 plain radiographs of the abdomen or chest,
ultrasonogram,
CT
- - calcified appendicolith, small bowel distention or obstruction, and soft tissue mass
effect.
lower lobe pneumonia
ultrasonography -in adolescent girls, to rule out
pelvic inflammatory disease
ovarian cysts
torsion.
CT of the abdomen has been used for - perforation with multiple intra-abdominal
abscesses. - localization, and percutaneous drainage of abscesses
Barium enema findings are - - mass effect on the cecum

DIFFERENTIAL DIAGNOSIS.

gastroenteritis caused by viral or bacterial ( Yersinia, Campylobacter ) agents.

Localized right lower quadrant pain - mesenteric adenitis.
Henoch-Schönlein purpura
hemolytic-uremic syndrome
Weight loss and prolonged symptoms, especially in a teenager, make inflammatory
bowel disease
Torsion of an undescended testis
Follicular cysts of the ovary
pelvic inflammatory disease
cystic fibrosis have a high incidence of , intussusception, constipation, and meconium
ileus
Children with malignancies may experience abdominal pain as a result of their
chemotherapy, constipation, typhlitis, or appendicitis.

the treatment is surgical appendectomy.

Meckel diverticulitis may mimic appendicitis and is usually diagnosed at surgery

TREATMENT.

intravenous fluids and antibiotics.

antibiotics - has decreased the incidence of postoperative wound infections.
Appendectomy should be done within a few hours of establishing the
Laparoscopic appendectomy has been used in children,
In children with an uncertain diagnosis, - adolescent females, the laparoscopic approach
has the advantage of allowing wider intraperitoneal exploration. Laparoscopy is
associated with a shorter recovery period and a lower incidence of wound infection but a
longer operative time.
Appendectomy for nonperforated appendicitis is associated with a low complication rate,
rapid recovery, and short (2–3 days) hospitalization.

If appendix has perforated, - with generalized peritonitis,

fluid resuscitation
broad-spectrum antibiotics -for a few hours before appendectomy.
Nasogastric suction should be used if the patient has significant vomiting or abdominal
distention.
Antibiotics should cover the commonly encountered organisms ( Bacteroides,
Escherichia coli, Klebsiella, and Pseudomonas species).
The commonly used intravenous regimens include ampicillin, gentamicin metronidazole

Appendectomy is performed with or without drainage of the peritoneal cavity, and

antibiotics are continued for 7–10 days.

COMPLICATIONS.

perforation.
Mortality from appendicitis is low (0.5–1%).
Wound infection
Intra-abdominal abscess
Multiple intra-abdominal abscesses are best treated by open laparotomy with drainage.
Liver abscess from portal vein sepsis
Intestinal obstruction
Infertility caused by adhesions or obstruction of the distal fallopian tube - likely after
perforation.