APPENDICITIS IN

CHILDREN

DR. Mohamed kamara

Registrar
Paediatric surgery
Uslthc-connaught
 u Introduction

u Historical background

u Anatomy (Embryo, Histology)

u Etiology
Outline
u Pathophysiology(Pathology, classification)

u Diagnostic pathway

u Differential diagnosis

u Management

u Complications and outcome

 INTRODUCTION
Appendicitis : Appendicitis is defined as an inflammation of
the inner lining of the vermiform appendix that spreads to its
other parts. This condition is a common and urgent surgical
illness with protean manifestations, generous overlap with
other clinical syndromes, and significant morbidity, which
increases with diagnostic delay.
Historical background

 In 1886 DR.REGINALD FITZ coined the term

appendicitis.
 Morton is credited with performing the first deliberate
appendectomy for a perforated appendix in the United
States in 1887.

In 1889 McBurney reported his treatment of

appendicitis with appendectomy before rupture
ANATOMY of appendix
• Appendix- is a blind-ended muscular tube attached
to the posteriomedial wall of caecum, about 2cm
below ileocaecal junction.
• Suspended by peritoneal fold-mesoappendix (where
the appendicular vessels pass through)
• Devoid of taenia coli, sacculations, appendix
eiploiacae.
 The appendix averages 8 cm in length but can vary
from 0.3 to 33 cm.

 The diameter of the appendix ranges from 5 to 10

mm.

 The base of the appendix arises at the junction of the

three taeniae coli, a useful landmark

 The mesoappendix arises from the lower surface of

the mesentery or the terminal ileum.

 Function is unknown.
 Embryology
 The appendix 1st becomes visible during the 8th week of gestation
as a continuation of the inferior tip of the cecum.
 The appendix rotates to its final position on the posteromedial
aspect of the cecum, about 2 cm below the ileocecal valve, during
late childhood.
 The variability in this rotation leads to multiple possible final
positions of the appendix.
 The exact location varies widely
Its blood supply is the appendicular artery is a branch of the ileocolic artery, which passes behind the
terminal ileum.
It is an end artery
 Demographics
•Most common acute surgical condition
•Life-time risk: 8.7% in boys; 6.7% in girls[1]
•Age specific risk: extremely low neonates to peak 12-18 years
•Higher family risk in children under 6 years[2]
•Rupture rate significantly increased in poorer children[3]
•Race – whites>black
•Season – peak incidence in autumn and spring
Histological structure

Its colonic epithelium and circular

and longitudinal muscle layers are
contiguous with the cecal layers.

The submucosa contains numerous

lymphatic aggregations
 Etiology
 EXACT CAUSE – not completely understood

 ASSOCIATED FACTORS:

 Fecoliths
 Decreased dietary fibre
 Increased consumption of refined carbohydrates
 Incompletely digested food particles
 Lymphoid hyperplasia
 INTRALUMINAL SCARRING
 blunt trauma
 •TUMORS OR MALIGNANCIES
 carcinoid tumors
 •MICROORGANISMS:
 b.VIRUSES –
 a. BACTERIA –  Mumps
 Yersinia  CoxsackievirusB
 Salmonella  Adenovirus
 Infectious mononucleosis
 Shigella spp  c. OTHERS - Ascaris
lumbricoides
Pathophysiology
CLASSIFICATION by I.V. KOLENSNIKOV

Acute appendicitis was classified by following:

1) mild (appendicular colic);

2) simple (surface) appendicitis;

3) destructive:

a) phlegmonous,

b) gangrenous,

c) perforated;
CLASSIFICATION by I.V. KOLENSNIKOV

4) complicated:
a)appendicular infiltrate (well-defined, progressive),
b)appendicular abscess,
c)diffuse purulent peritonitis,
d)other complications of acute appendicitis
(pylephlebitis, sepsis, retroperitoneal phlegmon,
local abscesses of abdominal cavity)
 PATHOLOGY

• Acute simple appendicitis

• Acute phlegmonous

• Acute gangrenous

• Perforative
Acute Simple Appendicitis
Acute phlegmonous Appendicitis
Acute gangrenous Appendicitis
Perforated Appendicitis
 Diagnosis:

 Best made with careful history and physical

examination

 Laboratory investigations

 Scoring systems
 Clinical presentation

 Children with appendicitis usually lie in bed with

minimal movement.
 Older children may limp or flex the
trunk
 Infants may flex ther right leg over the abdomen.
 Classical features :
• Periumbillical colic
• Pain shifting to the right
iliac fossa
• Anorexia
• Nausea
• Indigestion or subtle
changes in bowel habits
• Diarrohea
Age dependent signs and symptoms
Atypical presentation
 Physical examination

 Presence of LOCALIZED ABDOMINAL TENDERNESS the SINGLE MOST

reliable finding in the diagnosis of acute appendicitis
McBurney described :

“the seat of greatest pain . . . has been very

exactly between an inch and a half and two inches
from the anterior spinous process of the ilium on
a straight line drawn from the process to the
umbilicus.”

From then on, this location was known as

the McBurney point
Physical sign:
 Pyrexia
 Localized tenderness in the
right iliac fossa
 Muscle guarding
 Rebound tenderness
S
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g
n
s

t
ROVSING’S SIGN
 Palpating in the left lower quadrant causes pain in the right lower
quadrant
Obturator sign
 Spasm of the obturator internus when the hip is flexed and internally rotated.
 If inflamed appendix is in contact with the muscle, the maneuver causes pain in
the hypogastrium
Psoas sign
 Extending the right hip causes pain along posterolateral back and hip, suggesting
retrocecal appendicitis
Digital rectal examination

 If other signs point to appendicitis, the rectal

examination is unnecessary.

 Maybe helpful if pelvic appendix or abscess

suspected

 Tenderness in the rectovesical pouch or the pouch of

douglas,especially on the right sight – indicates pelvic
appendix
 If appendicitis is allowed to progress

 1.Diffuse peritonitis and shock – more common

in infants
 2.Formation of abscess – older children and
teenagers are more likely to have
periappendicular abscess.
Symptoms of simple appendicitis

1. Pain localized in a right iliac area. In 70 % of patients the pain arises in a

epigastric area – it is an epigastric phase of acute appendicitis. In 2-4 hours it

migrates to the area of appendix (the Kocher’s sign).

2. Single nausea and vomiting.

3. Fever to C.

4. Retention of stool or single diarrhea.

5. Muscular tension in a right iliac area.

Symptoms of simple appendicitis

Rovsing's sign - pain in right lower quadrant during palpation of left lower quadrant

Sitkovsky’s sign - increase of pain in a right iliac area when the patient lies on the left side

Bartomier’s sign - the increase of pain intensity during the palpation of right iliac area

when the patient lies on the left side.

Dunphy's sign-increased pain with coughing

Symptoms of phlegmonous appendicitis

1. Expressed pain in a right iliac area.

2. Fever to C.

3. Muscular rigidity in a right iliac area.

4. Peritoneal signs:
Symptoms of phlegmonous appendicitis

Blumberg’s sign. After gradual pressing by fingers of anterior

abdominal wall quick taking off the hand causes the sharp increase of
pain.
Voskresenky’s sign. The increase of pain during quick sliding
movements by the tips of fingers from epigastric to right iliac area.

Rozdolsky’s sign. Painfulness in a right iliac area during percussion.

Symptoms of gangrenous appendicitis

1. Pain in a right iliac area.

2. Grave condition of the patient.

3. Signs of local peritonitis.

4. Signs of intoxication
Symptoms of retrocaecal appendicitis

• 1. Non-expressive abdominal clinic.

• 2. Expressed pain in a right lumbar area.

• 3. Pain and muscular rigidity in a right iliac area during palpation.

• Yaure-Rozanov sign - Painfulness during palpation of Petit triangle

• Gabay’s sign - Blumberg’s sign in Petit triangle

• Pasternatsky’s sign - tapping of lumbar region cause the pain

• Psoas sign - pain on extension of right thigh

Symptoms of pelvic appendicitis

1. Clinic of irritation of pelvic organs (dysuria, pulling rectal

pain, tenesmus).

2. Absence of muscular tenderness.

3. Painfulness of anterior rectal wall and posterior vaginal vault.

 Paediatric appendicitis scores
•≤2 low likelihood
Features Score •3-7 needs further
evaluation
Fever >38oC 1
•≥8 high likelihood
Anorexia 1  Alvarado score:
Nausea/Vomiting 1  Score <4: No imaging required
(Appendicitis unlikely)
Cough/percussion/hopping tenderness 2  Score 4-6: CT Abdomen
Right lower quadrant tenderness 2  Score >6: Surgical Consultation

Migration of pain 1  Patient Score >6

Leukocytosis > 10,000/L 1
Polymorphonuclear neutrophilia>7500/L 1

Total 10
Differential diagnosis

Small
Appendix Cecum and colon Hepatobiliary
intestines
• Appendicular • Diverticulitis • Cholecystitis • Adenitis
tumor • Intestinal • Meckel’s
Obstruction • Hepatitis diverticulitis
• Carcinoid • Crohn's disease • Gastroenteri
tumor • Chron’s disease • cholangitis tis
• necrotizing • Intestinal
• Appendiceal enterocolitis obstruction
mucocele • Typhilitis • Intussuscep
• Cecal carcinoma tion
• TB
• Typhoid (ulcer
perforation)
 Urinary tract Gynecology Others
• Hydronephrosis • Ectopic pregnancy • Pancreatitis
• Parasitic infection
• Wilm’s tumor • Salpingitis • Pleuritis
• Pneumonia
• Ureteral or • Ruptured ovarian cyst • Schoenlein-Henoch purpura
renal calculus • Tubo-ovarian abscess • Porphyria
• Endometriosis • Psoas abscess
• Ovarian torsion • Kawasaki disease
• PID • Burkitt lymphoma
• Omental torsion
• Rectus sheath hematoma
• Sickle cell disease
• CMV
• Torsion of appendix
epiploica
Investigations
 CBC
 WBC – elevated leukocyte and neutrophil count

 Urine analysis
 Indicated to help exclude genitourinary conditions
 May have some WBC or RBC
Other investigation:
 Serum electrolytes
 Liver function tests
 C-reactive protein
 Tumor markers
 Tuberculin Test
 Viral markers
 Beta HCG
Imaging
 Plain radiographs
 Most helpful in evaluating complicated cases in
which small bowel obstruction or free air is
suspected
 Findings:
 Fecolith
Sentinel
loops of
bowel
and
localized
ileus
Scoliosis
USG of whole abdomen

 Highly operator dependent

 Helpful in other diagnoses
 Findings –
 Wall thickness >6mm
Appendicolith
Luminal distension
 Lack of compressibility
Complex mass in the RLQ
Barium enema contrast radiograph

 Absent or incomplete filling of appendix

 Irregularities of the appendiceal lumen

 Extrinsic mass effect on cecum or terminal ileum

Computed tomography

 Gold standard
 Findings
 Enlarged appendix >6mm
 Appendiceal wall thickening >1mm
 Periappendiceal fat stranding
 Appendiceal wall enhancement
Management
Medical management :
 Correction of dehydration
 Correction of electrolytes
 Management of pain
 Antibiotic therapy
 The use of antibiotic for treatment of appendicitis is clearly beneficial
 For simple appendicitis
 Single preoperative dose to 24 hours of post operative antibiotic therapy
 Complicated appendicitis
 A 10-day course of intravenous ampicillin, gentamicin,and clindamycin or
metronidazole is the gold standard for the treatment of complicated
appendicitis
Management:
1 Stabilize
IVF (D5 1L) + (NS 120ml/h)
2 Monitor
 NPO
 Pre op
 Anesthesia [omeprazole 40mg IV]
 Antibiotics [Cefuroxime 1.5g IV on call to OR]
3-surgery
open appendectomy
4- post surgery
 Antibiotics:
 cefuroxime750mg
BID IV,
 flagyl 500mg BID
IV
 Paracetamol
 1g Q6hrs IV
Surgical management
 For uncomplicated appendicitis
 Non-operative management :
Used in an environment where surgery not
available. Patient having spontaneous resolution.
Surgery remains the gold standard.
 Bowel rest
 Intravenous antibiotics
 If tends to be complicated, Surgery is the
choice of treatment.
 Criteria for stopping
 A rising pulse rate
 Increasing or spreading abdominal
pain
 For complicated appendicitis
 the majority of pediatric surgeons will perform appendectomy
within 8 hours

 Opinions range from nonoperative treatment to aggressive

surgical resection with antibiotic irrigation, drainage of the
peritoneal cavity, and delayed wound closure
 Operative interventions include

Interval appendectomy –

Performingappendectomy following initial successful non-operative

management in patients with no further symptoms

Majority of pediatric surgeons perform this routinely (6-8wk

interval)
Open appendectomy
Technique of retrograde appendectomy
Technique of retrograde appendectomy
Technique of retrograde appendectomy
Technique of retrograde appendectomy
Laparoscopic appendectomy
Laparoscopic appendectomy
Laparoscopic appendectomy
Laparoscopic appendectomy
Problems encountered during appendectomy

 A normal appendix is found

 The appendix cannot be found

 An appendicular tumour is found

 An appendix abscess found

 Pelvic abscess
Complications
 Wound infection

 Intraabdominal abscess

 Ileus

 Adhesive intestinal obstruction

 Faecal fistula
Outcome

 The mortality rate for complicated appendicitis has dropped to

nearly 0
 Antibiotics have markedly decreased the incidence of
infectious complications.
 The overall morbidity in children with complicated appendicitis
is
<10%
 

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