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A challenge for the general practitioner

World J Clin Pediatr. 2015 May 8; 4(2): 19–24.

Pierluigi Marzuillo, Department of Women and Children and General and Specialized Surgery, Seconda Università degli Studi di Napoli, 80138 Naples, Italy

Claudio Germani, Egidio Barbi, Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy

Baruch S Krauss, Boston Childrens Hospital, Boston, MA 02130, United States

Author contributions: Marzuillo P wrote the manuscript; Germani C supervised the manuscript drafting; Krauss BS critically revised and contributed to conceptually improve the manuscript; Barbi E conceived the manuscript.

Correspondence to: Pierluigi Marzuillo, MD, Department of Women and Children and General and Specialized Surgery, Seconda Università degli Studi di Napoli, Via L. De Crecchio 2, 80138 Naples, Italy. [email protected]

Telephone: +39-389-4873353 Fax: +39-040-3785727

Received 2014 Nov 2; Revised 2015 Feb 12; Accepted 2015 Mar 5.

Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.This article has been cited by other articles in PMC.

Abstract

Acute appendicitis is one of the most common indications for abdominal surgery in pediatrics with peak incidence in the second decade of life. Acute appendicitis in the first years of life is an uncommon event. The clinical presentation is often varied and the diagnosis may be overshadowed by other medical conditions. Gastroenteritis is the most common misdiagnosis, with a history of diarrhea present in 33% to 41% of patients. Pain is the most common presenting symptom in children less than 5 years old, followed by vomiting, fever, anorexia and diarrhea. The most common physical sign is focal tenderness (61% of the patients) followed by guarding (55%), diffuse tenderness (39%), rebound (32%), and mass (6%). Neonatal appendicitis is a very rare disease with high mortality; presenting symptoms are nonspecific with abdominal distension representing the main clinical presentation. The younger the patient, the earlier perforation occurs: 70% of patients less than 3 years develop a perforation within 48 h of onset of symptoms. A timely diagnosis reduces the risk of complications. We highlight the epidemiology, pathophysiology, clinical signs and laboratory clues of appendicitis in young children and suggest an algorithm for early diagnosis.

Keywords: Appendicitis, Children, Early diagnosis, Newborn, Appendicitis complications

Core tip: Acute appendicitis in the first years of life is an uncommon event but with a high incidence of early perforation the younger the patient. We highlight the epidemiology, pathophysiology, clinical signs, and laboratory clues of appendicitis in young children. The challenge for the practitioner is to perform a timely diagnosis of acute appendicitis in first years of life before complications occur.

INTRODUCTION

Acute appendicitis has the highest incidence during the second decade of life[1], and represents a frequent indication for abdominal surgery in pediatrics[2]. It is more common in males than in females (ratio 1.4:1)[2]. While up to 33% of affected children may present not distinct abdominal pain with consecutive pain localization in the right lower quadrant, nausea and vomiting, young children could show atypical or delayed symptoms presentation[3-5]. When the diagnosis is performed, perforation could be already present in 30%-75% of children, with young children being at higher risk[6]. Perforated appendicitis increases the morbidity with intra-abdominal abscess being an important complication[7]. In young children, appendicitis is an uncommon event with a varied presentation and complications that can develop rapidly[8,9]. A timely diagnosis although necessary can be difficult, representing a challenge for the physician.

EPIDEMIOLOGY

In a study over a 12-year period, 1836 pediatric appendectomies were reviewed. Three hundred and twenty (17%) patients were under 5 years of age, 103 (5%) were less than 3 years, with only 7 patients (0. 38%) younger than 1 year[7]. Perforation was more frequent in young children (the perforation rate was 86% in children less than 1 year of age, 74% between 1 and 1.9 years, 60% between 2 and 2.9 years, 64% between 3 and 3.9 years, and 49% between 4 and 4.9 years), while the rate in older patients was 5%[7]. Seven patients under 1 year of age were included so that the statistical relevance of the differences in the perforation rate of the different age groups would be limited[7]. Moreover, male patients present more risk of perforation than female patients also if the symptoms have a similar duration[10].

A single pediatric center study over a 28-year period reported a similar rate of appendicitis in patients under 1 year of age (0.34%) and 2.3% in patients under 3 years[11].

Andersen et al[9], in a cohort of Danish children, reported an annual incidence of 2.22/10000 among boys less than 4 years and 1.82/10000 among girls less than 4 years with a perforation rate of 0.64 and 0. 62, respectively. The annual incidence among 10-19 years old boys and girls was 22/10000 and 18/10000 respectively, with a perforation rate of one third the rate of young children[9].

The risk of perforation increases with diagnostic delay. In children 5-12 years old, if the diagnosis is made in less than 24 h from the outbreak of symptoms, the reported perforation rate is 7%, if between 24-48 h 38%, and if more than 48 h 98%[8]. In patients < 3 years, the perforation rate is high (70%), even if the time to diagnosis is less than 48 h[4].

A timely diagnosis is more difficult in toddlers because of presentation to emergency department delayed since the outbreak of symptoms of 1.6 d for patients less than 5 years[7], and 3 d in patients less than 3 years[11].

ANATOMIC AND PATHOPHYSIOLOGIC ELEMENTS

Differences in the appendicitis clinical presentation could be explained by age-related variations in appendiceal anatomy and development. In the neonatal period, the appendix is 4. 5 cm long reaching the length of 9.5 cm in adults[12]. Acute appendicitis is rare in neonates because they present a funnel-shaped appendix[13,14], have liquid diet, supine posture, low frequency of gastrointestinal and upper respiratory tract infections[15]. Furthermore, there is evidence that breast-feeding could reduce the risk of appendicitis[16].

Between 1-2 years of age, the appendix becomes similar to that of an adult and the susceptibility to inflammation increases. Lymphoid follicle hyperplasia and follicular size gradually increase with the major expression during adolescence, corresponding to the period of the highest rate of appendicitis[1]. Young children have an undeveloped omentum that is not able to limit the purulent material effusion from a perforation[17]. For this reason, diffuse peritonitis following a perforation is more likely in young children[18]. The mobility of fetal and infant appendices is accentuated and the probability of appendix to be fixed by mesenteric connections to the cecum, ascending colon, or abdominal wall is lower[19]. This could explain why the incidence of localized abscesses in young children is infrequent.

HISTORY AND CLINICAL EXAMINATION

In preverbal toddlers and preschoolers, the anamnesis about the pain is difficult to examine[20]. In preverbal children, clinicians need to relay on the physical examination and on detecting contingent signs of pathology evaluating how children eat, move around, play, sleep, and defecate[20]. Many children, in particular young children, can be easily influenced. Even though their conflicting significances, questions such as “Does it hurt here” and “This feels fine, right” may lead to the same positive answer[20]. Abdominal pain usually begins as vague mid-abdominal or periumbilical pain migrating to the right lower quadrant during an interval of hours to days, and many school-aged children can accurately report and localize their pain movement. However, young children may not be able to describe accurately their symptoms, and the clinicians could locate the pain exclusively asking the children to show the painful abdominal point[20].

Pain is the most frequent presenting symptom in children less than 5 years old. In a cohort of 120 patients less than 5 years, 94% presented with pain, 83% with vomiting, 80% with fever, 74% with refusal to eat, and 32% with diarrhea[21]. When the data was restricted to children less than 3 years, vomiting, fever and diarrhea were more frequent[11]. If the appendicitis is non-perforated the most common physical sign is localized tenderness (61%) followed by guarding (55%), diffuse tenderness (39%), rebound (32%), and mass (6%)[21]. If the appendicitis is perforated, the most frequent sign is the guarding (79%) followed by diffuse tenderness (62%), rebound (39%), localized tenderness (33%), mass (9%), and rigidity (7%)[21].

In the neonatal period, the signs and symptoms are nonspecific with irritability or lethargy (22%), abdominal distension (60%-90%), and vomiting (59%)[15,22]. Other symptoms include a palpable mass (20%-40%)[15], abdominal wall cellulitis (12%-16%), hypotension, hypothermia, and respiratory distress[22-25]. The most common clinical presenting signs and symptoms are reported in Figure [24].

Neonatal appendicitis: frequency of symptoms at presentation (modified from ref.[24]).

LABORATORY EVALUATION

White blood cell count (WBC) and C-reactive protein (CRP) are commonly used when an acute appendicitis is suspected. Conventional WBC count presents both low sensitivity and specificity, in fact it could increase in 70% of the patients presenting abdominal pain for causes different from appendicitis[26]. A high WBC count or a left shift (represented by higher than 80% polymorphonuclear cells along with bands) has good sensitivity (79%), while the coexistence of both positive WBC count and left shift present the greatest specificity (94%)[27]. The sensitivity and specificity of WBC counts range from 70%-80% and 60%-68%, respectively[28]. Up to 20% of children with pathologically proven appendicitis present a WBC in the normal range[29], while the leukocyte response declines in children younger than 5 years old with appendicitis[30].

CRP is more specific than WBC count, even if in the early stage of acute appendicitis the sensitivity is lower[26,31]. The reported sensitivity and specificity are of 57% and 87% respectively[28]. CRP presents higher sensitivity in discovering appendiceal perforation and abscess formation[26,31]. Recently, it has been demonstrated that the use of both WBC count and CRP may lead to enhanced negative predictive value[6,32]. Yokoyama et al[33] showed as indicative of surgical intervention a CRP cut-off value of 4.95 mg/dL (sensitivity 84% and specificity 76%). Procalcitonin is not helpful in the acute appendicitis diagnosis presenting a diagnostic accuracy lower than CRP and WBC[31]. When a complicated appendicitis is present the pooled procalcitonin sensitivity and specificity are 62% and 94%, respectively[31].

RADIOLOGICAL EVALUATION

Computed tomography (CT) has been considered the radiological gold standard to confirm clinical suspicion of appendicitis with high sensitivity and specificity[34,35]. Repeated CT carries an established risk of increased incidence of cancer in children and its use should therefore be limited to clear indications with a well-defined risk to benefit ratio[36]. Less operator dependence, easier visualization of retrocecal appendix, less interference of bowel gas, obesity, or patient pain and tenderness with image quality are included among CT advantages. For these reasons, CT remains the most common primary imaging method before appendectomy in children[25,37]. To increase sensitivity of diagnosis but decrease radiation exposure, CT used in conjunction with equivocal ultrasonography (US) has been recommended as the most judicious diagnostic imaging pathway[38].

Using US for the acute appendicitis diagnosis is convenient and safe, but is highly operator dependent with a wide reported sensitivity range (44%-100%)[34,36,39]. There is evidence that the diagnostic accuracy can be improved[40] using specific US criteria and using repeated scans[41].

Magnetic resonance imaging (MRI) may also be used in young children[42]. Diagnostic imaging with US selectively followed by MRI is possible and comparable to CT, without differences in time to antibiotic administration and appendectomy, negative appendectomy and perforation rate, or length of stay[43]. Aspelund et al[43] showed an high US-MRI pathway specificity (99%) with a sensibility of 100%.

DIFFERENTIAL DIAGNOSIS

Appendicitis in young children is a diagnostic challenge. In a case series of 27 children less than 3 years, 67% had been visited by one or more clinicians without the diagnosis of acute appendicitis had been performed[11]. At this age the diagnosis of appendicitis may be hided by other medical conditions (Table ). Gastroenteritis is the most common misdiagnosis (possible red flags to suspect appendicitis mimicking a gastroenteritis are shown in Table ), in fact diarrhea may be present in 33%-41% of patients[4,26]. Importantly, as prior infective diseases may play a role in the physiopathology of acute appendicitis[54], diagnosis of a gastrointestinal, respiratory or urinary infection, should not rule out concomitant acute appendicitis[55].

Table 1

Conditions mimicking childhood and neonatal appendicitis (modified from ref.[8])

Condition Diagnostic clues
Gastroenteritis Continuous abdominal pain
Poor clinical condition with mild or no dehydration, continuous, focal abdominal pain, and lack of movement in infants and young children distinguishes appendicitis from gastroenteritis Acute appendicitis is more common during viral epidemics and bacterial gastroenteritis[44]
Upper respiratory tract infection1 The presence of concomitant signs of upper respiratory infection are common in toddlers and does not rule out the possibility of appendicitis
Pneumonia Basal pneumonia may mimic appendicitis pain[45] Simultaneous pneumococcal pneumonia and appendicitis is well reported in the literature[46]
Sepsis An acute appendicitis should be suspected and ruled out in any case of sepsis associated with abdominal pain and or abdominal tenderness[47]
Urinary tract infection Peritoneal inflammation may cause voiding disturbances and bladder symptoms[48]
Blunt abdominal trauma Acute appendicitis may be associated with blunt abdominal trauma[49-51]
Intussception Abdominal US is highly operator dependent In presence of fever, localized pain and guarding in infants and young children, appendicitis should be ruled out[52]
NEC With a history of NEC outside prematurity and signs of abdominal cellulitis, neonatal appendicitis should be ruled out[53]

CONCLUSION

A timely diagnosis of acute appendicitis in young children is a challenge due to the rarity of the disease, the varied presentation, and the rapid development of complications. A high level of suspicion and the knowledge of specific red flags can increase diagnostic skill. We present a diagnostic algorithm (Figure ) that could be used to assess acute appendicitis in young children, optimizing diagnostic sources and limiting the CT use.

Diagnostic algorithm to assess acute appendicitis in young children. WBC: White blood cell count; CRP: C-reactive protein; US: Ultrasonography.

Footnotes

Conflict-of-interest: Nothing to declare.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4. 0/

Peer-review started: November 4, 2014

First decision: November 27, 2014

Article in press: March 9, 2015

P- Reviewer: Ince V, Kapischke M, Radojcic BS S- Editor: Gong XM L- Editor: A E- Editor: Wu HL

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A challenge for the general practitioner

World J Clin Pediatr. 2015 May 8; 4(2): 19–24.

Pierluigi Marzuillo, Department of Women and Children and General and Specialized Surgery, Seconda Università degli Studi di Napoli, 80138 Naples, Italy

Claudio Germani, Egidio Barbi, Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy

Baruch S Krauss, Boston Childrens Hospital, Boston, MA 02130, United States

Author contributions: Marzuillo P wrote the manuscript; Germani C supervised the manuscript drafting; Krauss BS critically revised and contributed to conceptually improve the manuscript; Barbi E conceived the manuscript.

Correspondence to: Pierluigi Marzuillo, MD, Department of Women and Children and General and Specialized Surgery, Seconda Università degli Studi di Napoli, Via L. De Crecchio 2, 80138 Naples, Italy. [email protected]

Telephone: +39-389-4873353 Fax: +39-040-3785727

Received 2014 Nov 2; Revised 2015 Feb 12; Accepted 2015 Mar 5.

Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.This article has been cited by other articles in PMC.

Abstract

Acute appendicitis is one of the most common indications for abdominal surgery in pediatrics with peak incidence in the second decade of life. Acute appendicitis in the first years of life is an uncommon event. The clinical presentation is often varied and the diagnosis may be overshadowed by other medical conditions. Gastroenteritis is the most common misdiagnosis, with a history of diarrhea present in 33% to 41% of patients. Pain is the most common presenting symptom in children less than 5 years old, followed by vomiting, fever, anorexia and diarrhea. The most common physical sign is focal tenderness (61% of the patients) followed by guarding (55%), diffuse tenderness (39%), rebound (32%), and mass (6%). Neonatal appendicitis is a very rare disease with high mortality; presenting symptoms are nonspecific with abdominal distension representing the main clinical presentation. The younger the patient, the earlier perforation occurs: 70% of patients less than 3 years develop a perforation within 48 h of onset of symptoms. A timely diagnosis reduces the risk of complications. We highlight the epidemiology, pathophysiology, clinical signs and laboratory clues of appendicitis in young children and suggest an algorithm for early diagnosis.

Keywords: Appendicitis, Children, Early diagnosis, Newborn, Appendicitis complications

Core tip: Acute appendicitis in the first years of life is an uncommon event but with a high incidence of early perforation the younger the patient. We highlight the epidemiology, pathophysiology, clinical signs, and laboratory clues of appendicitis in young children. The challenge for the practitioner is to perform a timely diagnosis of acute appendicitis in first years of life before complications occur.

INTRODUCTION

Acute appendicitis has the highest incidence during the second decade of life[1], and represents a frequent indication for abdominal surgery in pediatrics[2]. It is more common in males than in females (ratio 1.4:1)[2]. While up to 33% of affected children may present not distinct abdominal pain with consecutive pain localization in the right lower quadrant, nausea and vomiting, young children could show atypical or delayed symptoms presentation[3-5]. When the diagnosis is performed, perforation could be already present in 30%-75% of children, with young children being at higher risk[6]. Perforated appendicitis increases the morbidity with intra-abdominal abscess being an important complication[7]. In young children, appendicitis is an uncommon event with a varied presentation and complications that can develop rapidly[8,9]. A timely diagnosis although necessary can be difficult, representing a challenge for the physician.

EPIDEMIOLOGY

In a study over a 12-year period, 1836 pediatric appendectomies were reviewed. Three hundred and twenty (17%) patients were under 5 years of age, 103 (5%) were less than 3 years, with only 7 patients (0.38%) younger than 1 year[7]. Perforation was more frequent in young children (the perforation rate was 86% in children less than 1 year of age, 74% between 1 and 1. 9 years, 60% between 2 and 2.9 years, 64% between 3 and 3.9 years, and 49% between 4 and 4.9 years), while the rate in older patients was 5%[7]. Seven patients under 1 year of age were included so that the statistical relevance of the differences in the perforation rate of the different age groups would be limited[7]. Moreover, male patients present more risk of perforation than female patients also if the symptoms have a similar duration[10].

A single pediatric center study over a 28-year period reported a similar rate of appendicitis in patients under 1 year of age (0.34%) and 2.3% in patients under 3 years[11].

Andersen et al[9], in a cohort of Danish children, reported an annual incidence of 2.22/10000 among boys less than 4 years and 1.82/10000 among girls less than 4 years with a perforation rate of 0.64 and 0.62, respectively. The annual incidence among 10-19 years old boys and girls was 22/10000 and 18/10000 respectively, with a perforation rate of one third the rate of young children[9].

The risk of perforation increases with diagnostic delay. In children 5-12 years old, if the diagnosis is made in less than 24 h from the outbreak of symptoms, the reported perforation rate is 7%, if between 24-48 h 38%, and if more than 48 h 98%[8]. In patients < 3 years, the perforation rate is high (70%), even if the time to diagnosis is less than 48 h[4].

A timely diagnosis is more difficult in toddlers because of presentation to emergency department delayed since the outbreak of symptoms of 1.6 d for patients less than 5 years[7], and 3 d in patients less than 3 years[11].

ANATOMIC AND PATHOPHYSIOLOGIC ELEMENTS

Differences in the appendicitis clinical presentation could be explained by age-related variations in appendiceal anatomy and development. In the neonatal period, the appendix is 4.5 cm long reaching the length of 9.5 cm in adults[12]. Acute appendicitis is rare in neonates because they present a funnel-shaped appendix[13,14], have liquid diet, supine posture, low frequency of gastrointestinal and upper respiratory tract infections[15]. Furthermore, there is evidence that breast-feeding could reduce the risk of appendicitis[16].

Between 1-2 years of age, the appendix becomes similar to that of an adult and the susceptibility to inflammation increases. Lymphoid follicle hyperplasia and follicular size gradually increase with the major expression during adolescence, corresponding to the period of the highest rate of appendicitis[1]. Young children have an undeveloped omentum that is not able to limit the purulent material effusion from a perforation[17]. For this reason, diffuse peritonitis following a perforation is more likely in young children[18]. The mobility of fetal and infant appendices is accentuated and the probability of appendix to be fixed by mesenteric connections to the cecum, ascending colon, or abdominal wall is lower[19]. This could explain why the incidence of localized abscesses in young children is infrequent.

HISTORY AND CLINICAL EXAMINATION

In preverbal toddlers and preschoolers, the anamnesis about the pain is difficult to examine[20]. In preverbal children, clinicians need to relay on the physical examination and on detecting contingent signs of pathology evaluating how children eat, move around, play, sleep, and defecate[20]. Many children, in particular young children, can be easily influenced. Even though their conflicting significances, questions such as “Does it hurt here” and “This feels fine, right” may lead to the same positive answer[20]. Abdominal pain usually begins as vague mid-abdominal or periumbilical pain migrating to the right lower quadrant during an interval of hours to days, and many school-aged children can accurately report and localize their pain movement. However, young children may not be able to describe accurately their symptoms, and the clinicians could locate the pain exclusively asking the children to show the painful abdominal point[20].

Pain is the most frequent presenting symptom in children less than 5 years old. In a cohort of 120 patients less than 5 years, 94% presented with pain, 83% with vomiting, 80% with fever, 74% with refusal to eat, and 32% with diarrhea[21]. When the data was restricted to children less than 3 years, vomiting, fever and diarrhea were more frequent[11]. If the appendicitis is non-perforated the most common physical sign is localized tenderness (61%) followed by guarding (55%), diffuse tenderness (39%), rebound (32%), and mass (6%)[21]. If the appendicitis is perforated, the most frequent sign is the guarding (79%) followed by diffuse tenderness (62%), rebound (39%), localized tenderness (33%), mass (9%), and rigidity (7%)[21].

In the neonatal period, the signs and symptoms are nonspecific with irritability or lethargy (22%), abdominal distension (60%-90%), and vomiting (59%)[15,22]. Other symptoms include a palpable mass (20%-40%)[15], abdominal wall cellulitis (12%-16%), hypotension, hypothermia, and respiratory distress[22-25]. The most common clinical presenting signs and symptoms are reported in Figure [24].

Neonatal appendicitis: frequency of symptoms at presentation (modified from ref.[24]).

LABORATORY EVALUATION

White blood cell count (WBC) and C-reactive protein (CRP) are commonly used when an acute appendicitis is suspected. Conventional WBC count presents both low sensitivity and specificity, in fact it could increase in 70% of the patients presenting abdominal pain for causes different from appendicitis[26]. A high WBC count or a left shift (represented by higher than 80% polymorphonuclear cells along with bands) has good sensitivity (79%), while the coexistence of both positive WBC count and left shift present the greatest specificity (94%)[27]. The sensitivity and specificity of WBC counts range from 70%-80% and 60%-68%, respectively[28]. Up to 20% of children with pathologically proven appendicitis present a WBC in the normal range[29], while the leukocyte response declines in children younger than 5 years old with appendicitis[30].

CRP is more specific than WBC count, even if in the early stage of acute appendicitis the sensitivity is lower[26,31]. The reported sensitivity and specificity are of 57% and 87% respectively[28]. CRP presents higher sensitivity in discovering appendiceal perforation and abscess formation[26,31]. Recently, it has been demonstrated that the use of both WBC count and CRP may lead to enhanced negative predictive value[6,32]. Yokoyama et al[33] showed as indicative of surgical intervention a CRP cut-off value of 4.95 mg/dL (sensitivity 84% and specificity 76%). Procalcitonin is not helpful in the acute appendicitis diagnosis presenting a diagnostic accuracy lower than CRP and WBC[31]. When a complicated appendicitis is present the pooled procalcitonin sensitivity and specificity are 62% and 94%, respectively[31].

RADIOLOGICAL EVALUATION

Computed tomography (CT) has been considered the radiological gold standard to confirm clinical suspicion of appendicitis with high sensitivity and specificity[34,35]. Repeated CT carries an established risk of increased incidence of cancer in children and its use should therefore be limited to clear indications with a well-defined risk to benefit ratio[36]. Less operator dependence, easier visualization of retrocecal appendix, less interference of bowel gas, obesity, or patient pain and tenderness with image quality are included among CT advantages. For these reasons, CT remains the most common primary imaging method before appendectomy in children[25,37]. To increase sensitivity of diagnosis but decrease radiation exposure, CT used in conjunction with equivocal ultrasonography (US) has been recommended as the most judicious diagnostic imaging pathway[38].

Using US for the acute appendicitis diagnosis is convenient and safe, but is highly operator dependent with a wide reported sensitivity range (44%-100%)[34,36,39]. There is evidence that the diagnostic accuracy can be improved[40] using specific US criteria and using repeated scans[41].

Magnetic resonance imaging (MRI) may also be used in young children[42]. Diagnostic imaging with US selectively followed by MRI is possible and comparable to CT, without differences in time to antibiotic administration and appendectomy, negative appendectomy and perforation rate, or length of stay[43]. Aspelund et al[43] showed an high US-MRI pathway specificity (99%) with a sensibility of 100%.

DIFFERENTIAL DIAGNOSIS

Appendicitis in young children is a diagnostic challenge. In a case series of 27 children less than 3 years, 67% had been visited by one or more clinicians without the diagnosis of acute appendicitis had been performed[11]. At this age the diagnosis of appendicitis may be hided by other medical conditions (Table ). Gastroenteritis is the most common misdiagnosis (possible red flags to suspect appendicitis mimicking a gastroenteritis are shown in Table ), in fact diarrhea may be present in 33%-41% of patients[4,26]. Importantly, as prior infective diseases may play a role in the physiopathology of acute appendicitis[54], diagnosis of a gastrointestinal, respiratory or urinary infection, should not rule out concomitant acute appendicitis[55].

Table 1

Conditions mimicking childhood and neonatal appendicitis (modified from ref.[8])

Condition Diagnostic clues
Gastroenteritis Continuous abdominal pain
Poor clinical condition with mild or no dehydration, continuous, focal abdominal pain, and lack of movement in infants and young children distinguishes appendicitis from gastroenteritis Acute appendicitis is more common during viral epidemics and bacterial gastroenteritis[44]
Upper respiratory tract infection1 The presence of concomitant signs of upper respiratory infection are common in toddlers and does not rule out the possibility of appendicitis
Pneumonia Basal pneumonia may mimic appendicitis pain[45] Simultaneous pneumococcal pneumonia and appendicitis is well reported in the literature[46]
Sepsis An acute appendicitis should be suspected and ruled out in any case of sepsis associated with abdominal pain and or abdominal tenderness[47]
Urinary tract infection Peritoneal inflammation may cause voiding disturbances and bladder symptoms[48]
Blunt abdominal trauma Acute appendicitis may be associated with blunt abdominal trauma[49-51]
Intussception Abdominal US is highly operator dependent In presence of fever, localized pain and guarding in infants and young children, appendicitis should be ruled out[52]
NEC With a history of NEC outside prematurity and signs of abdominal cellulitis, neonatal appendicitis should be ruled out[53]

CONCLUSION

A timely diagnosis of acute appendicitis in young children is a challenge due to the rarity of the disease, the varied presentation, and the rapid development of complications. A high level of suspicion and the knowledge of specific red flags can increase diagnostic skill. We present a diagnostic algorithm (Figure ) that could be used to assess acute appendicitis in young children, optimizing diagnostic sources and limiting the CT use.

Diagnostic algorithm to assess acute appendicitis in young children. WBC: White blood cell count; CRP: C-reactive protein; US: Ultrasonography.

Footnotes

Conflict-of-interest: Nothing to declare.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4. 0/

Peer-review started: November 4, 2014

First decision: November 27, 2014

Article in press: March 9, 2015

P- Reviewer: Ince V, Kapischke M, Radojcic BS S- Editor: Gong XM L- Editor: A E- Editor: Wu HL

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Does This Child Have Appendicitis? Watch Out for Key Signs

A 5-year-old with abdominal pain, nausea and fever may have appendicitis or any of a number of other problems. But how does the child’s doctor decide whether to schedule an emergency appendectomy to surgically remove a presumably inflamed appendix — a procedure that carries its own risks like any surgery — or wait and observe what could be a ticking time bomb that could rupture and kill the patient in a matter of hours? It’s a classic physician’s dilemma, but a new study led by the Johns Hopkins Children’s Center may ease the pediatrician’s problem-solving and parents’ anxiety.

Reporting on their review of the frequency of the most common symptoms of actual appendicitis in children, the researchers concluded that beyond fever, the most telltale signs are “rebound” tenderness or pain that occurs after pressure is removed abruptly from the lower right part of the abdomen; abdominal pain that starts around the belly button and migrates down and to the right; and an elevated white blood cell count (10,000 or more per microliter), which is a marker of infection in the body.

Notably, loss of appetite, nausea and vomiting, hallmark appendicitis symptoms in adults, were NOT predictive of appendicitis in children.

“These signs don’t give you an absolute diagnosis, but they should prompt the doctor to refer the child to a surgeon for evaluation,” said study lead author David Bundy, M.D., M.P.H., a pediatrician at the Johns Hopkins Children’s Center.

Appendicitis is most common in teens and young adults in their early 20s. However, children younger than 4 years are at the highest risk for a rupture. Up to 80 percent of appendicitis cases in this age group end in rupture, partly because young children have fewer of the classic symptoms of nausea, vomiting and pain localized in the lower right portion of the abdomen than do teenagers and young adults, making the diagnosis easy to miss or delay.

In the study report, published in the July 25 issue of the Journal of the American Medical Association, the researchers said ultrasound and CT scan images can be helpful, but are not always conclusive, even if they are available on an emergency basis. And CT scans in particular expose young children to radiation, which should be avoided if possible.

“In a very young child, the presentation of symptoms associated with appendicitis tends to be different from adults, so when trying to decide between fast-track surgery versus watchful observation, you’re often damned if you do and damned if you don’t,” Bundy said. “In our analysis, we’ve identified some of the more powerful telltale signs that should help residents, general pediatricians and ER doctors narrow down what is seldom a clear-cut diagnosis.” 

The appendix is a small tube extending from the large intestine, and infections and inflammation of the organ can be dangerous. The only absolute way to diagnose the condition is surgery, and each year, appendicitis sends 77,000 American children to the hospital. An estimated one-third of them suffer a ruptured appendix, a life-threatening complication, before they reach the OR.

 In their analysis of previous research, investigators searched hundreds of studies, weeding out weak from solid science.  The 25 studies that made the final cut examined symptoms and outcomes in children who presented with abdominal pain and in whom appendicitis was considered a possible diagnosis.  

Abdominal pain in children is one of the most common and vaguest symptoms, and can suggest anything from innocent constipation to serious infections or blockages of the intestines.  Doctors advise parents that any abdominal pain should be evaluated for appendicitis.

 “We really want parents to keep in mind that children with appendicitis don’t always show up with the classic story that we see in adults,” Bundy says. “There isn’t a perfect formula, but we think the signs we’ve identified can help.”

Other researchers in the study: Julie Byerly, M.D., E. Allen Liles, M.D., Eliana Perrin, M.D. M.P.H., Jessica Katznelson, M.D., all of the University of North Carolina at Chapel Hill; and Henry Rice, M.D., Duke University Medical Center.

The research was funded in part by the Robert Wood Johnson Clinical Scholars Program and by the National Institutes of Health.

Appendicitis in Children: Signs and Symptoms

But if your child’s pain begins in the belly-button area and spreads to the lower right abdominal area, it may be the result of appendicitis, a medical condition in which the appendix — a small, finger-shaped pouch attached to the large intestine in the lower right belly area — becomes inflamed. In children who’ve gotten emergency medical care for acute abdominal pain, about 10 to 30 percent have had appendicitis or another condition requiring surgical intervention. (1)

Appendicitis most often affects teens and those in their twenties, but it can occur in children as well. According to the Cleveland Clinic, approximately 80,000 children in the United States are affected each year. (3) It’s usually caused by an abdominal infection that has spread to the appendix, or by a blockage that has obstructed the appendix.

If your child’s abdominal pain worsens with movement, deep breaths, coughing, or sneezing, the possibility that he or she has appendicitis should be seriously considered.

Still, it’s important to look for other signs of appendicitis.

The Signs and Symptoms of Appendicitis in Children

In most adults, there is a very specific set of appendicitis symptoms that accompany abdominal pain. These often include:

  • Loss of appetite
  • Nausea
  • Vomiting
  • Low-grade fever
  • Inability to pass gas or stool
  • Abdominal swelling
  • Constipation or diarrhea

But research suggests that appendicitis can affect children differently than adults. Along with abdominal pain, most kids with appendicitis often experience fever and a symptom known as “rebound tenderness,” (1) a sharp pain that develops after pressure is placed on the lower right abdominal area and quickly released. Children may also have an elevated white blood cell count, which is a sign of an infection. Your doctor can check this with a blood test. (4)

Importantly, although some kids with appendicitis do experience other hallmark symptoms of the condition, including nausea, vomiting, and lack of appetite, these signs are not predictive of appendicitis in children, according to a study published in July 2007 in the Journal of the American Medical Association. (5)

Appendicitis may also cause different sets of symptoms with very young children. Some studies suggest that kids between ages 2 and 5 most often experience stomachaches and vomiting if they have appendicitis; fever and loss of appetite also frequently occur.

For infants younger than 2 years old, appendicitis usually causes vomiting, a bloated or swollen abdomen, and fever, though diarrhea is also not uncommon. (6)

To confirm a diagnosis of appendicitis, doctors often use imaging procedures. For children, the American College of Radiology recommends performing an ultrasound first, followed by a computed tomography (CT) scan only if the ultrasound is inconclusive. This is due to caution concerning radiation exposure in kids. (7)

Treating Complicated and Uncomplicated Appendicitis in Children

An appendectomy, which involves the surgical removal of the appendix, is the standard treatment for appendicitis in children as well as adults. If appendicitis isn’t caught in its early stages, the appendix can rupture and cause an infection of the peritoneum, the membrane that lines the abdominal cavity. This infection, called peritonitis, can quickly spread, potentially causing death.

Because appendicitis is more difficult to diagnose in children than adults — especially in children younger than 5 — some 30 percent of kids with the condition will suffer from a perforated (ruptured) appendix before being treated. (3) (Some data suggests that in children younger than five, it may be up to 51 percent). (8)

For kids with acute, nonperforated appendicitis (meaning the appendix hasn’t ruptured), an urgent appendectomy is the accepted, optimal treatment. When the appendix has ruptured, though, there are two surgical courses of action: early appendectomy (performed within 24 hours of admission) or interval appendectomy (performed several weeks later) after antibiotics are used to treat infection.

As a study published in October 2017 in Pediatrics and Neonatology notes, there hasn’t been a clear consensus on which is the best way to manage ruptured appendices in children — with conservative treatment (antibiotics followed by interval appendectomy) or early appendectomy. (9)

Traditionally, the conservative treatment has been preferred, but other research, including a studypublished in the journal JAMA Surgery, suggested that kids recover more quickly and are less likely to suffer from post-surgery complications, such as surgical site infections, if their ruptured appendices are removed within 24 hours of diagnosis. (10)

Researchers conducting the 2017 Pediatrics and Neonatology study found that such patients may benefit from early appendectomy, as it could shorten the duration of antibiotics, reduce the need to increase antibiotics, and decrease the length of hospitalization. They note that more research is needed to confirm their findings. (9)

When acute appendicitis is uncomplicated and the appendix hasn’t ruptured, there’s increasing evidence supporting antibiotics as an alternative to surgery in adults, and recent studies have also examined if this holds true in pediatric cases. A meta-analysis of studies published in March 2017 in Pediatrics found that data suggests nonoperative treatment is safe and effective in children with acute uncomplicated appendicitis. (11)

Again, study authors say more research is needed. Clinical trials investigating appendectomy versus nonoperative treatment in children whose appendices are not ruptured are currently underway in the United States and the United Kingdom. (12,13)

Additional reporting by Deborah Shapiro.

Appendicitis in Children Information & More



Overview

What is appendicitis?

Appendicitis occurs when the appendix, an appendage (extension) of the colon, becomes inflamed (swollen) and infected. In many cases, an obstruction (blockage) within the appendix causes the infection, resulting in bacterial overgrowth. In 20 to 30 percent of children, the appendix ruptures and releases the infection into the abdominal cavity.

How common is appendicitis?

Appendicitis affects 80,000 children per year in the United States. It is most common in the second decade of life. Fifty percent of children will have a family history of appendicitis. Appendicitis is the most common cause for emergency abdominal surgery in childhood.

Ruptured appendicitis occurs in 30 percent of patients and is more common in children under five years old.



Symptoms and Causes

What are the symptoms of appendicitis?

Because the appendix is located in the lower right portion of the abdomen, the most important symptom is low abdominal pain. This often starts around the belly button and moves to the lower right side later. Other symptoms include:



Diagnosis and Tests

How is appendicitis diagnosed?

The main signs of appendicitis are a history of pain in the right lower portion of the abdomen followed by vomiting and low-grade fever, and tenderness and rigidity (stiffness) in the same area.

Most patients will have imaging of their abdomen with ultrasound and/or a computed tomography (CT) scan. Blood tests and examination of the urine may also be performed.

No one test or finding is 100 percent accurate and reliable in diagnosing appendicitis. The physician must piece together all available information. In some cases, the only way to diagnose appendicitis is to perform surgery.



Management and Treatment

How is appendicitis treated?

The treatment is removal of the infected appendix with surgery. In some cases, when the appendix has already ruptured, surgery is done after a period of treatment with antibiotics.

During the surgery

  • A pediatric anesthesiologist (a physician who specializes in pain relief and sedation in children) gives your child anesthesia, which brings on sleep.
  • If a laparoscopic (minimally invasive camera technique) procedure is used, the surgeon will enter the abdomen with small instruments and a camera, inserted through several tiny incisions (cuts). Sometimes, a mildly larger incision is necessary to take out the appendix.
  • The appendix is removed and the infected fluid is washed out of the abdominal cavity. In some cases, drains are placed to allow for the removal of infected fluid.
  • The surgery generally takes less than an hour to complete.

After the surgery

The usual length of stay in the hospital is 12-24 hours for simple appendicitis, and 5 to 7 days for ruptured appendicitis. The child will receive intravenous (in the vein) pain medication and antibiotics during the hospital stay. Oral feedings are started slowly, usually starting with clear liquids. Your child will gradually advance to a regular diet. There may be a dressing over the incision.

Your child will be ready for discharge from the hospital when he or she can eat a regular diet, has no fever or drainage from the incision, and has normal bowel function.



Living With

What to expect after discharge from the hospital following appendix surgery

Most children will need a few days of rest at home before returning to school, and 2 to 4 weeks before returning to gym and sports, depending on how much inflammation there is.

When to call your child’s health care provider

You may notice some minor swelling around the incision; this is normal. However, call your health care provider if your child develops any of the following:

  • Fever
  • Vomiting
  • Excessive swelling, redness, or drainage from the incision
  • Bleeding
  • Increasing pain

Follow-up office appointment

A follow-up outpatient visit will be scheduled one to two weeks after your child’s surgery. Your child’s health care provider will examine the wound and evaluate his or her recovery.

Kids Health Information : Appendicitis

The appendix sits in the lower right side of the abdomen (stomach). It is quite small and is a normal part of the bowel, but it is not thought to have an important role in the body. 

Appendicitis is an inflammation of the appendix. Inflammation is most commonly caused by a small, hard piece of faeces (poo) getting stuck in the tube of the appendix. If the appendix is inflamed it is usually necessary to remove it with an operation called an appendicectomy (uh-pen-deh-sect-a-me).

Anyone can get appendicitis, but it tends to occur in older children and teenagers. It is rare for someone under the age of five years to get appendicitis. As a common condition, it can occur in multiple family members by chance – it is not a genetic condition.

Signs and symptoms of appendicitis

There are many variations of the symptoms of appendicitis. Symptoms may include:

  • pain that starts around the belly button, then moves to the right side of the abdomen
  • fever
  • loose poo
  • nausea and sometimes vomiting
  • loss of appetite.

When to see a doctor

If you think your child has appendicitis, take them to your GP or local emergency department. A diagnosis of appendicitis is important because the inflammation causes the appendix to swell, and sometimes it can leak its contents into the stomach. This can make your child very sick.

If your child is in significant pain, which is made worse by moving or touching the stomach, go straight to your local emergency department.

How is appendicitis diagnosed?

The doctor will ask for a history of your child’s symptoms and illness. They will examine your child by checking the site of the pain and pressing on the abdomen.

Sometimes it can be difficult to work out the cause of stomach pain as there are many possible reasons. If the doctor is not sure if it is appendicitis, they may keep your child in hospital and watch them to see if their symptoms get worse. Sometimes tests will be performed to help work out
what is going on, but these tests are not always helpful or reliable. 

Your child may need an ultrasound or X-ray to take pictures of their abdomen. The doctor may also do a blood test to look for signs of infection or inflammation. In cases where children are sick and it is not clear why, your doctor may recommend an
operation to check the appendix even if they are not certain it is inflamed.

Treatment for appendicitis

Most cases of appendicitis need an operation called appendicectomy. The appendix is normally removed through a keyhole operation with three, small keyhole cuts about 1-2cm long each, made in different parts of your child’s abdomen. Rarely an open operation will need to be performed through a larger incision.

When a diagnosis of appendicitis is made, your child will be given antibiotics. Antibiotics will stop your child’s appendicitis getting worse while they wait for their operation. 

Before the operation

A surgeon, an anaesthetist (a doctor who puts your child to sleep during the operation) and nurses will explain all the procedures to you before they begin. If you have any questions or anything is unclear, ask staff to explain as many times as needed.

After the operation

After the operation, your child can be given medicine directly into a vein through a drip (intravenous or IV therapy) to stop them feeling sick or vomiting.

Your child may need to have pain medicine, and some will be given antibiotics through the drip to prevent infection of the wound.

The time your child will be in hospital for depends on what is found during the operation. Some children can go home the day after surgery, most after a couple of days and a few will need to be in hospital for five or more days.

Eating and drinking

After the operation, your child will be given fluids through their IV drip until they can eat and drink again. This may be four to six hours after the operation.

Doctors will tell you when and what your child can eat and drink. It is very important to follow staff instructions. The bowel may need to be empty of food or fluid so it can rest after the operation.

Care at home

When your child comes home from hospital, they should:

  • Stay home from school for one week and avoid sports for two weeks, but these times will depend on how sick your child has been. Always ask your surgeon if you’re not sure.
  • Be able to eat and drink as normal.
  • Be able to shower and bathe as normal.
  • Be in minimal pain. You can give paracetamol or ibuprofen as directed, if your child is in pain. See our fact sheet
    Pain relief for children.
  • Any sutures will be dissolving and you will be told what to do about any dressings your child has.

Follow-up

After you leave the hospital, a follow-up appointment will be made for your child to come back and see the surgeon.

There is a small risk of developing an infection or a bowel blockage after having a burst appendix. Contact your GP or take your child to the local emergency department if:

  • your child gets a persistent fever (above 38.5°C)
  • the wound starts to look infected (e.g. it looks red and inflamed, has a discharge, or it becomes more painful)
  • your child has increasing pain that is not controlled by paracetamol or ibuprofen.

Key points to remember

  • A diagnosis of appendicitis is important because a burst appendix can make a child very sick.
  • An appendicectomy is an operation to remove the appendix. The appendix is not useful to the body.
  • Your child will be in hospital for one to five days depending on the severity of the appendix infection.
  • Once you are home from hospital, contact your surgeon if you think your child is developing an infection.

For more information

Common questions our doctors are asked

How can I tell if my child has appendicitis or if it is just
gastro?

It can sometimes be difficult to tell what it causing your
child’s stomach pain, because many of the symptoms of gastro and appendicitis
overlap. Generally, the pain will only be in the right side of your child’s
stomach if it is appendicitis, and any vomiting or diarrhoea will be mild.

If your child has bad pain or persisting symptoms, see
your GP.

What is mesenteric adenitis?

Mesenteric adenitis occurs when the lymph nodes in the
abdomen enlarge in response to an infection – most commonly a viral infection.
This causes stomach pain. The symptoms of mesenteric adenitis are similar to
the symptoms of early appendicitis, but do not progress in the same way. 

What are the risks of surgery to remove the appendix?



All operations have some risks associated with
them, such as the risk of bleeding or infection. Complications due to surgery on the appendix are uncommon. Talk to your surgeon and anaesthetist about any concerns you
have.

Developed by The Royal Children’s Hospital Surgery Department. We acknowledge the input of RCH consumers and carers.

Reviewed August 2020.

Kids Health Info is supported by The Royal Children’s Hospital Foundation. To donate, visit

www.rchfoundation.org.au.

Appendicitis | Boston Children’s Hospital

What is appendicitis?

Appendicitis is a painful swelling and infection of the appendix (a narrow, finger-like pouch that branches off the large intestine). Doctors are not really sure what the appendix does, but removing it is not harmful. Appendicitis is the most common cause of emergency surgery in childhood.

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

What are the symptoms of appendicitis in children?

The following are the most common symptoms of appendicitis in kids. However, each child may experience symptoms differently. Symptoms may include:

  • pain in the abdomen, which may start in the area around the belly button and move over to the lower right-hand side of the abdomen, but may also start in the lower right-hand side of the abdomen
  • usually increases in severity as time passes
  • may be worse with moving, taking deep breaths, being touched, coughing, or sneezing
  • may spread throughout the abdomen if the appendix ruptures
  • nausea and vomiting
  • loss of appetite
  • fever and chills
  • changes in behavior
  • diarrhea or constipation

What causes appendicitis in children?

Appendicitis occurs when the interior of the appendix becomes filled with something that causes it to swell, such as mucus, stool, or parasites. The appendix then becomes irritated and inflamed. The blood supply to the appendix is cut off as the swelling and irritation increase. Adequate blood flow is necessary for a body part to remain healthy. When the blood flow is reduced, the appendix starts to die. Rupture (or perforation) occurs as holes develop in the walls of the appendix, allowing stool, mucus, and other substances to leak through and get inside the abdomen. An infection inside the abdomen known as peritonitis occurs when the appendix perforates.

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.

How we care for appendicitis

Appendicitis can be an emergency situation. The Department of Surgery at Boston Children’s Hospital has surgeons ready day and night to diagnose appendicitis and then remove your child’s appendix, either before or after it has ruptured.

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.

Emergency medicine physicians and scientists at the Proteomics Center at Boston Children’s have demonstrated that a protein detectable in urine might serve as a “biomarker” for appendicitis, potentially allowing diagnosis in a matter of minutes.

90,000 ▶ Appendicitis in children: symptoms, diagnosis, treatment✅ADONIS

Appendicitis is an acute, subacute or chronic inflammation of the appendix of the cecum, or appendix. It can develop in children of any age starting from several months of age. At the same time, the symptoms of the disease, especially in children of preschool and primary school age, may differ. According to statistics, only in 30% of cases, patients have a classic development of the disease. In the remaining 70%, an atypical course of appendicitis is diagnosed.

In case of abdominal pain in a child that does not go away within 1-2 hours or are accompanied by other symptoms, an urgent need to contact a pediatric surgeon. With timely diagnosis, appendicitis can be successfully treated surgically. However, if the operation is not carried out on time, pus from the appendix can burst into the abdominal cavity and provoke the development of severe complications that threaten the child’s life.

Causes of the development of appendicitis in children

The causes of appendicitis in children are not fully understood.Today there are about 6 theories, none of which has sufficient confirmation.

The mechanical theory is considered to be the main one today, according to which the cause of appendicitis is obstruction and infectious lesion of the appendix as a result of fecal stones, parasites or foreign objects entering its lumen. It is also possible that the development of appendicitis is provoked by infectious diseases and endocrine factors.

Most often the disease occurs in children over 5 years of age and in adults aged 20 to 40 years.

Symptoms of appendicitis in children

The most common in children is acute appendicitis. Its symptoms appear on average 12 hours after the onset of the disease, and its full cycle is 24 to 36 hours.

Symptoms of appendicitis in children can vary significantly due to the location of the appendix and the stage of the disease. Only a doctor can make a correct diagnosis after a diagnosis.

The main signs of appendicitis in children are:

  • Abdominal pain that can spread throughout the peritoneum or be localized in the lower right corner
  • Increased pain when moving, coughing and other activity
  • Sharp pain when pressing on abdomen
  • Irritation of the peritoneum (the abdomen becomes stiff)
  • Pain in the back or intestines
  • Increased urination, soreness
  • Diarrhea
  • One-time vomiting
  • Increased pulse and pressure
  • Fever up to 37-38 ° C (with complications – above)
  • Deterioration of general well-being
  • Lack of appetite.

One of the first symptoms of appendicitis is pain localized to the navel or stomach. A little later, it can pass into the lower right corner of the abdomen, lower back, right hypochondrium or suprapubic zone. Localization of pain depends on the location of the appendix. Young children, as a rule, cannot tell exactly where it hurts. They are more likely to complain of general abdominal or navel pain.

With the progression of appendicitis, the pain may become stronger, but at a certain stage of its development it may, on the contrary, decrease.This does not mean that the child is recovering. With appendicitis, pain may decrease if the nerve apparatus of the appendix dies or gangrenous inflammation begins. Also, pain may be mild if the appendix is ​​located behind the cecum.

A classic symptom of appendicitis is also vomiting, which occurs once, and a rise in temperature to subfebrile values. With an atypical course of appendicitis, a violation of urination and stool may also occur.

The diagnosis and treatment of appendicitis in children must be performed by a surgeon. This disease can only be treated promptly in a children’s hospital.

Features different forms of appendicitis

The appendix is ​​a small appendix that branches off from the rectum. Its length does not exceed 5-15 cm, and its diameter is 1 cm, while it gradually narrows and does not have a through passage.

With appendicitis, the appendix lumen is blocked, inflammation and the formation of pus begins.Depending on the degree of the disease and the location of the appendix, different forms of appendicitis are distinguished, the symptoms of which are somewhat different.

The atypical forms of appendicitis include:

  • Retrocecal appendicitis, accompanied by pain in the lumbar region, which may radiate to the thigh
  • Left-sided appendicitis, causing pain on the left side in the iliac region of the abdomen
  • T pain in the navel and lower abdomen, impaired urine output and fever
  • Emipiema, which is characterized by a slow development of the disease and pain in the iliac region of the abdomen.

Acute appendicitis in children

The most common type in children is acute appendicitis.

Symptoms of acute appendicitis in children may vary slightly. Up to 3 years of age, children often complain of abdominal pain due to indigestion or gas, so parents may not immediately suspect that in this case the symptom is caused by the development of acute appendicitis. For initial diagnosis at home, you need to know the main signs of acute appendicitis in children:

  • Severe abdominal pain that can migrate
  • Increased pain when palpating the abdomen
  • Reduction of pain when lying on the side with bent legs
  • Constant muscle tension abdomen
  • Constant nausea and intermittent vomiting
  • Constipation or diarrhea
  • Increase in body temperature
  • Decrease in child activity
  • Refusal to eat
  • Capriciousness.

Abdominal pain is the main symptom of acute appendicitis. However, it can manifest itself in different ways. In children, pain can occur in the upper abdomen, in the right or left side, under the ribs or in the genital area. The location of the pain may periodically change. This is what sometimes makes one think that appendicitis cannot be the cause of pain.

It should also be borne in mind that with an atypical course of appendicitis in children, the pain can be aching, alternately decreasing and increasing.With a temporary disappearance of pain for 2-3 days, it may seem that improvement has begun. However, this usually occurs when the appendix is ​​ruptured and preoperative complications of acute appendicitis develop in adults and children. As a result, peritonitis can occur, which is a serious threat to life.

Diagnosis of appendicitis in children

Doctors diagnose acute appendicitis in children by clinical manifestations, examination and palpation of the abdomen.If necessary, children undergo differential diagnostics, which allows them to identify acute appendicitis or other disease.

For the diagnosis of appendicitis, carry out:

  • Examination of the child and palpation of the abdomen
  • Ultrasound examination (US)
  • Computed tomography (CT)
  • Laboratory tests.

Ultrasound and CT are performed according to indications, when it is necessary to confirm the diagnosis and establish the exact location of the appendix.For differential diagnosis, the doctor may prescribe CT scan with contrast, which provides better visualization and allows you to identify not only appendicitis, but also, in its absence, to establish another cause of abdominal pain. Ultrasound is less informative. It allows you to confirm the development of appendicitis, but is not very informative for other diseases.

Laboratory tests are carried out to confirm the inflammatory process in the body and to prepare the child for surgery.

Treatment of appendicitis

Treatment of acute appendicitis in children and adults is carried out only by surgery. During the operation, the appendix is ​​completely removed.

Today, two types of appendectomy are used:

  • Classical – this is an abdominal operation that involves an incision in the abdomen;
  • Laparoscopic is an endoscopic operation that involves endoscopic access to the abdominal cavity through a small opening.

The choice of a surgical method depends on the location of the appendicitis, the stage of the disease and other factors.The experience of the doctor and the availability of equipment for endoscopic operations in the clinic are also important.

Laparoscopic appendectomy is less traumatic. It is accompanied by less soft tissue damage and less blood loss. The rehabilitation period after it is shorter than after strip surgery, when the child can be left in the pediatric surgery department for up to 10 days.

Appendectomy for children is usually performed under general anesthesia. Patients are immersed in a state of medication sleep for the duration of the operation and taken out of it immediately after the completion of the procedure. If there are contraindications to anesthesia, local anesthesia is sometimes used.

First aid

For pain in the abdomen, the child should not be given pain relievers and antispasmodics. They can change symptoms or provoke the development of complications. Also, you should not apply a hot heating pad or other heat to your stomach. This accelerates the development of the inflammatory process. In some cases, ice is applied to relieve pain.

If you suspect appendicitis, the child should be seen as soon as possible.If the treatment is not carried out within 1-2 days, the disease can provoke the development of peritonitis and other complications.

Prevention of appendicitis

From what appendicitis appears in children is not fully known. Therefore, preventive recommendations are general in nature. To reduce the risk of the disease, it is recommended to adhere to proper nutrition, prevent the formation of constipation, and treat infectious and inflammatory diseases in a timely manner.

Acute appendicitis in children – causes, symptoms, diagnosis and treatment of appendicitis in a child in Moscow in the children’s clinic “SM-Doctor”

Acute appendicitis is a disease that requires urgent (emergency) surgical care, i.e.because the inflammatory lesion of the appendix of the cecum can quickly pass to the peritoneum, provoke peritonitis and other unfavorable ways of developing this clinical situation. In childhood, the disease proceeds quickly enough, therefore, when the first suspicious symptoms appear, you should immediately contact a pediatric surgeon.

Acute appendicitis is a pathology that has no age and can occur even in newborns. However, most often the disease develops in children over 7 years old, reaching a peak in the age group 9-12 years.Acute appendicitis with the same prevalence is recorded among both girls and boys.

Complications

Acute appendicitis can lead to a variety of complications, the rate of development of which depends on the individual characteristics of the child’s body.

  • The appendicular infiltrate is a conglomerate of intestinal loops and an omentum that envelops the inflamed appendix.
  • Perforation of the appendix – purulent fusion of the appendix wall.
  • Diffuse and diffuse peritonitis is an acute inflammatory lesion of the peritoneum of the entire abdominal cavity, which threatens an infectious-septic shock.
  • Intestinal insufficiency syndrome – against the background of inflammation, intestinal motility is disturbed.

The diagnosis of acute appendicitis is a direct indication for surgery. Conservative treatment does not allow to stop the inflammatory process. The operation consists in removing the appendix and sanitizing the abdominal cavity.

Surgical intervention is performed by laparoscopic approach. This option is the gold standard for the surgical treatment of acute appendicitis. Laparoscopic appendectomy has a good aesthetic result, quick recovery and minimal tissue trauma. However, for laparoscopic appendectomy, there must be the necessary conditions, in particular, the absence of total peritonitis. Therefore, it is so important to seek medical help in the first hours after the development of the disease.

The duration of the operation in the absence of complications is from 10 to 50 minutes, in their presence or atypical anatomical location of the appendix – it can increase up to 2 hours.

In the first case, the child spends 3-5 days in the hospital, and in the second – at least 10 days. In some cases, with prolonged preoperative illness of the patient and the presence of complicated forms of appendicitis, the patient needs to stay in the intensive care unit.

How do I get 24/7 help?

When anxiety symptoms appear in a child and depending on his general condition, you can choose 3 methods of receiving medical care: you can go directly to the clinic, call a doctor at home or call an ambulance.”SM-Doctor” has the capacity to provide all three types of assistance.

Symptoms

The main symptom of beginning acute appendicitis in children is abdominal pain, which has no clear localization. It can hurt both in the umbilical region and in the epigastrium. Pain syndrome is accompanied by nausea and refusal to eat, vomiting may also occur, which does not bring relief. After a few hours, the pain becomes more localized and the child indicates the place where it hurts – in the right iliac region of the abdomen.

Because of the pain, the child is in a forced position – bends and pulls his legs to his stomach and lies on his right side. As the pathological process progresses, the child spares the stomach, therefore, turns off the participation of the abdominal wall in the act of breathing.

In the first hours of acute inflammation of the appendix, the body temperature is normal or slightly elevated. A fever of more than 38 ° C usually indicates the development of purulent and destructive forms of appendicitis, an immediate appeal to a pediatric surgeon is required.Delay can threaten the development of infectious-toxic shock and the threat of perforation of the appendix.

Usually a child with acute appendicitis has no stool. However, if the blind process has a pelvic location, then diarrhea is observed (frequent stools of a liquid consistency with an admixture of mucus). Against the background of acute appendicitis, intoxication of the body develops. This is manifested by an increased heart rate and the presence of a white coating on the tongue.

Let us separately dwell on the symptoms of acute appendicitis in children under 3 years of age.Despite the fact that this is a rare disease for this age, it still occurs, and it is characterized by a particularly violent and aggressive course. Symptoms appear amidst complete well-being. The kid becomes capricious, refuses to eat, and the temperature almost immediately rises to 38-39 ° C. There is repeated vomiting and frequent loose stools, which may be streaked with blood and mucus. If you have these symptoms, it is important to immediately contact a clinic that provides round-the-clock medical assistance.

Treatment result

After a surgical intervention for acute appendicitis, the child recovers completely – the causative focus is removed from the body. Early postoperative treatment lasts for several days (after laparoscopy – 2-3 days). The child can return to his usual way of life in 1-2 weeks.

“SM-Doctor” is a clinic that specializes in providing urgent care to children 24/7. Our experts will help you understand and cope with even the most difficult clinical situation.

You can make an appointment or ask questions around the clock by phone +7 (495) 292-59-86

Acute appendicitis in children | Clinic “Oberig”

Acute appendicitis in children is not uncommon. This is due to the anatomical and physiological characteristics of the child’s body, which determines the increased degree of danger during this disease in children. The first is that it is much more difficult to diagnose a child with acute appendicitis than an adult.This is due to the fact that the manifestations of the disease are not pronounced as in adults and the inflammatory process in the appendix develops much faster than in adults. Therefore, much more often it ends with the onset of peritonitis (diffuse inflammation of the abdominal cavity) and other complications.

Appendicitis can occur in all age groups, however, it is very rare in the first 2 years of life. In subsequent years, the incidence of the disease increases, reaching its peak at 8-12 years.

The causal factors of appendicitis are varied: this is how the development of appendicitis is possible against the background of any previous somatic inflammatory diseases, the introduction and change of the child’s diet, as well as provoking factors of development can be anomalies of the appendix (incorrect position, kinks), getting into the lumen of the appendix of foreign bodies (fecal stones, bones, parasites). The appendix consists mainly of lymphatic tissue and any inflammatory process in the gastrointestinal tract can lead to appendicitis.

In the younger age group (up to 3-4 years), the disease begins with seemingly common symptoms. The child is worried, does not sleep. But after a while, he has repeated vomiting, the temperature rises. Loose stools with mucus are not uncommon. Complaints of pain in the right iliac region, which are characteristic of acute appendicitis in adults, almost never occur at this age. Usually the child complains of pain around the navel, the child does not sleep, curls up, “knocks” his legs and is worried about changing the position of the body.If your child complains of abdominal pain, then in no case should you put a HEATER on the sore spot and give the child pain reliever. Heat will increase the speed of the inflammatory process many times over and contribute to the occurrence of complications, and pain relieving drugs can lead to smoothing of the symptoms of appendicitis. When a child develops the listed symptoms (pain, diarrhea, fever, vomiting and weakness), an urgent consultation with a pediatric surgeon is required.

SLOW IS NOT PERMISSIBLE!

In no case should you expect (as often happens) the spontaneous disappearance of these signs or self-medicate.With the development of peritonitis, painful sensations begin to quickly spread throughout the abdomen and very soon it becomes swollen. At the same time, gas and stool retention is often observed. As for the external signs, the child looks restless, he has frightened eyes, his facial features are pointed, and the skin takes on a gray-green tint. Such a condition in a child can develop almost immediately after the first complaints, and therefore parents may simply not have time to adequately react. In all cases of acute appendicitis, surgery is necessary.There is no worthy alternative to surgical treatment of acute appendicitis.

TREATMENT OF ACUTE APPENDICITIS IN CHILDREN

Modern pediatric surgery should no longer be associated with large operations and incisions, which later remain in the form of a scar for life (surgeon’s signature). The development of new technologies has led to the replacement of incisions with small punctures of the abdominal wall. This means that the operation is performed seamlessly, and the appendicitis is removed through a small puncture, 5-7 mm in size.The operation takes less than an hour and within a few days after it the child does not even remember the trouble that happened to him.

In the standard surgical procedure, an incision is made in the right iliac region and the appendix is ​​pulled out and removed. In severe forms, large midline incisions below the navel are often used. The laparoscopic method gives the surgeon a number of advantages, such as a miniature camera, which will help examine the entire abdominal cavity to exclude other pathology, the maximum elimination of the inflammatory process in severe forms of appendicitis, remove all pus in case of peritonitis, working with instruments with a diameter of 3-5 mm leads to a careful attitude to the organs abdominal cavity.

The advantage of this technique is the cosmetic and aesthetic appearance after surgery. And also this method of appendicitis correction is so low-traumatic that after 1-2 days the patient can be discharged home.

At the Center for Innovative Technologies in Pediatric Surgery and Urology, we use such low-traumatic techniques in the surgical treatment of children of any age. We know how to minimize the suffering of the child and the amount of surgeon’s interventions. If you are looking for an expert center in the field of pediatric surgery and urology, contact the Oberig Universal Clinic and we will find the most optimal solution to the problem for your child! Hospitalization around the clock! Call:

(044) 521 30 03

Features of acute appendicitis in children

Acute appendicitis is an inflammation of the appendix of the cecum and one of the most frequent diseases of the abdominal cavity in childhood, requiring urgent surgical intervention.In children, the course of acute appendicitis is somewhat different from adults, which is associated with age characteristics.

In childhood, appendicitis develops faster and more often leads to peritonitis (a severe complication of the disease) than in adults, especially in children in the first years of life. Acute appendicitis can occur at any age, but it is mainly observed after 7 years. Girls and boys get sick equally often.

Symptoms of acute appendicitis

In children over 3 years of age, acute appendicitis usually begins gradually.The main symptom is pain, more often near the navel, then captures the entire abdomen and only after a few hours is localized in the right iliac region. Usually the pain is constant aching in nature. Vomiting, as a rule, occurs once, in some children, stool retention is noted. Body temperature in the first hours is normal or slightly elevated in uncomplicated forms of acute appendicitis. As a rule, sleep is disturbed, appetite decreases or is completely absent.

The clinical picture of acute appendicitis in toddlers most often develops rapidly, against the background of complete health.The child becomes restless, capricious, refuses to eat, the temperature rises to 38 – 39 about C, repeated vomiting occurs and multiple loose stools often develop. Feces may contain blood or mucus.

If parents notice all or some of the above symptoms in a child, an urgent need to consult a doctor to take urgent measures or eliminate the need for surgical intervention. Before the arrival of the doctor, it is important to remember what and when the child ate the last time, when and how many times there was a bowel movement and vomiting.It is imperative to measure the temperature and pay attention to how the child prefers to lie down.

Diagnosis of acute appendicitis

In most cases, the diagnosis can be established by a doctor during examination, without the use of additional research. Despite this, it is mandatory to perform a clinical blood test, in which changes characteristic of the inflammatory process are visible. And patients with acute abdominal pain are shown an ultrasound examination (ultrasound), which allows to identify changes characteristic of acute appendicitis, and to determine changes in the abdominal and pelvic organs, which can give a picture similar to acute appendicitis.To obtain reliable information, an ultrasound scan should be performed by a pediatric specialist who is well aware of the features of the abdominal organs in children.

In case of doubt about the diagnosis, the child must be hospitalized and followed up within 24 hours. The child should be under the constant supervision of a surgeon. In some cases, diagnostic laparoscopy is shown, which is the only way of preoperative visual assessment of the condition of the appendix, and if acute appendicitis is excluded, it allows a sparing revision of the abdominal organs to identify the cause of abdominal pain.

Acute abdominal pain in children can be caused by other diseases such as pleuropneumonia, intestinal infections, viral respiratory diseases, renal colic and other acute surgical diseases of the abdominal cavity, which can be difficult to differentiate from acute appendicitis.

Surgical treatment of acute appendicitis

In the EMC Children’s Clinic, preference for surgical intervention is given to laparoscopic appendectomy, which is associated with a lower risk of complications and wound infections, is less traumatic for the child and has an excellent cosmetic effect.However, traditional intervention has not completely lost its significance and in some cases may be more preferable.

All the necessary conditions are provided for the surgical treatment of appendicitis in the EMC Children’s Clinic:

  • highly qualified surgeons of the clinic are proficient in all modern methods of laparoscopic interventions and have the appropriate certificates;

  • , the necessary high-tech equipment and special tools for minimally invasive interventions are used;

  • , the operation is accompanied by an experienced anesthesiologist, and modern and child-safe anesthesia for laparoscopic procedures is used.

Postoperative period

The postoperative period is no less important. The clinic has created all the conditions for a comfortable stay of children in the intensive care unit, where they can stay with their mother. The ward is equipped with high-tech equipment, round-the-clock monitoring systems have been installed, and a nurse continuously monitors the condition of young patients.

Children after surgery are always given antibiotic therapy.After traditional appendectomy, pain relief is usually required for 2-3 days, and after laparoscopic – usually within the first days after surgery. They start feeding the child from the first postoperative day. On the 4th – 5th day, control ultrasound and clinical analyzes are performed.

Within a week after discharge from the hospital, the child can attend a kindergarten or school. For the first two weeks after the child is discharged, it is recommended to feed in small portions several times a day to eliminate the possibility of overeating.As a rule, the child is exempt from physical education for 1 month.

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90,000 Appendicitis in children: causes, symptoms, features

This happens because, firstly, young children do not know how to correctly determine the localization of pain, and, secondly, appendicitis in a child has its own characteristics that prevent parents from quickly understanding than the problem.

Often in everyday life we ​​confuse the terms “appendix” and “appendicitis”. In fact, the difference is simple to remember: the appendix is ​​an organ, the appendix of the cecum, and appendicitis is an acute disease of the appendix that requires surgical intervention.

Contrary to popular belief, the appendix is ​​not a completely useless rudimentary organ. Doctors often call the appendix “the inner tonsil of the abdomen”: as the tonsils protect the lungs, the appendix protects the intestines, it contains lymphoid tissue, which is involved in various immune processes.That is why modern medicine has abandoned the practice of removing the appendix for “prophylactic” purposes, since this is a direct intervention in the immune system. If you remove the appendix to a child against the background of complete health (as it was at one time it was customary to do, for example, in the USA), his body will be less resistant to infections. In the case when the appendix becomes inflamed (appendicitis begins), doctors are forced to remove it. Then the immune functions of the removed organ will be taken over by other organs and tissues (lymph nodes, spleen, liver).

How does the appendix get inflamed?

The mechanism of appendicitis is well known. Normally, food moving along the gastrointestinal tract should not enter the appendix. If the route changes, then the “lost” particles will no longer be able to leave this organ on their own, decompose in it, causing inflammation. At first, it occurs only in the appendix, but after 12 hours it can spread to the entire abdominal cavity. Gases and mucus formed during the decay of digested food overwhelm the appendix, rupture its walls, the poisonous contents spreads, poisoning the body.

Appendicitis in a child – causes, diagnosis and treatment

Appendicitis is an inflammation of the appendix of the cecum (appendix). Most often, appendicitis occurs in people 10-30 years old.

Reasons

The exact cause of appendicitis is unknown. Inflammatory processes in the intestines, decreased immunity, overeating can provoke the disease.

What’s going on?

There are several theories to explain the development of appendicitis.According to the most popular – mechanical theory – the main reason for the development of acute appendicitis is the activation of the intestinal flora of the appendix against the background of mechanical blockage of its lumen. Obturation (blockage) of the lumen of the appendix is ​​caused by fecal stones (35% of observations), an increase in lymphoid follicles, less often blockage by a foreign body, tumor or parasite occurs. This leads to the accumulation of mucus in the lumen of the appendix and the excessive development of microorganisms, which causes inflammation of the mucous membrane and underlying layers, thrombosis (formation of blood clots and blockage) of blood vessels, necrosis (necrosis) of the wall of the appendix.

Some infectious diseases such as typhoid fever, yersiniosis, tuberculosis, parasitic infections, amoebiasis independently cause appendicitis.

How is it manifested?

The child complains of a stomach ache. If the pain is not very severe, it lasts for several days, the parents sometimes do not pay attention to them. The child goes to school, plays on the street, but then his health deteriorates, he becomes “sour”, sedentary, refuses to eat, tries to lie down more, which alarms the parents.

It also happens like this: in the morning, the abdomen became sharply ill, nausea appeared, the temperature rose, when walking, the pain radiates to the right leg and the right side of the abdomen. The child does not allow him to touch his stomach with his hand, when he is pressed sharply on him, he cries out in pain. There is every reason to suspect acute appendicitis – inflammation of the appendix of the cecum (appendix). But the final diagnosis can only be made by a doctor using blood test data.

Appendicitis is a rather cunning and insidious disease.It can disguise itself as many other ailments, which often makes it difficult to diagnose. This is due to the fact that the appendix is ​​often located not classically – in the lower right corner of the abdomen, but in other places, that is, atypical. And the disease can proceed in different ways. In children, only 30 percent of cases of appendicitis are typical, the remaining 70 percent are completely atypical.

With an atypical location of the appendix, appendicitis can manifest itself as pain in the back, in the rectum.With a pelvic appendix, there may be increased urination, which is accompanied by increased abdominal pain. With subhepatic location of the appendix, pain may appear in the stomach area, then “go down” to the right side of the abdomen.

In children under the age of three, pain is usually not concentrated in one place. The disease can only be judged by a change in the child’s behavior – he becomes whiny, refuses food, vomiting, diarrhea may appear, the temperature rises quickly to 39-39.5 degrees.The child’s condition worsens, he does not allow him to touch his stomach, throws his hand away. The mucous membranes of the mouth and tongue are dry, dehydration quickly sets in.

In children aged three to seven years, the picture is different: they complain of pain in the navel, which then moves to the right iliac region. She is constant, not strong, the child can vomit once. The temperature, if it rises, is not higher than 37.5 degrees, it may be normal.

With the development of purulent processes in the appendix, the child’s condition may deteriorate sharply: thirst appears, the skin turns gray, the lips and mucous membrane of the mouth dry.In combination with diseases such as measles, viral hepatitis, dysentery, salmonellosis, appendicitis can cause a rise in temperature up to 38-39 degrees, nausea, vomiting, loose stools.

Treatment

If the child begins to complain about the stomach, refuse to eat, or his condition has deteriorated sharply, do not self-medicate. Do not give the child any no-shpy, analgin, but immediately contact the surgeon at the clinic. In no case should you put a heating pad on the baby’s stomach. This can provoke a rupture of the appendix and the occurrence of peritonitis.

Often, mothers, having learned that their child has a suspicion of appendicitis, panic: they ask if it is possible to do without an operation. If surgeons confirm the diagnosis of appendicitis, an operation – appendectomy (removal of appendicitis) – is necessary, and it should be carried out as soon as possible.

Post-operation

If the outcome is favorable, the child is discharged on the seventh or tenth day. After discharge, he must be observed by a surgeon in a polyclinic, at least for a week.It is better to stay at home during this time. Sometimes visits to the local surgeon are delayed – if the wound does not heal well or any complications arise.

After being discharged from the hospital, the child is released from physical education. He cannot lift weights, ride a bicycle, sled, jump from a height for a month. But this does not mean that at home he should not lift anything “heavier than a tablespoon.” The best prevention of adhesions and intestinal adhesive disease is the transition to an active life. So at home, the child can do whatever work is possible.

With regard to food, no restrictions should be imposed here. It is advisable to give the child vegetable soups to normalize intestinal motility and stool regulation.

Unfortunately, appendicitis does not always go away without complications. After purulent processes in the abdominal cavity, adhesions often remain and adhesive disease may develop. Such children are registered at the dispensary until they recover.

Sources

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  • Reimer RP., Heneweer C., Juchems M., Persigehl TT. [Imaging in the acute abdomen – part 1: Case examples of frequent organ-specific causes: liver, gallbladder, pancreas, spleen and vessels]. // Radiologe – 2021 – Vol61 – N5 – p.497-510; PMID: 33860818
  • Raoudha K., Amel T., Nesrine J., Najla S., Samia B., Sana M., Jihene B., Abdellatif N., Samia T., Lamia B. Bilateral pheochromocytoma revealed by acute abdominal pain in a child. A case report. // Pediatr Endocrinol Diabetes Metab – 2021 – Vol – NNULL – p .; PMID: 33853288
  • Valitutti F., Verde A., Pepe A., Sorrentino E., Veneruso D., Ranucci G., Orlando F., Mastrominico A., Grella MG., Mandato C. Multisystem inflammatory syndrome in children. An emerging clinical challenge for pediatric surgeons in the COVID 19 era.// J Pediatr Surg Case Rep – 2021 – Vol69 – NNULL – p.101838; PMID: 33846690
  • Belgacem A., Miane H., Fillali W., Hangard P., Ponthier L., Ballouhey Q. Hemolytic uremic syndrome following complicated appendicitis in a child: what is the missing link? // J Int Med Res – 2021 – Vol49 – N4 – p. 3000605211006952; PMID: 33840247
  • Choi SY. Comparison of Clinical Characteristics According to the Existence of Secondary Appendicitis in Pediatric Acute Enterocolitis: A Single Center Study.// Pediatr Gastroenterol Hepatol Nutr – 2021 – Vol24 – N2 – p. 127-134; PMID: 33833968
  • Fadgyas B., Garai GI., Ringwald Z. How COVID-19 pandemic influences pediatric acute appendicitis cases? // Orv Hetil – 2021 – Vol162 – N16 – p.608-610; PMID: 33830938
  • Sharma K., Tomar S., Sharma S., Bajpai M. Floating appendix: post-traumatic amputation of the appendix as sequela or complication ?: a case report. // J Med Case Rep – 2021 – Vol15 – N1 – p.192; PMID: 33827681
  • Moratilla Lapeña L., Delgado-Miguel C., Sarmiento Caldas MC., Estefanía K., Velayos M., Muñoz-Serrano A., De Ceano-Vivas M., López-Santamaría M., Martínez L. Impact of SARS-CoV-2 pandemic on emergency department activity at the pediatric surgery unit of a third-level hospital. // Cir Pediatr – 2021 – Vol34 – N2 – p.85-89; PMID: 33826261
  • Vaziri M., Nafissi N., Jahangiri F., Nasiri M. Comparison of the appendicitis inflammatory response and Alvarado scoring systems in the diagnosis of acute appendicitis in children.// J Med Life – 2021 – Vol14 – N1 – p.75-80; PMID: 33767789

What to do if a child has a stomach ache

Many mothers will read this article after their baby complains of tummy pains. For them I will say right away – urgently to the doctor! And I’ll tell everyone else about the possible and very dangerous causes of abdominal pain in children and what needs to be done immediately.

It so happened that for all three years as a mother, I have never encountered a situation when a baby grabs his tummy and shouts “It hurts!”I lived in peace, treated ARVI and did not even think that I would have to go through what, fortunately, had already ended.

One September day after a walk, my son bent over and, holding on to his stomach, wheezed “Mom, it hurts!” I put him in the crib and tried to lull him to sleep. The pain intensified, and when the son had already stopped crying and curled up into a ball, she called a taxi and rushed to her private pediatrician. She examined her son and sent him to a pediatric surgeon, and she told me that the situation was very similar to acute appendicitis.The surgeon had a different opinion and sent us to the hospital with a diagnosis of colitis. My baby spent two days in intensive care and almost died of painful shock. Then we were treated for an acute intestinal infection for a week, and then we were discharged home. A month later, the situation repeated itself with shocking precision. Now I, without delay, drove my son to the surgeon, and he grinned and reproached me that I again “fed” the child with something. Again resuscitation, from which we were taken by ambulance to the regional children’s surgery. And then an urgent operation and 3 weeks of nightmare in the department.My son had his appendix cut out. A month ago, he (the appendix) was simply “stabbed” with antibiotics. For a month the child walked on the edge of a knife, and after the operation the surgeon said that if we had arrived a day later, he would have done nothing.

I told this story not to scare you, dear mothers. It’s just that my situation is not an isolated case. It’s all too often! And such “professional” doctors too! But after going through all this hell, I realized that a baby’s tummy is not something that is treated at home or with advice from the Internet.I want to tell you about everything.

OCI (acute intestinal infection)

This is the most common cause of abdominal pain. Children under the age of 6 most often suffer from various intestinal infections. Why? The child’s immunity is imperfect, and the intestines cannot always cope with the infection on their own. Germs live everywhere – on the kitchen table, doorknobs, toys, TV remote, and more. Any infection causes vomiting, diarrhea, abdominal pain, weakness, fever, and in small children, the body is instantly dehydrated.And if an adult in case of poisoning is enough to drink activated charcoal and drink a lot of liquid, then serious losses of the child’s body can be restored only in a hospital (antibiotics, droppers).

What should mom do? If you suspect poisoning, try to provide your child with a copious fractional (teaspoon every 5 minutes) alkaline drink (Borjomi without gas, Humana electrolyte). Along with this, exclude dairy products, raw vegetables and fruits. Giving a disinfectant in such cases is categorically contraindicated!

Closely monitor the condition of the child.As soon as you notice that the baby is lying exhausted, or vomiting / diarrhea does not stop, pack up and go to the children’s infectious diseases department. And don’t be afraid, it just sounds so scary. The child will be instilled, and in a day or two they will be allowed to go home.

In order to prevent infection, I recommend that you carefully monitor the baby’s nutrition. Eggs, meat, fish, milk require careful and prolonged heat treatment. All kitchen surfaces, toys, floors should be washed once a week with laundry soap. Do not give your baby food with a dubious shelf life (children are often poisoned with Rastishka, Mashenka, ice cream, citrus fruits).From an early age, teach children to wash their pens, not to take anything from the floor, not to iron cats and dogs.

Mesentery

This terrible word means inflammation of the lymph nodes of the peritoneum. The cause of mesenteric adenitis can be a common ARVI (most often it happens) or an intestinal infection. Lymphogenous spread of infection – from one node to another – gives a similar complication. In this case, lymph nodes can become inflamed both in the neck, behind the ear, and near the joints, but only inflammation of the lymphatic tissue in the intestine causes such acute pain.

What should mom do? The worst thing about this disease is diagnosis only by ultrasound. That is, at home, you will not distinguish mesenteric adenitis (symptoms: acute pain, nausea, diarrhea).

Another unpleasant moment – neglected mesenteric adenitis can cause suppuration of the lymph nodes, and this, as it is easy to understand, is very scary and can only be treated surgically.

So the only thing that mom can do is to ensure the prompt hospitalization in the surgical department. Timely recognized mesenteric adenitis is treated with antibiotics, albeit for a long time.

To prevent it. No matter how trite it sounds, the prevention of mesenteric infection is the absence of infections, both viral and bacterial. So, dear mothers, increase your child’s immunity in all possible ways!

Acute appendicitis

Each of us lives with an appendix. And everyone knows about it. But not many of us know about the symptoms of appendicitis inflammation. An increase in temperature (and vomiting that occurs against its background), diarrhea and acute pain in the right iliac region (and even radiating to the groin and perineum) are not a complete list of them.The baby complains about the tummy, curls up, can only lie on its side? There is every reason for concern for parents. Moreover, each child has individual symptoms, all are characterized by only acute pain. The most acute pain occurs when you release your hand from the place of pressure in the painful area – this is the first sign that you need to lead to surgeons.

In children, appendicitis is especially violent, it gets complicated very quickly. No one knows the clear causes of inflammation of the cecum. Do not listen to grandmothers, the cause of acute appendicitis is not eating seeds with husks.As the surgeon answered me, most often it is an individual feature of the body. Although power supply errors play a significant role.

What should mom do? Many believe that the appendix becomes inflamed in children aged 6-10 years. Such is the critical period. But in our surgery, the operation was performed on a seven-day-old child. Therefore, we do not read nonsense about age characteristics on the Internet, but immediately go to the surgery. Better, as they say, to play it safe.

Even if the child cannot tolerate pain, in no case give him pain relievers before the diagnosis is made – the result will be a blurry clinic and an incorrect diagnosis.Do not try to prick no-shpu – it greatly lowers the pressure, and this is fraught!

Do not be afraid to take your child to the hospital, no one will “cut” him at random. The diagnosis will be confirmed (or not confirmed) by ultrasound, and only then a decision will be made about the operation.

To prevent. Proper nutrition will significantly reduce the likelihood of inflammation of appendicitis. People who eat a lot of plant foods are practically out of the risk group. And you should constantly monitor the child’s stool, because constipation can lead to various inflammation of the intestines.

In addition, I would like to say that some people (2-4%) have more than one appendix.

Intussusception and intestinal obstruction

As a child, my grandmother always forbade my sister and me to run and jump after eating. She said that there would be volvulus. “Fears of some sort,” we thought, and were not going to listen to her. But she was right. In three weeks in the surgical department, I realized this. You should have seen how many children are admitted with suspicion of intussusception. In an accessible language – this is a twisting of the intestine or a situation when one intestine is “inserted” into the other … Symptoms of intussusception: constipation, acute cramping abdominal pain, vomiting, weakness.To the symptoms of obstruction is added the absence of gas discharge, a sharp decrease in peristalsis (no rumbling in the stomach is heard).

What should mom do? And again, only an ultrasound scan will establish the correct diagnosis. To relieve the pain, you can give your child an antispasmodic and take it to the doctor as an EMERGENCY. The fact is that in the first few hours a similar situation is reversible – the baby will be given an enema, the intestines are blown out with air or a special substance is injected, and the ultrasound scan will be repeated. If the intussusception has disappeared, the baby will drink a suspension of barium, which will come out with the first stool (evidence of intestinal patency), and they will let you go home.If you start the situation, you cannot do without an operation!

To prevent it. Most often, intussusceptions occur in children under five years of age, mainly in boys. If your child is at risk, try to monitor his diet, do not allow outdoor games after meals.

I would like to add that the baby’s tummy is the most difficult to reach place for diagnosis. If you can notice the symptoms of sore throat or allergies yourself, then diagnosing the listed diseases is a matter for an experienced surgeon! And you, as a loving parent, should show just such an experienced surgeon of the child – this is your main task !!!

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