Appendicitis in children

BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
APPENDICITIS IN CHILDREN
DR.FARJANA NASRIN INA
RESIDENT,PHASE – A
CARDIOVASCULAR & THORACIC SURGERY
BSMMU

AKNOWLEDGEMENT
Dr. Md. Nooruzzaman
Assistant Professor
Department of Paediatric Surgery

CONTENTS
 Introduction
 Historical background
 Anatomy
 Etiology
 Pathophysiology
 Diagnostic pathway
 Differential diagnosis
 Management
 Complications and outcome

INTRODUCTION
 Appendicitis :
Inflammation of the appendix

Historical background
 In 1886 DR.REGINALD FITZ coined the term
appendicitis.
 Morton is credited with performing the first deliberate
appendectomy for a perforated appendix in the United States
in 1887.
In 1889 McBurney reported his treatment of
appendicitis with appendectomy before rupture

Incidence
 Most common acute surgical condition in children
 Major cause of childhood morbidity
 The lifetime risk
9% for male
7% for female
 Peak incidence between age 11-18
 Race – whites>black
 Season – peak incidence in autumn and spring

Anatomy
 The appendix 1st becomes visible during
the 8th week of gestation as a
continuation of the inferior tip of the
cecum.
 The appendix rotates to its final position
on the posteromedial aspect of the cecum,
about 2 cm below the ileocecal valve,
during late childhood.
 The variability in this rotation leads to
multiple possible final positions of the
appendix.
 The exact location varies widely

Retrocecal/retrocolic(64%)
Subcaecal(32%)
Pre-ileal(1%)
Post-ileal(2%)
Pelvic appendix

 The appendix averages 8 cm in length but can vary
from 0.3 to 33 cm.
 The diameter of the appendix ranges from 5 to 10 mm.
 The base of the appendix arises at the junction of the
three taeniae coli, a useful landmark
 The mesoappendix arises from the lower surface of
the mesentery or the terminal ileum.
 Function is unknown.

Its blood supply is the appendicular artery is a branch of the ileocolic artery, which passes
behind the terminal ileum.
It is an end artery

Histological structure
Its colonic epithelium and circular
and longitudinal muscle layers are
contiguous with the cecal layers.
The submucosa contains numerous
lymphatic aggregations

Etiology
 EXACT CAUSE – not completely understood
 ASSOCIATED FACTORS:
 Fecoliths
 Decreased dietary fibre
 Increased consumption of refined carbohydrates
 Incompletely digested food particles
 Lymphoid hyperplasia

 INTRALUMINAL SCARRING
 blunt trauma
 •TUMORS OR MALIGNANCIES
 carcinoid tumors
 •MICROORGANISMS:
 a. BACTERIA –
 Yersinia
 Salmonella
 Shigella spp
 b.VIRUSES –
 Mumps
 CoxsackievirusB
 Adenovirus
 Infectious mononucleosis
 c. OTHERS - Ascaris lumbricoides

Pathophysiology

Clinical course
 Simple
 Acute appendicitis
 Suppurative appendicitis
 Complicated
 Gangrenous appendicitis
 Perforated appendicitis

Diagnosis:
 Best made with careful history and
physical examination
 Laboratory investigations
 Scoring systems

Clinical presentation
 Children with appendicitis usually lie in
bed with minimal movement.
 Older children may limp or flex the
trunk
 Infants may flex ther right leg over the
abdomen.

Classical features :
• Periumbillical colic
• Pain shifting to the right
iliac fossa
• Anorexia
• Nausea
• Indigestion or subtle
changes in bowel habits
• Diarrohea

Age dependent signs and symptoms

Atypical presentation

Physical examination
 Presence of LOCALIZED ABDOMINAL TENDERNESS the SINGLE MOST
reliable finding in the diagnosis of acute appendicitis

McBurney described :
“the seat of greatest pain . . . has been very
exactly between an inch and a half and two inches
from the anterior spinous process of the ilium on a
straight line drawn from the process to the
umbilicus.”
From then on, this location was known as the
McBurney point

Physical sign:
 Pyrexia
 Localized tenderness in the
right iliac fossa
 Muscle guarding
 Rebound tenderness
Signs to elicit in appendicitis :
 Pointing sign
 Rovsing’s sign
 Psoas sign
 Obturator sign

ROVSING’S SIGN
 Palpating in the left lower quadrant causes pain in the right lower
quadrant

Obturator sign
 Spasm of the obturator internus when the hip is flexed and internally rotated.
 If inflamed appendix is in contact with the muscle, the maneuver causes pain in the
hypogastrium

Psoas sign
 Extending the right hip causes pain along posterolateral back and hip, suggesting
retrocecal appendicitis

Digital rectal examination
 If other signs point to appendicitis, the rectal examination is
unnecessary.
 Maybe helpful if pelvic appendix or abscess suspected
 Tenderness in the rectovesical pouch or the pouch of douglas,especially
on the right sight – indicates pelvic appendix

If appendicitis is allowed to progress
 1.Diffuse peritonitis and shock – more common in infants
 2.Formation of abscess – older children and teenagers are
more likely to have

Differential diagnosis
Appendix Cecum and colon Hepatobiliary
Small
intestines
• Appendicular
tumor
• Carcinoid tumor
• Appendiceal
mucocele
• Diverticulitis
• Intestinal
obstruction
• Crohn's disease
• Typhilitis
• Cecal carcinoma
• Cholecystitis
• Hepatitis
• cholangitis
• Adenitis
• Meckel’s
diverticulitis
• Gastroenteritis
• Intestinal
obstruction
• Intussusception
• TB
• Typhoid (ulcer
perforation)

Urinary tract Uterus/ovary Others
• Hydronephrosis
• Wilm’s tumor
• Ureteral or renal
calculus
• Ectopic pregnancy
• Salphingitis
• Ruptured ovarian cyst
• Pancreatitis
• Parasitic infection
• Pleuritis
• Pneumonia
• Schonlein-Henoch purpura
• Porphyria
• Psoas abscess
• Kawasaki disease
• Burkitt lymphoma
• Omental torsion
• Rectus sheath hematoma
• Sickle cell disease
• CMV
• Torsion of appendix
epiploica

Investigations
 CBC
 WBC – elevated leukocyte and neutrophil count
 Urine analysis
 Indicated to help exclude genitourinary conditions
 May have some WBC or RBC

Other investigation:
 Serum electrolytes
 Liver function tests
 C-reactive protein
 Tumor markers
 Tuberculin Test
 Viral markers
 Beta HCG

Imaging
 Plain radiographs
Most helpful in evaluating complicated cases in
which small bowel obstruction or free air is
suspected
Findings:
Fecolith
Sentinel loops of bowel and localized ileus
Scoliosis from psoas muscle spasm
Abnormal gas shadow in the RLQ
Calcified appendicolith

USG of whole abdomen
Highly operator dependent
Helpful in other diagnoses
Findings –
Wall thickness >6mm
Appendicolith
Luminal distension
Lack of compressibility
Complex mass in the RLQ

Barium enema contrast radiograph
 Absent or incomplete filling of appendix
 Irregularities of the appendiceal lumen
 Extrinsic mass effect on cecum or terminal ileum

Computed tomography
 Gold standard
 Findings
 Enlarged appendix >6mm
 Appendiceal wall thickening >1mm
 Periappendiceal fat stranding
 Appendiceal wall enhancement

Clinical scoring system
<3 – low likelihood
4-6 – needs further evaluation
>7 – high likelihood
The ALVARADO (MANTRELS) Score
Symptoms Score
Migratory RIF pain 1
Anorexia 1
Nausea and vomiting 1
Signs
Tenderness(RIF) 2
Rebound tenderness 1
Elevated temperature 1
Laboratory
Leukocytosis 2
Shift to left(segmented neutrophils) 1
Total 10

Paediatric appendicitis scores
Features Score
Fever >38oC 1
Anorexia 1
Nausea/Vomiting 1
Cough/percussion/hopping tenderness 2
Right lower quadrant tenderness 2
Migration of pain 1
Leukocytosis > 10,000/L 1
Polymorphonuclear neutrophilia>7500/L 1
Total 10
•≤2 low likelihood
•3-7 needs further evaluation
•≥8 high likelihood

Management
Medical management :
 Correction of dehydration
 Correction of electrolytes
 Management of pain
 Antibiotic therapy
 The use of antibiotic for treatment of appendicitis is clearly beneficial
 For simple appendicitis
 Single preoperative dose to 24 hours of post operative antibiotic therapy
 Complicated appendicitis
 A 10-day course of intravenous ampicillin, gentamicin,and clindamycin or
metronidazole is the gold standard for the treatment of complicated appendicitis

Surgical management
 For uncomplicated appendicitis
 Non-operative management :
Used in an environment where surgery not available.
Patient having spontaneous resolution.
Surgery remains the gold standard.
Bowel rest
Intravenous antibiotics
If tends to be complicated, Surgery is the choice of treatment.
Criteria for stopping
 A rising pulse rate
 Increasing or spreading abdominal pain
 Increasing size of the mass

 For complicated appendicitis
the majority of pediatric surgeons will perform appendectomy
within 8 hours
Opinions range from nonoperative treatment to aggressive
surgical resection with antibiotic irrigation, drainage of the
peritoneal cavity, and delayed wound closure

Operative interventions include
Interval appendectomy –
Performing appendectomy following initial successful non-operative
management in patients with no further symptoms
Majority of pediatric surgeons perform this routinely (6-8wk
interval)

Open appendectomy

Laparoscopic appendectomy

Problems encountered during appendectomy
 A normal appendix is found
 The appendix cannot be found
 An appendicular tumour is found
 An appendix abscess found
 Pelvic abscess

Complications
 Wound infection
 Intraabdominal abscess
 Ileus
 Adhesive intestinal obstruction
 Faecal fistula

Outcome
 The mortality rate for complicated appendicitis has dropped to
nearly 0
 Antibiotics have markedly decreased the incidence of infectious
complications.
 The overall morbidity in children with complicated appendicitis is
<10%

Summary
 Appendicitis is a common cause of abdominal pain in children.
 Repeated abdominal pain should not be overlooked.
 A careful history and physical examination can reliably make
diagnosis in majority of cases
 Minimally invasive appendectomy is treatment of choice.
 Post-operative management is determined by operative findings.

Appendicitis in children

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