John E. Monaco, M.D.
Appendicitis remains one of the major reasons for surgery in children. Although there have been advances in making the diagnosis, and even some treatments, the basic pathophysiology has not changed: the appendix becomes inflamed, then infected and must be removed before it ruptures, spreading infection throughout the abdomen.
Who Can Get Appendicitis?
Basically anyone with an appendix, which is virtually everyone, can experience inflammation of this tiny structure. We tend to think of it as a condition common in later childhood and early adulthood, but the fact is it can be seen in infants and toddlers as well. The younger the child, however, the more difficult it is to diagnose.
We recently cared for a 15-month-old admitted for gastroenteritis and dehydration who was found to have appendicitis after three days of worsening symptoms despite aggressive medical management.
What Is The Appendix?
The vermiform ("wormlike") appendix is a blind pouch attached to junction of the large intestine (colon) and the end of the small intestine (cecum). Embryologically, it appears to have had an immunologic function playing a role in the development of white blood cells. Today it is thought of as a organ which may have had in function in the past, but currently has none. In millions of people it has been removed with impunity. This is somewhat analogous to tonsils, which were routinely removed in many kids of my generation, but also due to their undoubted immunologic importance, are now taken out only if absolutely necessary.
How Does The Appendix Become Inflamed?
There are several proposed mechanisms. One is that the opening of the appendix, which in its normal state secretes fluid into the gut, becomes obstructed with stool or other debris. The obstruction leads to inflammation, swelling, infection and ultimately perforation or rupture. Other mechanisms such as spasm or primary infection have been proposed as well.
What Are The Symptoms Of Appendicitis?
Classically, a patient with appendicitis comes to the doctor with fever and right lower quadrant abdominal pain. This can be associated with vomiting. Usually the white blood cell count is elevated and if the physical exam is typical for an appendicits, the diagnosis is made.
The pain of appendicitis is typically described as beginning around the area of the belly button and then progressing the right lower quadrant of the abdomen. When the appendix is sufficiently inflamed there will be distinct and severe tenderness in the abdominal wall just above the appendix, the so called "McBurny's point."
Findings are very often not classical however, and in the very young or obese patient, the exact location of the pain may be difficult to determine. In these cases other diagnostic methods may need to be employed. And, if the appendix has already ruptured, the location and severity of the pain is completely unpredictable. Severe peritonitis (inflammation of the inside of the abdominal wall) is a severe complication, which is call by doctors a "board like abdomen."
What Other Tests May Be Done To Diagnose Appendicitis?
History and physical exam remain the most reliable tools in diagnosing this condition. However, with the advent of sophisticated imaging techniques, combined with increasing medicolegal concerns, CT scan and ultrasound are used more often to diagnose the diseased appendix. By utilizing sound waves or x-rays respectively, the appendix can be fairly well visualized and assessed, adding more information to a sometimes unclear diagnostic situation. The ultimate goal of all testing is to aid in the decision as whether surgery is indicated or not.
Does The Appendix Always Have To Be Removed If It Is Diseased?
In the vast majority of situations, the appendix does have to be removed when it is inflamed and causing problems. In one scenario, however, the decision may be made to observe the patient on antibiotics and supportive care without immediately going to the operating room. This is when the appendix has already ruptured, therefore the pressure within the structure has naturally been released. In this case, the surgeon may elect to place the patient on broad-spectrum intravenous antibiotics in the hospital under close observation. A CT scan will most likely be done to look for abscesses or other problems that would necessitate surgery. Once the infection is under control and the patient is stable, sometimes weeks later, the patient may be taken to the operating room to have the appendix removed.
What Is The Mortality Rate From Appendicitis?
Thankfully, it is very low. Due to advances in hospital medical care, diagnostics and improved surgical technique, the death rate from appendicitis and its complications is low. Still, this illness should not be treated as routine. In the not too distant past, before antibiotics and contemporary surgical techniques, people did die from appendicitis.
I still remember my grandmother recounting the story of her first child who, at the age of twelve, died on the dining room table of an unknown abdominal ailment that turned out to be appendicitis with rupture. Most physicians know of stories like these, which is why if your child complains of lower abdominal pain and has fever combined with a suggestive or equivocal abdominal exam and an elevated white blood cell count, he or she will be treated as if they have appendicitis until proven otherwise.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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