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Incidence
Appendicitis is the most common surgical emergency in children.
The overall lifetime risk is estimated to be around 8%with an age peak during 10 years.
There is a slight male predominance (60%).
Etiology
Half the cases arise from luminal obstruction from stool fecaliths.
lymphoid hyperplasia or neoplasm.
A family history imparts a nearly threefold increased risk, with genetic factors accounting
for 30% of the risk of developing appendicitis.
resolution without treatment can occur as is seen in cases of relapsing or chronic appendicitis.
Perforation rates have been reported to be as high as 82% in children younger than 5 years and
nearly 100% in 1-year-old children.
Bacteria such as Yersinia, Salmonella, and Shigella, viruses such as mumps, Coxsackie B, and
adenovirus.
Diagnosis
1.History
(Clinical features)
1. Anorexia Common
2. vague periumbilical pain Problem in
3. migrating to the right lower quadrant School Age
4. Nausea & vomiting Children
5. Diarrhea is often seen with perforated appendicitis
6. Fever is common and usually of low grade in acute appendicitis
This pain is of visceral nerve origin and is referred to the common dermatome of the 8th–10th thoracic dorsal ganglia,
which results in the sensation of periumbilical pain. It is important to remember that inflammation of any midgut
derivative will cause this same symptom.
The pain becomes localized to the right lower abdomen when the inflammation on the appendix irritates the local
peritoneum, which has potent somatic sensation.
In general, gastroenteritis is more likely with a history of repeated episodes of vomiting and diarrhea starting at a similar time
or preceding the onset of the pain. This is especially true when the abdominal pain is the minor symptom, it is not localized, and
there is no focal tenderness
A palpable mass in the RLQ is difficult or nearly impossible to identify in the patient with guarding or rigidity. The
mass often becomes evident on the operating table after anesthesia has been induced.
The classic picture outlined previously with progression of pain to tenderness and anorexia to vomiting
actually occurs in fewer than half of patients.
50% of those with appendicitis presented without pain migration,
50% with-out rebound tenderness,
40% without anorexia
29% without nausea.
Bowel sounds are also quite nonspecific (and may be absent if perforation has occurred) compared with
informs being hyperactive with gastroenteritis
rectal examination is a traumatizing and nonspecific adjunct that is unlikely to contribute to the evaluation .
.
Appendicitis Risk Scores
The Alvarado Score is similar to the Pediatric Appendicitis Score (PAS), which is specifically designed
for children age 4–15 years.
The Appendicitis Inflammatory Response (AIR) Score may be preferable in young children because
the Alvarado Score requires children to identify nausea, anorexia, and migration of pain.
The Alvarado Score compares more favorably to the AIR Score in adolescents.
The PAS and the Alvarado Score have been investigated the most thoroughly, and both had initially
shown sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV)
over 90%.
The scoring systems are even less reliable in adolescent females, which demonstrates the necessity
for investigation beyond the scoring system in these patients.
APPENDECTOMY
The historic standard for management of appendicitis has been urgent appendectomy.
Although the operation used to be considered an emergency, this is no longer the case.
antibiotics alone can treat appendicitis the operation can be performed the next day after initiation
of antibiotics without concern for a negative impact.
delays of 12–24 hours were not associated with increased rates of perforation or postoperative
abscess.
delay was not associated with an increased risk for wound infection, intra abdominal abscess,
reoperation, or readmission.
In addition, appendectomies during the night place stress on the family, the surgeon, and the
hospital, and are no longer justified.
Most appendectomies today are performed laparoscopically, currently well over 90% compared
with 20% twenty years ago.
Advantages
no difference in abscess risk between the open and laparoscopic
laparoscopy has been shown to decrease wound infections In addition, the clinical importance of
port site infections is relatively small.
After appendectomy for no perforated appendicitis, current evidence suggests an additional dose of antibiotics is not necessary or
recommended. Recently, there has been a movement to discharge these patients without an additional night in the hospital.
NONOPERATIVE MANAGEMENT
Managing children with uncomplicated appendicitis without an appendectomy is a treatment choice.
Avoiding an operation avoids an unnecessary anesthetic for those patients who do not have appendicitis.
NOM had fewer complications, better pain control, and shorter sick leave, but with a high rate of recurrence
compared with initial appendectomy.
A challenge to no operative management (NOM) of acute appendicitis in children is parental misperception that a delay in
appendectomy is likely to lead to a ruptured appendix, with a high likelihood of major complications or death.
Perforated Appendicitis
perforation is an identifiable hole in the appendix or a fecalith in the abdomen, with a high risk of
developing an abscess (20%).
A retrospective comparative study found once-a-day dosing with ceftriaxone and metronidazole was
as effective as traditional triple therapy and less costly.
A multicenter case-control study suggests that the patient who is clinically well by postoperative day
3 is unlikely to develop an abscess.
A randomized trial found early transition to oral antibiotics to be as effective as a prolonged course
of IV antibiotics.
A follow-up prospective observational study found that further oral antibiotic therapy was not
needed if the patient is eating and has a normal WBC count.
patients will require antibiotic therapy postoperatively at least until clinical resolution.
Three general strategies are applied for the treatment of perforated appendicitis:
antibiotics only.
antibiotics followed by interval appendectomy.
and appendectomy on presentation.
The rationale for treating initially with antibiotics is to avoid a difficult operation during the peak of the
inflammatory process, which can make the operation more difficult. After treating the acute
presentation with antibiotics, an operation becomes more straight forward , and then the decision
becomes whether to perform the appendectomy or not.
Those who do not perform an appendectomy think there is a low risk of recurrent
appendicitis, is 8–14%.
In the antibiotic and observation gro up, 12% recurred with appendicitis in the one -
year time.
These results were not different from the rate of complications in the
antibiotics/interval appendectomy group, and the authors concluded that antibiotics
and observation may be a reasonable approac h.
Several studies have compared early versus delayed appendectomy for perforated
appendicitis,
Those undergoing a delayed operation had fewer overall complications, wound
infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations .
No significant difference was found in the duration of the initial hospitalization, the
overall duration of hospitalization, and the duration of IV antibiotics.
increase in the postoperative development of an abscess resulting from the use of
irrigation,
Abscess on Presentation
In the past, the operations were difficult and required large incisions with high morbidity.
Treatment of the abscess, with percutaneous aspiration with or without placement of a drain
followed by interval appendectomy when the inflammation has resolved, allows for a less
morbid operation.
culture of the fluid has been shown to be of no benefit it is routine clinical practice to flush
the drains once or twice a day with saline to maintain patency.
we do not recommend the routine use of instilling tissue plasminogen activator tPA into
abdominal abscesses.