APPENDICITIS IN CHILDREN

DR.FARJANA NASRIN INA

RESIDENT,PHASE – A
CARDIOVASCULAR & THORACIC SURGERY
BSMMU
BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
AKNOWLEDGEMENT

Dr. Md. Nooruzzaman

Assistant Professor
Department of Paediatric Surgery

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CONTENTS

 Introduction
 Historical background
 Anatomy
 Etiology
 Pathophysiology
 Diagnostic pathway
 Differential diagnosis
 Management
 Complications and outcome
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INTRODUCTION
 Appendicitis :
Inflammation of the appendix

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 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

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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

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

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 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.

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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

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 Histological structure
Its colonic epithelium and circular
and longitudinal muscle layers are
contiguous with the cecal layers.

The submucosa contains numerous

lymphatic aggregations

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Etiology

 EXACT CAUSE – not completely understood

 ASSOCIATED FACTORS:

 Fecoliths
 Decreased dietary fibre
 Increased consumption of refined carbohydrates
 Incompletely digested food particles
 Lymphoid hyperplasia

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

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Pathophysiology

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Clinical course

 Simple
 Acute appendicitis
 Suppurative appendicitis

 Complicated
 Gangrenous appendicitis
 Perforated appendicitis

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Diagnosis:

 Best made with careful history and

physical examination
 Laboratory investigations
 Scoring systems

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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.

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Classical features :

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

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Age dependent signs and symptoms

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Atypical presentation

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 Physical examination

 Presence of LOCALIZED ABDOMINAL TENDERNESS the SINGLE MOST

reliable finding in the diagnosis of acute appendicitis

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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

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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

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

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 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

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

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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

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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

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Differential diagnosis

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

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

 CBC
 WBC – elevated leukocyte and neutrophil count

 Urine analysis
 Indicated to help exclude genitourinary conditions
 May have some WBC or RBC

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Other investigation:

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

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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

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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

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Barium enema contrast radiograph

 Absent or incomplete filling of appendix

 Irregularities of the appendiceal lumen
 Extrinsic mass effect on cecum or terminal ileum

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Computed tomography

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

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 Clinical scoring system
The ALVARADO (MANTRELS) Score
Symptoms Score
Migratory RIF pain 1
Anorexia 1
Nausea and vomiting 1
Signs <3 – low likelihood
Tenderness(RIF) 2 4-6 – needs further evaluation
Rebound tenderness 1 >7 – high likelihood
Elevated temperature 1
Laboratory
Leukocytosis 2
Shift to left(segmented neutrophils) 1
Total 10
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 Paediatric appendicitis scores
Features Score
Fever >38oC 1 •≤2 low likelihood
•3-7 needs further evaluation
Anorexia 1 •≥8 high likelihood
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
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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

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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
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 For complicated appendicitis

 themajority 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

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 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)

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Open appendectomy

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Laparoscopic appendectomy

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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

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Complications

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

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Outcome

 The mortality rate for complicated appendicitis has dropped to

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

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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.

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