Appendicitis in children – what is it and how it can be treated in Malaysia
Appendicitis is the most common surgical emergency (needing surgery) in children in Malaysia and can present at any age. It is uncommon in children under 5 but when it happens, they can present at a more advanced stage of illness, (ie. perforation). Older children usually present with more classical symptoms and signs. The diagnosis for abdominal pain in adolescent girls may be difficult as ovarian or uterine issues may be the underlying cause. An excellent paediatric surgeon is patient in developing a good relationship with you and your child to successfully evaluate your child, to diagnose the cause of his or her tummy pain.
Causes of Appendicitis
The appendix is a small worm like, blind ending, tubular structure where the open end is connected to the beginning of the large intestine (see diagram).
What happens with appendicitis is that a small piece of faeces (fecolith) enters its open end from the large bowel and gets lodged there. As a result, the mucus that’s been produced by the inner lining of the appendix gets trapped within and distends the appendix.
This mucus is food for the bacteria that’s found inside the intestine and hence they multiply, forming pus (at this point, it may give your child pain, which is non-specific dull aching type of pain around the belly button). As the infection and inflammation inside the appendix progresses it causes inflammation to the surrounding area and tummy wall in the right side (this is when the pain will be localised to the right lower tummy and is sharp in nature and worsens with movement). As the appendix wall weakens further and as the pressure inside increases due to accumulation of the mucus/pus, the appendix will finally burst, spilling the infective pus into the tummy cavity.
There will be terrible pain before the appendix bursts and some relieve after but gradually gets worse again as the spilled pus causes inflammation throughout the abdomen.
There are different rates of progression of this disease and as mentioned, it’s much faster in children under 5.
Symptoms of Appendicitis
An older child with appendicitis may present with abdominal pain, vomiting and low grade fever (37.5 – 38 degrees Celsius). Initially, the pain is typically around the belly button and dull in nature. As it progresses, the pain gradually becomes localized and sharper, to the right lower part of your child’s tummy. Movement such as walking and jumping may exacerbate the pain. Other symptoms include nausea and vomiting and loss of appetite. Rarely, there can be loose frequent stools passed especially when there is perforation.
Children under the age of 5 may have a more varied presentation such as lethargy, refusal to move, fever and vomiting or even just diarrhoea. Diarrhoea is present when there is pus in the lower tummy causing irritation to the colon and rectum.
The conditions that could mimic appendicitis are mesenteric adenitis (swollen lymph nodes, usually secondary to a viral illness), acute gastro enteritis, constipation, urinary tract infection, testicular issues in boys or ovarian issues in girls.
Assessment of Appendicitis by a Paediatric Surgeon
Your child’s paediatric surgeon will firstly seek to find out information on the course of your child’s symptoms. He will try to differentiate the cause of the pain, if its appendicitis or any of the other causes listed above. The examination will include gentle palpation of your child’s tummy without causing too much distress. If the cause is clearly not appendicitis, then your child will be treated appropriately. If its highly suspicious of appendicitis or if the diagnosis is still unclear, some further investigations may be required to confirm the diagnosis.
Bear in mind that no one investigation is definitive in diagnosing appendicitis. Sometimes the examination and the investigations may be equivocal or non-conclusive. This is sometimes seen with mesenteric adenitis or with early appendicitis. In that case, it’s advisable that your child is admitted into the hospital, so your surgeon can do repeated examinations every 6 hours or so to see if the signs changes (active observation).
The pain with appendicitis here usually worsens whereas most other conditions improves. It’s important not to start antibiotics before the definitive diagnosis is made as this can mask the signs of an acute appendicitis, giving a false negative appearance.
Investigations of Appendicitis
Urine sample is usually taken when the child arrives at the hospital, to look for urinary tract infection. Some blood tests are also done. A high white blood cell count suggests inflammation or infection. The other useful blood test include serum C-reactive protein (CRP) to confirm the clinical suspicion of an active inflammatory process.
Abdominal ultrasound (US) is often helpful in children especially in adolescent girls to rule out ovarian or uterine pathology. In most cases an Ultrasound scan is the preferred imaging method as there is no radiation involved and it can be repeated if necessary. However, it may not always pick up an appendicitis if your child’s tummy is bloated or if the appendix is “hiding” behind the large intestine (retrocecal appendix)
A tummy xray is occasionally indicated if there is a history suggestive of urinary stones or if there was evidence of constipation.
Computed Tomography (CT) scans is rarely done in children due to the high radiation dose. As a rule, I avoid the use of CT scans for the diagnosis of acute appendicitis as the history form parents, my examination (extended duration of active observation if required) and the other investigations are sufficient to make the diagnosis or otherwise of appendicitis. It is safer in the long run to perform a diagnostic laparoscopic procedure (keyhole surgery) than a CT scan for your child to look for acute appendicitis.
Management of Appendicitis
Following initial clinical assessment, the child is put into one of three categories:
1) Not appendicitis
If your child has no significant symptoms or signs of an acute abdomen, they can be discharged home but to return if there is worsening of the condition.
2) Has appendicitis
If appendicitis is likely, preparation for surgery should commence with intravenous fluid and intravenous antibiotics
In situations where the symptoms are significant but the diagnosis is doubtful, your child should be admitted for active observation and possibly for further investigations. During this period your child is given mild analgesia as required and is allowed to drink clear fluids only, to avoid delays if surgery is required. Appendicitis is an evolving process and if the diagnosis is unclear when your child is first seen, it may be confirmed or refuted with active observation. The decision to proceed to appendicectomy can then be made. If the pain and tenderness resolve spontaneously during active observation, your child will be discharged home.
Surgery for Appendicitis
Your child’s surgeon will explain to you about the process of surgery and obtain a formal consent for the procedure. As with any surgery under general anaesthesia, our child should be fasted from food or milk for at least 6 hours prior and is allowed to drink water only up to to 2 hours prior to surgery.
Surgery is conducted under general anaesthesia and usually one parent can accompany your child into the operating theatre until your child falls asleep. When you leave the room, the anaesthetic set up will take another 20 minutes before surgery commences.
I perform the surgery by the keyhole or laparoscopic technique. There are numerous proven benefits for the laparoscopic method over the traditional open procedure, including significant pain that children will have to endure with the latter. In addition, it provides shorter duration of hospital stay and better appearance in the long term.
Surgery can take anything from 30 minutes to about 2 hours depending in how advanced the appendicitis is or how “stuck” the appendix may be. If there is pus in the tummy, samples are taken and sent for analysis, so that the antibiotics therapy subsequently can be targeted for the bacteria that’s found in the pus. The appendix that’s removed will also be sent to the laboratory for analysis.
On completion of surgery your child will be sent to the recovery area where you can meet them. Usually your surgeon will discuss with you what was found at surgery and the subsequent plans post-surgery. A mildly inflamed appendix without any pus in the tummy will recover quickly following surgery and may even be discharged the following day, however more complex situation may take a little longer in the hospital. Once discharged they are back to their normal functioning in about 3 – 4 days with the keyhole technique, compared to over 1 week with the open operation. A follow up appointment is usually made 1 week after surgery to enable your surgeon to assess your child’s surgical wound and to discuss the results from the sample of appendix sent to the laboratory. After this there is usually no need for further follow up with your surgeon.
Prognosis of Appendicitis
Earlier presentation and improved clinical diagnosis by paediatric surgeons are the likely important contributors to good outcomes for children with appendicitis. Most complications arise from delayed presentation for medical opinion and poor surgical technique (mostly from adult general surgeons). Overall, however, children with acute appendicitis managed appropriately, generally recover with negligible long-term complications.
As a reminder, here are some tips for you to remember when your child has tummy pain.
Indication to take your child to see a doctor General Practitioner (GP) for a start or to the emergency department at a hospital ( preferably one with a Paediatric Surgeon):
- Constant, persistent abdominal pain that lasts more than 2 hours, without relief.
- Diarrhoea lasting more than 24 hours, particularly with associated lower abdominal pain.
- Tummy pain with vomiting, especially when the vomitus is green or blood stained.
- Tummy pain with blood in your child’s faeces.
- A younger child who prefers to lie still, refuses to be cuddled, wants to be left untouched.