Appendicitis in children – what is it and how it can be treated in Malaysia

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Dr Nada Sudhakaran

Paediatric Surgeon & Urologist

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).

The Appendix

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

The first signs of appendicitis are often a mild fever and pain around the belly button. It might seem like just a stomachache. But with appendicitis, the pain usually gets worse and moves to the lower right side of the belly.

If your child has belly pain, be on the lookout for these signs of appendicitis: 

  • strong pain, mainly around the belly button or in the lower right part of the belly (the pain might come and go at first, then grow steady and intense)
  • low-grade fever
  • loss of appetite
  • nausea (feeling sick) and vomiting (throwing up)
  • diarrhea (especially small amounts, with mucus)
  • swollen belly

If pain spreads across the belly, it may mean the appendix has burst. Doctors call this ruptured appendicitis, and it’s serious. A high fever reaching 104°F (40°C) is another sign of a burst appendix. 

Call your doctor right away if you think your child has appendicitis. The sooner it’s caught, the easier it will be to treat.

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.

Laparoscopic view of an inflamed swollen appendix

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

3) Uncertain

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.

Patient Testimonials

Hello, I am Liloïa, I am 10 years old and two weeks ago I had my appendix taken out by DR Nada with keyhole surgery. This was on a Monday, it happened very quickly, only 4hours after arriving at ER I was going to surgery. On Tuesday, Dr Nada agreed to discharge me and sent me home.

After that my surgery recovered pretty well until a girl jumped on my wound from height 10days after surgery. My wound bleed and hurt but on the next day I had a big important athletics competition and Dr Nada gave me green light to go. I didn’t practice for 2months (had knee problem before), had that surgery 10days before and still managed to win 3 gold medals ? ??(400m, 200m and 100m relay against 7 other runners from different schools).

Thanks a lot Dr Nada for your help, for your amazing job, for being available and listening to me. I am very very grateful.

Marion Fages, mother

My son is 6 years old this year. Two weeks ago, 20/10/20, because of constant vomiting, I took him to the general clinic to see a doctor. The doctor diagnosed that he had eaten the wrong thing. The next day, he still vomited, had a stomachache and had a slight fever. He went to another clinic and said he had intestinal inflammation.

On the third day, he did not get better, so he took him to a pediatric specialist. The doctor said that he should go to the hospital for appendicitis. The doctor gave me DR.NADA’s phone number and letter of introduction to the hospital.

After seeing DR.NADA and doing ULTRASOUND in the hospital, he was diagnosed with appendicitis and ruptured. The doctor immediately ordered him to perform the operation at night. DR.NADA explained that the operation uses the laparoscopic method, which can alleviate the huge pain that the child must endure. The operation took about an hour and a half.

The next day, my son recovered well, the wound was small and he would not feel very painful. He was discharged after 5 days in the hospital.

Return to the clinic 1 week after discharge to allow DR.NADA to evaluate the child’s surgical wound and discuss the results of the appendix analysis sent to the laboratory.

Thank you very much for DR.NADA’s help, thank you for your excellent work. I am very, very grateful.

Yee C.P, mother

On 24th July 2019 while I was living in Kuala Lumpur with my beloved family for my work, I took my 8 years old son, Hafiz Maulvi Abdul Malik to clinic in Kuala Lumpur for checking up his abdominal pain.

It was 3 days that my boy had been having a bad cold, vomiting, loss of appetite and gradually stomach illness that left him unable to walk. Based on clinic’s doctor observation my boy had suspect symptoms of appendicitis, so the doctor suggested me to straight away send him to Prince Court Medical Centre for further treatment.

Once abdominal ultrasound scan done, he was diagnosed with appendicitis and a ruptured case at that. The doctor recommended me to see Dr Nada who is a Paediatric Surgeon and Urology specialist in Prince Court Medical Centre. After seeing Dr Nada, the surgery decision shall be conducted immediately at that time to avoid the severe condition on my boy since he was feeling severe pain in his stomach which become sharper even if he didn’t move his body.

Finally, Dr Nada undertook keyhole surgery and did excellent work on my boy. It took longer time (more than 2 hours) that allowed for washing and cleaning up inside of my boy’s abdomen due the pus has spread up to his liver. After successful completion of surgery, the condition of my little boy began to gradually improve well. The result of surgery by the ‘keyhole’ technique that looked like the wound was very small and painless of post-surgery.

After the surgery, Dr. Nada frequently visited to take care of my boy and gave him an intravenous antibiotics treatment that targeted for bacteria due to spreading of pus. My little boy was discharged and went home in 5 days later.

Now Hafiz is in good health and cheerful. Alhamdulillah, I’m very grateful and thank you Dr Nada for all your help.

Puthut Kariwibowo, father

In June 2019, while on a vacation from India to KL, my daughter Vanya, 9 years old, complained of severe abdominal pain and was restless for a full day. Being in a new country, we were clueless as to how to handle the situation. Upon advise from a friend who stayed in KL for a while, we took her to Emergency at Pantai Hospital, where the On call Doctor on preliminary examination confirmed appendicitis and referred us to Dr. Nada.

Despite it being a Sunday, Dr. Nada was with us within a couple of hours and patiently explained us the entire process of how Laparoscopic surgery will help Vanya in the best possible way. The very same evening she was operated upon. Dr. Nada took personal care of my daughter and cooled up our anxieties as the next day we had our flight back to India.

His calm demeanour and giving a keen ear to our queries gave us strength to overcome all apprehensions we had in that emergency situation in a foreign land. With his expert handling of the situation, Vanya showed a speedy recovery and next day he gave us a go ahead to fly back.

I thank Dr. Nada for everything he did and wish him all the best. All his patients are very lucky to have him as their doctor?

Monica Nigam Sachdeva, mother

As a reminder, here are some tips for you to remember when your child has tummy pain.

Best 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):

  1. Constant, persistent abdominal pain that lasts more than 2 hours, without relief.
  2. Diarrhoea lasting more than 24 hours, particularly with associated lower abdominal pain.
  3. Tummy pain with vomiting, especially when the vomitus is green or blood stained.
  4. Tummy pain with blood in your child’s faeces.
  5. A younger child who prefers to lie still, refuses to be cuddled, wants to be left untouched.

Remember, if your child is diagnosed to have appendicitis, do ask for a Paediatric Surgeon and preferably one who performs laparoscopic or keyhole surgery.

If you visit Emergencies at Pantai hospital or Glenagles hospital (Kuala Lumpur) you can ask the on-call doctor to refer you to Dr Nada.

For further information on Appendicitis check out this latest article

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Dr Nada Sudhakaran

Paediatric Surgeon & Urologist

Paediatric Surgeon


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