Acute appendicitis

Causes and Risks:
Appendicitis is one of the most common causes of emergency abdominal surgery in children. Approximately 4 appendectomies per 1000 children under age 18 are done anually in the United States (Note: appendicitis is not diagnosed in 100% of appendectomies). It is more common in males than females and incidence peaks in the late teens and early twenties. Appendicitis is uncommon under age two but can occur. Appendicitis generally follows obstruction of the appendix by feces (fecalith), a foreign body, or tumor .

Symptoms of appendicitis in young children are seldom classic so diagnosis is commonly delayed and perforation more likely. Older children and adolesents have a more typical presentation.

Classic presentation of appendicitis begins with crampy or "colicky" pain around the navel (periumbilical). There is usually a marked loss or total absence of appetite ( anorexia ). As the inflammation in the appendix increases the pain tends to move downward and to the right (right lower quadrant, RLQ) and localizes directly above the position of the appendix at a point called " McBurney's Point ". (If a line is drawn from the navel to the prominence on the right pelvic bone (right superior iliac crest) and divided into thirds, McBurney/s Point is 2/3 away from the navel).

The child may be quite tender when the abdomen is pressed at McBurney's Point. When the abdomen is depressed on the left side, held momentarily, and then rapidly released the child may experience a momentary increase in pain (rebound). This finding suggests inflammation has spread to the peritoneum.

If the appendix ruptures the pain may disappear for a short period and the child feels suddenly better. However, within a short period peritonitis sets in, the pain returns, and the child becomes progressively more ill. At this time the abdomen may become rigid and extremely tender.

Prevention:
Not preventable.

Symptoms:
  • abdominal pain
    • pain may begin in the upper-middle abdomen (epigastric), then develop to sharp localized pain
    • pain may shift from the epigastric area to become most intense in the lower right side of the abdomen ("typical" presentation), tenderness of this area is common
    • pain initially may be vague, but getting increasingly more severe

  • point tenderness
  • abdominal pain may be worse when walking or coughing
  • nausea and vomiting
  • fever usually occurs within several hours
  • the patient may prefer to lie with knees pulled up to abdomen to relieve muscletension on the abdomen

Later symptoms:

Additional symptoms that may be associated with this disease:



Signs and Tests:
When the abdomen is gently pressed in the painful area, and then the pressure is suddenly released, the pain increases (rebound tenderness). Touching the abdomen may cause spasm of the abdominal muscles if peritonitis is developing. Rectal examination causes pain that is localized on the right side. Psoas sign is positive--the person is placed on his (her) back in a supine position and the legs are extended straight. Tapping the heels or jarring the leg upwards causes increased pain on the right side of the abdomen.

Appendicitis may be strongly suspected based on the following tests:

The diagnosis may be confirmed by the surgeon during an exploratory laparotomy .

This disease may also alter the results of the following tests:



Treatment:
Close observation within the first 8 to 12 hours after the onset of symptoms is indicated.

For uncomplicated appendicitis, surgery ( appendectomy ) is performed as soon as possible. Little preparation is required. If an abscess is suspected, the surgery may be delayed until antibiotic therapy has reduced the infection.

Prognosis:
Early surgery has a death rate of less than 1%.

Complications:



Call Your Healthcare Provider:
Call your health care provider if right-lower quadrant abdominal pain or other symptoms suggestive of appendicitis develop.


Anatomical areas on the front of the body that may be referred to in the symptom analysis section are labeled. These three body views (front, back and side) may be helpful if you are uncertain of a body area. Many areas are referred to by both descriptive and technical names. For example, the back of the knee is called the popliteal fossa. However, areas like the "flank" may not have both terms so the location may be unclear. These illustrations should clarify the position of those anatomical sites.



This illustration shows the major organs of the digestive system. Their relative sizes and positioning in the body are also demonstrated.



The appendix is near the junction of the small bowel and the colon. On occasion, it may become infected. Although most people are familiar with appendicitis, it is a relatively rare disease. It is treated by surgical removal of the appendix (appendectomy). Recovery time for uncomplicated appendicitis is usually just three days.