Pediatric Appendicitis

Appendicitis is a painful swelling, inflammation and infection of the appendix. It's a medical emergency because the appendix can burst or rupture. This is serious and can lead to more widespread infection. If not treated, it can be fatal.

The appendix is a thin, finger-shaped tube that is joined to the large intestine. It sits in the lower right part of the belly (abdomen). Experts don’t know for sure what role the appendix has in the body. It's not a vital organ. Removing it is not harmful.

Surgery to remove the appendix is called an appendectomy. It's the most common type of emergency surgery for children. Most children recover with no long-term problems.

Appendicitis happens when the inside of the appendix is blocked by something, causing an infection. The blockage may be caused by mucus, stool or parasites. Or the blockage may be caused by a bend or twist in the appendix itself.

The appendix then becomes sore and inflamed or swollen. This is because the germs (bacteria) in the appendix begin to increase quickly. As the swelling and soreness get worse, the blood supply to the appendix is cut off.

All parts of the body need the right amount of blood flow to stay healthy. When blood flow is reduced, the appendix starts to die. The appendix will burst or rupture as its walls start to get holes. These holes let stool, mucus, and other substances leak through and get inside the belly or abdomen. A serious infection called peritonitis may occur in the belly when the appendix bursts. If not treated, it can be fatal.

Most cases of appendicitis happen between the ages of 10 and 30 years. Children with cystic fibrosis may have a greater risk. Having a family history of appendicitis may also increase a child’s risk for this condition.

Each child’s symptoms may vary. Below are some common symptoms of appendicitis.

Pain in the belly (abdomen) is the most common symptom. This pain:

• May start in the area around the bellybutton, and move to the lower right-hand side of the belly. Or it may start in the lower right-hand side of the belly.
• Often gets worse as time passes
• May be worse when the child is moving, taking deep breaths, being touched or coughing and sneezing
• May be felt all over the belly if the appendix bursts

Other common symptoms include:

• Upset stomach (nausea) and vomiting
• Loss of appetite
• Fever and chills
• Changes in behavior
• Trouble having a bowel movement (constipation)
• Loose stool (diarrhea)
• Swollen belly in younger children

Your child’s healthcare provider will take a health history and do a physical exam. The provider may also order tests, including:

• Abdominal ultrasound. This imaging test uses high-frequency sound waves and a computer to create images of blood vessels, tissues and organs. It's used to see internal organs as they work.
• CT scan. This imaging test uses both X-rays and computer technology to show detailed images of any part of the body. This includes the bones, muscles, fat and organs. It's more detailed than a general X-ray.

Other tests may include:

• Blood tests. These tests check for infection and inflammation. They can also see if there are any problems with other abdominal organs, such as the liver or pancreas.
• Urine test. This test can tell if there is a bladder or kidney infection, which may have some of the same symptoms as appendicitis.

Symptoms of appendicitis may look like other health problems. Always see your child’s healthcare provider for a diagnosis.

Treatment will depend on your child’s symptoms, age and general health. Appendicitis is a medical emergency. It's likely the appendix will burst and cause a serious, deadly infection. For this reason, your child’s healthcare provider will likely advise that your child have surgery to remove the appendix. Your child may be given antibiotics and fluids through an intravenous line (IV) before surgery starts.

Surgery is the most common treatment for appendicitis. But for some children, the healthcare provider may give antibiotics instead of surgery.

The appendix may be removed in two ways:

• Open or traditional surgery. Your child is given anesthesia. A cut or incision is made in the lower right-hand side of the belly. The surgeon finds the appendix and removes it. If the appendix has burst, a small tube or shunt may be placed to drain out pus and other fluids from the belly. The shunt will be taken out in a few days, when the surgeon feels the infection is gone.
• Laparoscopic surgery. Your child is given anesthesia. This method uses a few small incisions and a camera called a laparoscope to look inside the belly. The surgical tools are placed through one or more small incisions. The laparoscope is put in through another incision. This method is not usually done if the appendix has already burst.

Interval Appendectomy

Sometimes the appendix bursts, and a collection of infected fluid or pus (abscess) may form. If this happens and your child is stable, the provider may recommend not removing the appendix right away. Instead, the provider may want to treat the infection first and drain the infected fluid from the abscess. The appendix will be removed later. This delayed surgery is called an interval appendectomy.

For an interval appendectomy, your child will be given IV antibiotics. These are given through an IV tube called a PICC line, or a peripherally inserted central catheter. This stays in place about 10 to 14 days. The provider may also use CT or ultrasound-guided images to drain the abscess. Once the infection and inflammation are gone, your child will have surgery to remove the appendix about six to eight weeks later.

After Surgery

A child whose appendix ruptured will have to stay in the hospital longer than a child whose appendix was removed before it burst. Some children will need to take antibiotics by mouth for a certain period of time after they go home.

After surgery, your child will not be allowed to eat or drink anything for a certain period of time. This lets the intestine heal. During this time, fluids, antibiotics and pain medicine will be given by IV into the bloodstream.

As the healing progresses, your child will be able to drink clear liquids such as water, sports drinks or apple juice. and will gradually move on to soft then solid foods.

After your child leaves the hospital, the healthcare provider will likely limit his or her activities. Your child should not do any heavy lifting or play contact sports for a few weeks after surgery or as instructed. If a drain is still in place when your child goes home, he or she should not take a bath or go swimming until the drain is removed.

You will be given a prescription for pain medicine for your child to take at home. Some pain medicines can make a child constipated, so ask your healthcare provider or pharmacist about any side effects. Moving around after surgery rather than lying in bed can help prevent constipation. Drinking fruit juices may also help. Once your child can have solid foods again, eating fruits, whole grain cereals and breads, and vegetables can also help stop constipation.

Most children who have their appendix removed will have no long-term problems.

An irritated appendix can quickly turn into an infected and ruptured appendix. This can happen in a few hours. A ruptured appendix is an emergency situation. If not treated, it could be fatal. When the appendix ruptures, germs (bacteria) infect the organs inside the abdominal cavity. This causes a bacterial infection called peritonitis. The bacterial infection can spread very quickly. It may be hard to treat if diagnosis is delayed.

An infected appendix can burst or rupture. This is an emergency and could be fatal. If you think your child may have appendicitis, call your child’s provider and go to the emergency room right away.