Appendicitis is an intra-abdominal pathology that is common in all seasons and requires surgical treatment. Appendicitis is the inflammation of the structure called appendix vermiformis, which is located in the beginning of the large intestine, with a blind ending at one end. The appendix vermiformis is a tonsil-like structure filled with lymphoid tissue in terms of its function. The cause of appendicitis is the obstruction due to lymphoid tissue hyperplasia in the appendix lumen. Lymphoid tissue hyperplasia is caused by pieces of poo that we call fecalitis, intestinal parasites, bacterial infections such as salmonella-shigella and some viral infections. In addition, cherry seeds and some foreign bodies can directly block the appendix. Acute appendicitis is common in children aged 6-12 years.
How Does Appendicitis Occur?
When the lumen is blocked, secretions accumulate in the appendix and the internal pressure increases. Depending on this increase, lymphatic and venous circulation is impaired. Bacteria also accumulate in the lumen. As a result of these events, the appendix wall becomes ulcerated. Explosion occurs as the table progresses.
What Are The Signs and Symptoms Of Appendicitis in Children?
First there is loss of appetite and then there is abdominal pain. Appendicitis pain is mostly a blunt pain. Abdominal pain is initially around the navel. It is then localized to the lower right side of the navel. Vomiting may also accompany the picture. Sometimes the form of pain can be different. Pain may hit the back in retrocecal localizations, which are popularly called occult appendicitis. In appendicitis located in the pelvis, the findings may mimic urinary tract infection. Fever is not common in acute appendicitis. If there is a fever, this is usually a sign of perforation (explosion).
How Is Appendicitis Diagnosed?
The gold standard for diagnosing appendicitis in children is intermittent, sequential physical examination. In the initial stage, the child is close to normal. But as the disease progresses, we come across a child who has lost his temper. Children walk with a limp, leaning forward. They have trouble climbing stairs. Young children, on the other hand, prefer to lie still with their right legs bent towards their stomachs and try to resist the examination. There is tenderness, defense and rebound in the right lower quadrant. The child feels an increase in abdominal pain when both heels hit the ground at the same time. In perforated appendicitis, these findings occur in every quadrant of the abdomen and this picture is called wooden abdomen. Depending on the location of the appendix, sometimes there may be difficulty in urinating and pooping. It is important to repeat the physical examination at separate times in suspicious cases. Abdominal examination to be done in a quiet environment by catching a good frequency in communication with the child and chatting with him is valuable. If necessary, it will be very useful to let the child sleep and repeat the abdominal examination. The probability of having appendicitis is low in a child who is comfortable on the examination table, has fast movements, can tie his own shoes easily, and can run in the room. But some children realize that they will have surgery and choose to hide their pain. You should also be vigilant against this situation.
What is the Importance of Laboratory and Radiological Findings in Diagnosing Appendicitis?
In the laboratory, leukocytosis, increased neutrophil ratio and increased c-reactive protein are common findings in acute appendicitis. There may be an increase in leukocytes in the urine. This condition can be confused with a urinary tract infection. There may be gas withholding in the right lower quadrant on the standing abdominal X-ray. The effort to protect the right side, which is the part with pain, which we call antralgic position, can be directly reflected on the X-ray. This may be perceived as having lumbar scoliosis. Standing abdominal X-ray can also give an idea in terms of differential diagnosis. A swallowed foreign body, kidney stones, and fecalomas may be seen. Intestinal obstruction and bowel perforation findings may also be reflected in this imaging. Abdominal ultrasonography is highly diagnostic, although it varies according to the experience of the radiologist and the location of the appendix. However, it also has the potential to mislead the treatment. Especially in pediatric patients, if the radiologist can blend clinical findings with radiological findings, the probability of correct diagnosis will increase. In a child who feels pain when the ultrasound probe is pressed, and whose anamnesis is suggestive of appendicitis, an appendix that cannot be compressed, whose diameter exceeds 6 millimeters, and whose wall is edematous, will be seen with a patient ultrasonography. In retrocecal and subserous appendicitis, it is very difficult to see the abnormal appendix. However, the radiologist can see edema, fluid and the enveloping movement of the omentum around the cecum, which we call secondary findings. The criterion for saying that there is no appendicitis in abdominal ultrasonography is the presence of a normal appendix. In all other findings, the responsibility of diagnosis rests entirely with the clinician. On the other hand, in cases where it is not possible to have abdominal ultrasonography, taking suspicious patients for observation or calling them for control at short intervals is another solution. Frequent polyclinic control and, if necessary, pediatric surgery consultation is recommended in patients who are slightly suspicious for appendicitis, whom we treat for gastroenteritis or urinary tract infection. Having an abdominal tomography for appendicitis in pediatric patients brings with it many risks. Exposure to high doses of radiation is not desirable for a growing organism. Abdominal tomography may be performed in adolescent obese children to protect the patient from a negative appendectomy due to the failure of ultrasonography in adolescent obese children. But this should never become a routine. In addition, having children have a CT scan for appendicitis should not be a decision made by a single physician. Radiology specialist, pediatrician and pediatric surgeon should act with a joint decision on this issue. Sometimes a second ultrasound performed by another radiologist will eliminate the need for abdominal tomography.
What is Perforated (exploded) Appendicitis? Is Appendicitis Burst Common in Children?
The burst rate in appendicitis cases is around 20%. This percentage increases as the age of the child decreases. Perforation usually occurs 24-36 hours after the onset of appendicitis. The child appears dehydrated and septic. It vomits yellow-green. He has a high fever. He has difficulty walking and does not touch his stomach. The main reasons for the perforation of the appendix in children are the family's late awareness of the situation, the administration of painkillers to the child with abdominal pain, the atypical findings in retrocecal and subserous appendicitis, and the difficult diagnosis of children under the age of 6 years. In a child with right lower quadrant pain, the clinician should always keep in mind the fact that appendicitis can always be overlooked when he arranges gastroenteritis or urinary tract infection treatment after an abdominal ultrasonography report stating "no findings in favor of acute appendicitis" were found in a child with right lower quadrant pain.
Otherwise, the patient, who was given painkillers and antipyretics due to his fever, applied to the emergency room again after 4-5 days because his condition did not improve, and it was only then that it could be understood that the case was perforated appendicitis. In order to prevent this situation, the clinician should call the patient for polyclinic control at close intervals in case the symptoms do not regress or progress in pediatric patients and should include the pediatric surgeon in the team from the beginning. Another situation to be considered in cases of perforated appendicitis is the picture of plastron appendicitis. When the appendix is perforated, the omentum and surrounding tissues surround the appendix; mass in the right lower quadrant. Here the patient is not very fond of common perforated appendicitis patients. On examination, a mass is palpable in the right lower quadrant. Sometimes this situation can be confused with cecum masses.
What Are The Diseases That Can Be Confused With Appendicitis in Children?
Urinary tract infection, urinary system stones, ovarian torsion, ovarian cysts, cholecystitis, gastroenteritis, mesenteric lymphadenitis, right-sided pneumonia and Meckel's diverticulitis should be considered in the differential diagnosis. Especially gastroenteritis and urinary tract infection are frequently confused with appendicitis. Since the appendix is in close proximity to the ureter, there may be findings suggestive of urinary tract infection in the complete urinalysis in cases of appendicitis. In addition, gastroenteritis can be confused with what we call peritonitis diarrhea in perforated appendicitis. Also, diffuse mesenteric lymphadenitis can be seen in the abdominal ultrasonography in cases of appendicitis. Acute tonsillitis (tonsillitis) may sometimes be simultaneous with appendicitis. Acute appendicitis can easily be overlooked in the antibiotic and antipyretic-painkiller treatment given for acute tonsillitis due to incomplete abdominal examination.
What is the Treatment of Appendicitis?
The treatment of appendicitis is surgery. However, sometimes in cases that are in the initial stage and the lumen is not completely obstructed, intravenous antibiotic treatment by hospitalization and resting the intestines by stopping oral intake regresses the picture and saves the patient from the operation. Appendicitis surgery is performed openly and laparoscopically. Hospitalization may be required for 1-2 days in acute appendicitis and 5-7 days in perforated appendicitis. Antibiotics should be started at the preoperative stage and continued for 1-3 days in acute appendicitis and 7 days in perforated appendicitis. Histopathological examination of the removed appendix must be performed. Rarely, appendicitis may be caused by carcinoid tumor or parasitosis.
What Are The İssues That Families And Doctors Should Pay Attention To About Childhood Appendicitis?
An additional common surgical cause of abdominal pain in children is appendicitis. Childhood appendicitis differs from adults, especially at the stage of diagnosis. Because the child cannot express himself or sometimes chooses to hide his pain because of fear. Since the intra-abdominal structures are very close to each other, it progresses with a high risk of disability and death in cases where it is diagnosed late or cannot be diagnosed. Therefore, parents and physicians have important responsibilities. Parents should have their children with abdominal pain examined by a pediatric and/or pediatric surgeon before giving painkillers. They should not forget that appendicitis, which is perceived as simple among the public, can lead to problems that can lead to death in children. On the other hand, it is important for emergency, pediatric, radiology and pediatric surgery physicians to act jointly from the beginning in childhood abdominal pain.
