Appendicitis

Appendicitis has most likely plagued man for centuries. Fortunately, today, the outlook for patients who develop appendicitis is generally excellent. Doctors do not know why the appendix exists, as it seems to serve no useful purpose. The absence of one's appendix has no impact on one's quality of life.

The appendix is a hollow tube located at the beginning of the large intestine and is filled with bacteria. Only when these bacteria become trapped in the appendix do problems with appendicitis develop. An understanding of the body's responses to the infection is helpful when deciding if appendicitis may be present.

The typical symptoms of appendicitis begin with intermittent pain centered around the belly button (umbilicus), ultimately becoming a steady pain in the right lower portion of the abdomen. Nausea and/or vomiting are common in the initial 24 hours. Fever and pain during walking, coughing and movement develop at the end of the first day and into the second.

However, appendicitis can have a variety of less typical symptoms. There are two main reasons appendicitis may cause unusual symptoms. The first is that the appendix can be found in many different positions within the right lower portion of the abdomen. The second reason is that the intestines, including the appendix, have very limited ability to sense pain. The only painful sensation from the intestines is stretching of the wall. This is typically caused by swelling or distension, which occurs when there is a blockage and the intestine fills up. This is similar to what happens when a garden hose becomes kinked and swells with water.

This swelling or distension of the intestine is sensed as vague cramping in the upper, mid and lower portions of the abdominal cavity. In contrast, the membrane lining the abdominal cavity (peritoneum) can sense ordinary pain. When inflammation caused by an infection penetrates the intestinal wall, pain is felt at the precise location of the infection. In some cases, the inflammation is shielded from the abdominal wall by other intestines and the patient may experience only minimal localized pain.

Appendicitis occurs when the appendix becomes blocked by swelling of the intestinal lining or by a plug of stool (called an appendicolith). The trapped bacteria multiply until there is enough pressure to cause distension of the appendix with stretching of the wall. This is felt as a cramp around the belly button.

As the infection progresses, the inflammation penetrates the wall of the appendix and causes localized pain and tenderness in the right lower portion of the abdomen. This causes pain with walking, coughing, and other movement. As the infection progresses further, fever becomes common and, with time, the appendiceal wall may become so inflamed that the wall weakens and the appendix bursts. This results in the bacteria leaving the appendix and causing more widespread infection within the abdominal cavity. At this point, the appendicitis becomes a more serious illness with a higher potential for complications.

Nearly all children develop abdominal pain at some point in their lives. The most common cause is constipation, which causes dull pain in the left lower portion of the abdomen and is associated with very hard stool or absence of stool for one or more days.

Another common cause of pediatric abdominal pain involves illnesses associated with vomiting and diarrhea, such as gastroenteritis or the "intestinal flu." The swelling and distension of the intestine caused by these disorders leads to severe abdominal cramping. This cramping pain is intermittent in nature and is usually centered around the umbilicus. The "stomach flu" may begin with any combination of vomiting, diarrhea, or fever. This type of intermittent cramping pain is unlike appendicitis pain, which is constant in nature and localized to the right lower part of the abdomen.

Children with appendicitis remain motionless, whereas children suffering from abdominal cramps often writhe around on the bed trying to find a comfortable position. They cry out in pain, whereas patients with appendicitis remain quiet. When the abdominal cramping subsides, these children usually feel much better and are able to get up and walk around. When the pain subsides, they may have fever but no significant pain in their abdomen, which is the opposite of what occurs in appendicitis. Patients with appendicitis and a fever nearly always have abdominal pain because the fever implies a well-established intra-abdominal infection.

If your child is suffering from abdominal pain, take note of what the initial symptoms are. The symptoms of appendicitis generally start with pain alone or pain and vomiting. Appendicitis almost never begins with fever. The pain of an appendicitis is constant in nature, rather than intermittent as is common with the intestinal flu. Diarrhea can occur in advanced cases of appendicitis but is unusual early in the illness. If your child is running a high fever at the onset of the illness, and does not have constant abdominal pain, then he most likely does not have appendicitis.

If you are unsure if your child has an appendicitis, take him to his doctor without delay. The doctor may order some routine tests, such as a urine test to see if your child has a bladder infection and a blood test to see if your child has an elevated white blood cell count (a sign of significant infection). When the pain is severe and, especially, if your child has been vomiting, an intravenous (IV) line may be inserted into a vein to reverse any dehydration that may be present. In some cases an imaging test, such as an ultrasound or a CT scan of the abdomen, will be done to look specifically for evidence of a swollen, inflamed appendix.

While these tests are helpful, they are only accurate in about 80% of cases. Your child's doctor will need to decide when to consult a surgeon. The surgeon is the doctor with the most experience in diagnosing appendicitis and ultimately will provide the final recommendation as to whether your child requires surgery.

Surgery for appendicitis is generally straightforward, usually lasting about one to one and a half hours. The surgery may be done either with a limited incision directly over the point of tenderness or laparoscopically typically using 3 small incisions. The surgeon may occasionally (10% of cases) find that the appendix is not inflamed. This is considered normal and doesn't mean the surgeon made a mistake.

In such situations other, less common, conditions will be searched for such as inflamed mesenteric lymph nodes, inflamed small intestines, an inflamed Meckel's diverticulum (an unusual birth defect causing an outpouching of the small intestine) or, in girls, a problem with the ovary or fallopian tube. In some cases, these conditions require surgical correction which is usually performed at the same time.

Postoperative antibiotics are given in order to help prevent infectious complications such as skin infections and deeper pockets of internal infection (abscesses). The antibiotics are continued as long as the surgeon believes they will be beneficial, typically one day for non-ruptured appendicitis and several days for ruptured appendicitis. Severe infections, typically in cases of ruptured appendicitis, may cause enough inflammation to prevent normal intestinal function for a period of several days following surgery. In this case your child will be unable to eat and will be given a balanced salt solution through an IV to maintain proper hydration while awaiting the return of normal bowel function.

Even though up to one-half of children do not complain of abdominal pain until the condition is advanced, it is our hope to be able to remove the infected appendix before it ruptures. This assures us that the recovery following surgery will be rapid and problem-free. On the other hand, some cases of appendicitis are not diagnosed until the infection is very advanced and the intestines are quite inflamed. In these cases, the surgeon may decide to initially treat the infection with antibiotics alone, postponing surgery for days or weeks until the inflammation has subsided. Fortunately, the availability of potent modern antibiotics allows us to successfully treat all cases of appendicitis, no matter how advanced, with a very high success rate.

Dr. Shaul is a fifth generation Californian who is both a pediatric surgeon and pediatric urologist. He enjoys training future pediatricians and pediatric surgeons at Children's Hospital Los Angeles. He is an associate professor of clinical surgery at the Keck School of Medicine at the University of Southern California. He sees patients in his offices in Encino, Thousand Oaks and at Children's Hospital.

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