General Information:

Acute appendicitis is acute inflammation and infection of the vermiform appendix,

which is most commonly referred to simply as the appendix. The appendix is a
blind-ending structure arising from the cecum. Acute appendicitis is one of the most
common causes of abdominal pain and is the most frequent condition leading to
emergent abdominal surgery in children. The appendix may be involved in other
infectious, inflammatory, or chronic processes that can lead to appendectomy;
however, this article focuses on acute appendicitis. Appendicitis and acute
appendicitis are used interchangeably.

Common symptoms of acute appendicitis include abdominal pain, fever, and

vomiting. The diagnosis of appendicitis can be difficult in children because the
classic symptoms are often not present. (See Clinical Presentation.)
A delay in the diagnosis of appendicitis is associated with rupture and associated
complications, especially in young children. Improvements in rupture rates have
been made with advanced radiologic imaging. Appendicitis is a clinical diagnosis
with imaging used to confirm equivocal cases. (See Workup.)
The definitive treatment for appendicitis is currently appendectomy. Initiation of
antibiotics upon diagnosis is critical to initiate treatment, slow the infectious
process and prevent progression of a nonperforated appendix. Key to any
evaluation and treatment plan are the following: relieve the patient's pain and
discomfort early and consistently; communicate with the patient and family about
the plans; repeat the examination often; adjust the differential diagnosis as
appropriate; and keep the patient for observation if a firm diagnosis is not made.

The most widely used antibiotic regimen is a penecillin based regimen such as
piperacillin/tazobactam or ampicillin/clavulanic acid or the combination of
ampicillin, clindamycin (or metronidazole), and gentamicin. If a penicillin allergy
exists, regimens incluidng cephalosporins, aminoglycosides and clindamycin may be
used. (See Medication.)

Anatomy:

The vermiform appendix is generally 5-10 cm in length. It arises from the cecum,
which in most children is located in the right lower quadrant of the abdomen.

Although the base of the appendix is fixed to the cecum, the tip can be located in the
pelvis, retrocecum, or extraperitoneum. Note that the anatomic position of the
appendix determines the symptoms and the site of tenderness when the appendix
becomes inflamed. Because the visceral nerve fibers associated with the appendix
typically become inflamed first, there are often vague and referred symptoms to the
periumbilical region through the T10 dermatome. As the somatic sensory fibers of
the peritoneal lining become involved in the inflammatory process, the pain will
frequently shift to the right lower abdomen and tenderness is focused at the site of
inflammation.
The appendix is lined by typical colonic epithelium. The submucosa contains
lymphoid follicles, which are very few at birth. This number gradually increases to a
peak of about 200 follicles at age 10-20 years and then subsequently declines. In
persons older than 30 years, less than half that number is present, and the number
continues to decrease throughout adulthood. The appendix may act as a reservoir
for the flora of the gut which may aid in recovery from intestinal infections.
However, this function is not vital for life and removal of the appendix is well
tolerated.

Pathophysiology:

Tradition holds that once the appendix becomes obstructed, bacteria trapped within
the appendiceal lumen begin to multiply, and the appendix becomes distended. The
increased intraluminal pressure obstructs venous drainage, and the appendix
becomes congested and ischemic.

The combination of bacterial infection and ischemia produce inflammation, which

progresses to necrosis and gangrene. When the appendix becomes gangrenous, it
may perforate. The progression from obstruction to perforation usually takes place
over 72 hours.

One study noted that appendiceal perforation is more common in children,

specifically younger children, than in adults. A substantial risk of perforation within
24 hours of onset was noted (7.7%) and was found to increase with duration of
symptoms. While perforation was directly related to the duration of symptoms
before surgery, the risk was associated more with prehospital delay than with in-
hospital delay.[1]

During the initial stage of appendicitis, the patient may feel only periumbilical pain
due to the T10 innervation of the appendix. As the inflammation worsens, an
exudate forms on the appendiceal serosal surface. When the exudate touches the
parietal peritoneum, a more intense and localized pain develops.

Perforation results in the release of inflammatory fluid and bacteria into the
abdominal cavity. This further inflames the peritoneal surface, and peritonitis
develops. The location and extent of peritonitis (diffuse or localized) depends on the
degree to which the omentum and adjacent bowel loops can contain the spillage of
luminal contents.

If the contents become walled off and form an abscess, the pain and tenderness may
be localized to the abscess site. If the contents are not walled off and the fluid is able
to travel throughout the peritoneum, the pain and tenderness become generalized.

Etiology:
Acute appendicitis is a complex disease with quite a bit of variability in presentation
and pathophysiology. Several theories have been promoted to explain the etiology,
epidemiology and natural history of the disease. Many contend that appendicitis is
due to obstruction of the blind ending appendix, resulting in a closed loop. In
children, obstruction usually results from lymphoid hyperplasia of the submucosal
follicles. The cause of this hyperplasia is controversial, but dehydration and viral
infection have been proposed. Another common cause of obstruction of the
appendix is a fecalith.

Rare causes include foreign bodies, parasitic infections (eg, nematodes), and
inflammatory strictures.

The obstructive theory of appendicitis is widely taught but may not explain all the
data regarding providers' experience with this common disease. Outbreaks and
clusters of appendicitis have been reported making a true infectious etiology a
possible etiologic agent. Appendicitis seems to run in families with first degree
relatives of those who have had appendicitis being at a much higher risk of
developing the condition which suggests an role of the host genetics. Finally,
perforated and non-perforated appendicitis, which should be linked by the
progression from early to late appendicitis, appear to act epidemiologically as two
separate disease processes. Even though appendicitis is very common, much is not
understood about the etiology or pathophysiology of this disease process.

Clinical Presentation:

The classic history of anorexia and vague periumbilical pain, followed by migration
of pain to the right lower quadrant (RLQ) and onset of fever and vomiting, is
observed in fewer than 60% of patients.[2] If the appendix perforates, an interval of
pain relief is followed by development of generalized abdominal pain and
peritonitis. Although some patients progress in the classical fashion, some patients
deviate from the classic model. Atypical presentations are common in neurologically
impaired and immunocompromised patients, as well as in children who are already
on antibiotics for another illness.

In patients with a retrocecal appendix, who constitute 15% of cases, signs and
symptoms may not localize to the RLQ but instead to the psoas muscle, the flank or
right upper quadrant. In other patients, the tip of the appendix is deep in the pelvis,
and the signs and symptoms localize to the rectum or bladder resulting in pain with
defecation or voiding.

Certain features of a child's presentation may suggest a perforated appendix. A child

younger than 6 years with symptoms for more than 48 hours is much more likely to
have a perforated appendix. The child may have generalized abdominal pain and
may have a high heart rate and a temperature higher than 38C.
A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one
study and was found to increase with duration of symptoms. While perforation was
directly related to the duration of symptoms before surgery, the risk was associated
more with prehospital delay than with in-hospital delay.[1]

Pain:

All patients with appendicitis have abdominal pain, and many have anorexia;
absence of both of these findings should place the diagnosis of appendicitis in
question. A child who states that the ride to the hospital is painful when the vehicle
hits bumps in the road suggests peritoneal irritation.

Acute onset of severe pain is not typical of acute appendicitis but is seen with acute
ischemic conditions such as volvulus, testicular torsion, ovarian torsion,
orintussusception. If the pain is initially located in the right lower quadrant, severe
constipation should be considered. A high index of suspicion should be maintained
when attributing pain to constipation, especially in a child who does not have a prior
history of constipation. Many children do not report the early symptoms of
appendicitis and only appreciate the pain when it localizes to the RLQ. In addition,
children with a retrocecal appendicitis may have a delay in the appreciable pain,
leading to a delay in presentation.

As appendicitis progresses, the pain migrates to the RLQ due to inflammation of the
parietal peritoneum. This pain is more intense, continuous, and localized than the
initial pain. This shift of pain rarely occurs in other abdominal conditions.

Atypical pain is common and occurs in 40-45% of patients. This includes children
who initially have localized pain and those with no visceral symptoms. Pain on
urination can be seen with pelvic appendicitis.

Nausea and vomiting:

A unique feature of appendicitis is gradual onset of pain followed by vomiting.

Vomiting first is more typical of gastroenteritis.

Generally, vomiting that occurs prior to pain is unusual. However, in patients with
retrocecal appendices, particularly those that extend cephalad along the posterior
surface of the right colon, inflammation of the appendix irritates the nearby
duodenum, resulting in nausea and vomiting prior to the onset of RLQ pain.

Diarrhea:

Significant diarrhea is atypical in appendicitis, and the physician should consider

other diagnoses, while not ruling out appendicitis. In patients with an appendix in a
pelvic location, inflammation of the appendix occasionally results in an irritative
stimulation of the rectum. These patients often report diarrhea. However, upon
closer questioning, such patients usually describe frequent, small-volume, soft
stools rather than true diarrhea.
Fever:

Most children with appendicitis are afebrile or have a low-grade fever and
characteristic flushing of their cheeks. Severe fever is not a common presenting
feature unless perforation has occurred, and even then it may still be rare.
According to one study, vomiting and fever are more frequent findings in children
with appendicitis than in children with other causes of abdominal pain.

Physical Exmination:

The physical examination findings in children may vary depending on age.

Irritability may be the only sign of appendicitis in a neonate. Older children often
seem uncomfortable or withdrawn. They may prefer to lie still because of peritoneal
irritation. Teenaged patients often present in a classic or near-classic fashion.
Examination of the child requires skill, patience, and warm hands. Initial and
continued observation of the child is of critical importance. An ill-appearing quiet
child who is lying very still in bed, perhaps with the legs flexed, is much more a
cause for concern than a child who is laughing, playing, and walking around the
room.
The examination should be thorough and start with areas other than the abdomen.
Because lower lobe pneumonias can cause abdominal findings, a history of such
should be elicited and a thorough chest examination performed. It is also important
to exclude urinary tract infection (UTI) as a cause of abdominal pain.
Children vary in their ability to cooperate with the physical examination. It is
important to tailor the physical examination to the child's age and developmental
stage.

General examination:

Patients general state should be observed before interacting with them. The
patients state of activity or withdrawal may lend information into their condition.
The child's gait may be observed if they are well enough to ambulate. A patient in
obvious distress with abdominal pain gives the impression of an infectious process;
however, other causes must be ruled out.
Cardiac and pulmonary examination
The findings on evaluation of the heart and lungs typically reflect the patients
overall state more than they may suggest appendicitis. Patients are often
dehydrated or in pain and may be tachycardic or tachypneic. Pediatric patients have
great physiological reserves and may not show any general symptoms until they are
very ill.

Abdominal examination:
Full exposure of the abdomen is key. Before examining the abdomen, ask the child to
point with one finger to the site of maximal pain. Begin palpation of the abdomen at
a site distant to this, with the most tender area examined last. If the child is
particularly anxious, palpation may be performed with a stethoscope.
Distracting questions concerning school and family members may be helpful to
relieve anxiety during the examination. Observing the child's facial expressions
during this questioning and palpating is critical.
Palpation of the abdomen should be performed with a gentle and light touch,
searching for involuntary guarding of the rectus or oblique muscles. In early
appendicitis, children may not have significant guarding or peritoneal signs.
Younger children are much more likely to present with diffuse abdominal pain and
peritonitis, perhaps because their omentum is not well developed and cannot
contain the perforation.
Typically, maximal tenderness can be found at the McBurney point in the RLQ. A
mass may be palpable in the RLQ if the appendix is perforated.
However, the appendix may lie in many positions. Patients with a medially
positioned appendix may present with suprapubic tenderness. Patients with a
laterally positioned appendix often have flank tenderness. Patients with a retrocecal
appendix may not have any tenderness until appendicitis is advanced or the
appendix perforates.
Presence of the Rovsing sign (pain in the RLQ in response to left-sided palpation or
percussion) strongly suggests peritoneal irritation.
To assess for the psoas sign, place the child on the left side and hyperextend the
right leg at the hip. A positive response suggests an inflammatory mass overlying
the psoas muscle (retrocecal appendicitis).
Check for the obturator sign by internally rotating the flexed right thigh. A positive
response suggests an inflammatory mass overlying the obturator space (pelvic
appendicitis).
During the abdominal examination, try to avoid eliciting rebound tenderness. This is
a painful practice and certainly destroys any trust that has been garnered during the
examination. Peritonitis can be confirmed with gentle percussion over the right
lower quadrant. Involuntary contraction of the abdominal wall musculature
(involuntary guarding) and tenderness can be elicited with minimal stress or
discomfort to the child.
Other methods can be used to establish that the patient has peritoneal irritation.
Asking the patient to sit up in bed, cough, jump up and down, or bounce his or her
pelvis off the bed while in the supine position may elicit pain in the presence of
peritoneal irritation. Alternatively, other acceptable maneuvers are tapping the
patient's soles and shaking the stretcher. A child with advanced appendicitis
typically prefers to lie still due to peritoneal irritation.

Rectal examination:

The digital rectal examination is often deferred but can be helpful in establishing the
correct diagnosis, especially in sexually active adolescent girls. The patient should
 be told that the examination is uncomfortable but should not cause sharp pain. The
caliber of the patient's anus should be taken into consideration, and smaller digits
should be used for examining younger patients.
The rectal examination is particularly important in the child with a pelvic appendix,
in whom the findings on the abdominal examination for appendicitis may be
equivocal and indicative of peritoneal irritation.
Objective information to ascertain includes impacted stool or an inflammatory mass.
Right-sided tenderness of the rectum is the classic finding in patients with pelvic
appendicitis or in those with pus that pools in the pelvis from an inflamed appendix
elsewhere in the abdomen.
Patients who are able to communicate should be asked if they have tenderness in
different areas of the rectum. The rectal examination in a young child may have to
be completely objective because they may not be able to communicate variations in
tenderness or may have general discomfort from the examination.

Genitourinary examination:

An external genitourinary (GU) examination is helpful to rule out testicular or

scrotal tenderness in males and hematocolpos in pubertal girls.
Pelvic examination
A pelvic examination should be considered in sexually active adolescent girls to
evaluate for tenderness (adnexal and/or cervical motion tenderness), masses,
bleeding, or discharge.
Atypical findings
Becker et al found that 44% of patients diagnosed with appendicitis presented with
6 or more of the following atypical features[3] :
No fever
Absence of Rovsing sign
Normal or increased bowel sounds
No rebound pain
No migration of pain
No guarding
Abrupt onset of pain
No anorexia
Absence of maximal pain in the RLQ
Absence of percussive tenderness

Workup:

Making a timely diagnosis of appendicitis is a difficult challenge in children with

abdominal pain. Laboratory findings may increase suspicion of appendicitis but are
not diagnostic. The minimum laboratory workup for a patient with possible
appendicitis includes a white blood cell (WBC) count with differential and
 urinalysis. Liver function tests and amylase and lipase assessments are helpful when
the etiology is unclear. Baseline blood urea nitrogen and creatinine are needed prior
to intravenous contrast CT scanning.

Other studies, such as interleukin 6 and C-reactive protein (CRP) assays, have been
advocated by some in the diagnosis of appendicitis. However, in multiple clinical
series, these studies have not been shown to be of clear benefit and, for the most
part, only add to the cost of the evaluation.

Treatment:

Given that patients with possible appendicitis may have an equivocal history and
physical examination findings and inconclusive supporting test results, the
following measures are key to any evaluation and treatment plan:
Relieve the patient's pain and discomfort early and consistently
Communicate with the patient and family about the plans
Repeat the examination often
Adjust the differential diagnosis as appropriate
Keep the patient for observation if a firm diagnosis is not made or for follow-up
Algorithms, scoring systems, imaging studies, and consultation reports are part of
the clinician's armamentarium. Documentation of medical decision making is
important, as is knowledge of the current literature. Consultations with a
pediatrician or general surgeon may be appropriate.
Because of the short time from obstruction of the appendix to perforation, 20-35%
of patients who present with acute appendicitis have already perforated. In fact,
estimates suggest that most patients perforate within 72 hours of symptom onset. A
substantial risk of perforation within 24 hours of onset was noted (7.7%) in one
study and was found to increase with duration of symptoms. While perforation was
directly related to the duration of symptoms before surgery, the risk was associated
more with prehospital delay than with in-hospital delay.[1]
If a patient presents beyond 72 hours from symptom onset, perforation is highly
likely. However, if a patient presents with symptoms of appendicitis beyond 72
hours and has not perforated, diagnoses other than appendicitis must be
entertained.
Avoid treating vague abdominal pain by administering parenteral opiates and then
discharging the patient. Narcotics and potent nonsteroidal anti-inflammatory drugs
may be needed for pain control. Large doses or ongoing use should be avoided until
after surgical consultation.
Patients with a classic history require prompt surgical consultation. Maintain
nothing-by-mouth status in patients with suspected appendicitis, and start
intravenous fluids to restore intravascular volume. Antibiotics should be started
upon diagnosis of appendicitis.
 Emergency medical service (EMS) personnel are well trained and cognizant of how
to assess and begin treatment of the febrile, vomiting child with abdominal pain.
Intravenous fluid administration, pain management, and antiemetic medication
should be administered based on local EMS protocols.
The insertion of nasogastric tubes (when necessary), intravenous lines, and urethral
catheters (when necessary) and the administration of antibiotics, antiemetic drugs,
antipyretic drugs, and analgesia should ideally be part of the emergency department
protocol for preoperative management.

Complications may include the following:

Perforation
Sepsis [19]
Shock
Postoperative adhesions
Infertility
Wound dehiscence
Wound infection
Bowel obstruction

Medication:

Administer 1 dose of preoperative antibiotics to children with suspected

appendicitis. Antibiotics can be discontinued after surgery if no perforation is noted.
 Antibiotics are selected to provide coverage for aerobic and anaerobic organisms.
The most widely used regimen is the combination of ampicillin, clindamycin (or
metronidazole), and gentamicin. Alternative regimens include the following:
Ampicillin/sulbactam
Cefoxitin
Cefotetan
Piperacillin/tazobactam
Ticarcillin/clavulanate
Imipenem/cilastatin
Resistant organisms develop in 15% of patients with a ruptured appendix.
Antibiotic substitutions are made for patient allergies, poor clinical improvement or
deterioration on current regimen, or culture-proven antibiotic resistance.
Patients with appendicitis also require medication for pain control. Antiemetic and
antipyretic agents may also be indicated.
Antibiotic regimens should cover the most commonly encountered organisms,
including Escherichia coli and Bacteroides, Klebsiella, Enterococcus, and
Pseudomonas species.

MINISTRY OF PUBLIC HEALTH OF UKRAINE

NATIONAL MEDICAL UNIVERSITY O.O BOGOMOLETS

DEPARTMENT OF PEDIATRIC SURGERY

SUPERVISOR: ASST. PROF. ALEXANDRE VICTOROVICH
LATEOVICH

ACUTE APPENDICITIS

BY ERNESTO PADRON

5TH YEAR (MEDICINE)

GROUP 31A