Appendicitis in a child

Question 1

What age is appendicitis most common in children?

Answer 1

Least common in <3 year olds

Most common surgical cause of abdominal pain in children

Question 2

What are the clinical features of appendicitis in children?

Answer 2

• Anorexia
• Vomiting
• Abdominal pain aggrevated by movement
• Fever
• Tenderness with guarding in McBurney’s point (may be absent in a retrocaecal appendix)

Question 3

What are clues to diagnosis of appendicitis in pre-school children? Why is this age group at risk of perforation?

Answer 3

Diagnosis is difficult but faecoliths may be seen on plain AXR

Perforation rapid due to less developed omentum failing to surroung the appendix

Question 4

What investigations are useful in appendicitis in a child?

Answer 4

None helpful in making a diagnosis - neutrophilia is not always present and white cells may be present in urine because the appendix is adjacent to the ureter or bladder

Ultrasound may show a thickened, non-compressible appendix with increased blood flow, abscesses, perforation or appendix mass

Laparoscopy may be used to see if the appendix is inflamed

Question 5

What features are associated with complicated appendicitis and what should be done?

Answer 5

• Appendix mass
• Abscess
• Perforation - generalised guarding present

Management: fluid resuscitation and antibiotics, laparotomy.

Question 6

What are the features of uncomplicated appendicitis and what is the management?

Answer 6

Palpable mass in RIF and no signs of generalised peritonitis

Management: IV antibiotics and elective appendicectomy after several weeks

Question 7

What are the risk factors for appendicitis?

Answer 7

Genetic factors — a positive family history is associated with a nearly three-fold increased risk of appendicitis.

Environmental factors — there is a typically seasonal presentation with peaks in the summer months.

Infection — usually with aerobic and anaerobic bacteria, such as Escherichia coli and Bacteroides spp.

Malignancy (rare) — in about 1% of people with appendicitis there may be an underlying neuroendocrine tumour of the appendix (carcinoid), adenocarcinoma, or mucinous cystadenoma.

Question 8

What is the pathophysiology of appendicitis?

Answer 8

Luminal obstruction:

• faecolith (hard mass of faecal matter),
• lymphoid hyperplasia during an infection,
• impacted stool,
• foreign body,
• or rarely appendiceal or caecal tumour.

Luminal obstruction–> distension of the appendix due to increased mucus production, bacterial overgrowth, and suppurative inflammation. This results in impaired lymphatic and venous drainage from the appendix, with eventual ischaemia and necrosis, and potential perforation.