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appendicitis in children (children Appendicitis); It is an emergency condition that must be treated surgically quickly in order not to show serious consequences that can cause death in case of neglect. What are the main causes? How is the diagnosis made? And what about the treatment?
Overview of appendicitis in children
Appendicitis in children is considered one of the most urgent surgical cases between the ages of 5-14 years. But in general, it can affect different ages (newborns and infants, for example), but the incidence in the first two years is few and rare and increases with age.
Appendicitis in children and adults
Appendicitis in children is more serious than in adults. This is because it is difficult to diagnose and progresses faster towards serious outcomes. This is supported by the presence of specificity in the anatomical and functional features of the children’s bodies.
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Causes of appendicitis in children
The causative agent is bacteria of various types:
- Gram-negative (eg, coliform).
- Gram-positive (staph and streptococci).
These microorganisms cause inflammation when the balance between the gut microbiota and the normal beneficial bacteria in the body is disturbed. Infection occurs and the infection is transmitted through the blood or lymphatic route.
The specificity of the speed of transmission of infection in a child
Due to the immaturity of the local nervous system of the appendix and the junction area between the ileum and cecum, rapid transmission of infection occurs, and pathological changes spread rapidly in the child’s body. Eventually, the intestinal wall can necrosis (lose its blood supply and die) and serious consequences may begin.
The younger the child, the faster the spread of inflammation and necrosis.
immaturity of the nervous reflex
This means that when a child is in pain, he will point to his navel, and this is not the typical area for an adult to develop pain, so the symptoms are not typical and can make and delay diagnosis.
High permeability of the intestinal mucosa
The permeability of the intestinal mucosa is high in children, through which germs and toxic substances enter the blood, and if the capillaries are damaged due to this infection, the expansion of inflammation and necrosis (interruption of blood perfusion) will occur, followed by perforation of the intestine, which is very common in the first year of life (95% of cases).
The great omentum is not fully developed
The lack of development of the large omentum causes serious consequences and the development of perforation occurs faster, because the non-developing omentum is unable to surround the perforation, and generalized peritonitis develops in the child.
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How does appendicitis occur in children?
- Initially, the lumen of the appendix is occluded from the inside (lumen) in the proximal region (closest to the axis of the body) with one of the following conditions:
- Fibrous streaks blockage.
- Hyperplasia of the lymphatic tissue in it (due to viral infections such as measles and smallpox).
- Fecal stones (15%).
- Intestinal parasites.
- Tumors in the intestine.
- Cystic fibrosis (intestinal mucus becomes sticky and clogs the extra lumen).
- Fruit and vegetable seeds (eg cherries).
- The distal section of the lumen of the appendix becomes closed.
- The secretions cause it to expand and swell, leading to a rise in pressure within the lumen of the appendix.
- The nerve endings of the pain fibers afferent to the brain and located in the viscera.
- The child at this stage feels pain in the middle part of the abdomen or lower epigastrium (upper stomach).
- As the pressure increases in the lumen of the appendix, the bacteria that are already in the appendix activate.
- The passage of blood in the veins (venous return) is disturbed and swelling and congestion occur.
- Inflammation passes to the serous layer of the intestine and the parietal peritoneum.
- As a result, the pain becomes localized in the right iliac fossa.
- As the pressure continues to rise and the bacteria invade, the arterioles close.
- Ischemia (interruption of blood perfusion) occurs.
- The opposite edge of the intestinal mesentery dies and perforation occurs in the wall of the appendix.
- The contents of the appendix come out of the abdominal cavity, either causing a local abscess or a generalized inflammation of the peritoneum.
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Symptoms of appendicitis in children
Symptoms of appendix in children vary according to the child’s body reaction and immunity, his age and the anatomical position of the appendix. But it all starts with:
- Discomfort and unknown pain in the middle of the child’s abdomen.
- This is followed by nausea, loss of appetite and indigestion.
- Pain: constant, continuous, not severe and accompanied by mild cramps.
- Vomiting once or twice.
- After a few hours, the pain moves to the right iliac region.
- Diarrhea occurs especially if the appendix is located behind the cecum or pelvis or if it is perforated.
- The child’s temperature rises (up to 38 degrees).
- They are common.
- inability to sleep
The pain of appendicitis increases with coughing, movement, deep breathing and walking. In addition, it is noted that the pain forces the child to take a special position.
Perforation of the appendix in children
This dangerous complication occurs 36-48 hours after the start of the infection, and the persistence of symptoms for more than 72 hours indicates the emergence of serious consequences, especially in young children. Therefore, the child must be taken to the nearest emergency center for the required surgical intervention. There are several signs that indicate a perforation, including:
- The temperature is over 39 degrees.
- Leukocytes (above 14,000) in the hemogram.
Constipation is the predominant symptom with appendicitis in adults, but in children, diarrhea is the most common symptom and begins from the second day.
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Diagnosis of appendicitis in children
An abdominal examination should be conducted for the child, and the child’s pain is noted at a point identified by the scientist (McBurney) and named after him, a point 5 cm away from the anterior superior iliac spines of the iliac bone along the line between the iliac spines and the child’s navel. (that is, on the border of the connection of the lateral third with the middle third of the line connecting the umbilicus and the anterior superior iliac spine).
Abdominal examination to diagnose (children Appendicitis)
- An involuntary contraction of the abdominal muscles occurs when this point is palpated (muscular defense).
- Pain when the pressing hand is raised (Bloomberg’s sign) is called rebound tenderness.
A group of signs indicating the presence of appendicitis in children is differentiated on examination of the abdomen. We summarize them in the following table:
|Rufsing sign:||Pain in the right iliac fossa on palpation of the left iliac fossa.
The reason: irritation of the peritoneum (a serous membrane lining the abdominal cavity).
|Psoas muscle sign:||Pain when the right thigh is overextended while the child is lying on his left side.|
|Also, the gentle muscle sign:||The pain is localized in the right iliac fossa when the right thigh is flexed and internally rotated.|
|Danvi’s sign:||Induction of pain when a child coughs.|
An important examination and has a role in differentiating appendicitis from pelvic abscesses and ovarian cysts in adolescent girls.
X-ray diagnosis of appendix
The child may:
- Simple x-ray: non-specific and does not help much, but it can show fecal stones.
- Ultrasound: hypoechoic lumen cecum incompressible end, faecal calculus, pericaecal fluid.
- Computed tomography: very accurate, shows the size of the inflamed appendix and reveals the collection of pus around the cecum.
- Barite feeding (not performed in case of colitis).
Appendicitis in children laboratory
- In 90% of children, an elevated white blood cell count (above 10,000 per cubic millimeter of blood) appears.
- The elevation of moderates is more than 75%.
- CRP: more than 5.
Laboratory examination can be normal in some cases of appendicitis in children.
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Serious consequences of appendicitis in children
If the disease is left untreated, its progression may lead to the extension of the inflammation to the peritoneum, either directly or due to the perforation of the appendix. Then, generalized peritonitis that results in septic shock occurs due to the transmission of bacteria into the bloodstream. Finally, the case ends in death.
- The most important 5 serious consequences of appendicitis in children if it is not treated:
- Pelvic abscess (accompanied by diffuse peritonitis).
- Abscess around the appendix (local peritonitis).
- Generalized peritonitis and septic shock.
- Excess shield.
Inflamed appendix shield
It is a non-motile inflammatory mass located in the right iliac fossa. It is painful when palpated and is formed by:
- inflamed appendix
- The cecum and labia of the adjacent small intestine.
- Great omentum.
It is caused by the delayed diagnosis of appendicitis in children, and it is associated with pain, fever and an increase in white blood cells. In the event that it is present, it is forbidden to perform an appendectomy before it is completely cured.
Inflamed appendix shield treatment
Either without surgery (conservative) or the child may need surgery.
- Conservative treatment: antibiotics for 1-2 weeks. Then, in the event of a reduction in the size of the lump and improvement, the surgical procedure is determined after 4-6 weeks.
- Surgical treatment: If the cyst turns into an abscess, the abscess must be drained while continuing antibiotic treatment.
Treatment of appendicitis in children
In the absence of an appendix shield, the treatment is with an appendectomy, which is the preferred and only treatment. The surgery is done by following these steps:
- Laparotomy with a transverse or diagonal incision in the right lower quadrant (McBurney’s point).
- Entry through the layers of the abdominal wall.
- Take out the excess, tie its mesang, then tie its base.
- The surgeon uses a vicryl thread to sew the remainder of the appendix into the shape of a money bag.
- The wound is closed.
An appendectomy can be done with traditional open surgery or endoscopic (the best method).
Children’s appendicitis is a condition that requires awareness, caution, and rushing to take the child to the nearest medical center to avoid serious consequences and perforation.