Appendicitis

Appendicitis is inflammation and infection of the appendix, a small tube-shaped piece of tissue attached to the large intestine. The appendix is located in the right lower abdomen (belly). Appendicitis results from blockage in the appendix caused by dried mucus, hard stool, parasites or other foreign bodies. Mucus, which is secreted by the inner lining of the appendix, builds up behind the blockage when it can no longer drain into the large intestine. As the mucus builds up, the patient may complain of belly pain, loss of appetite and nausea. The blockage and build-up of mucus can impair blood flow through the appendix, and cause swelling and infection. Over time, this swelling and infection can cause the appendix to perforate (burst or rupture). If untreated, the infection can then spread and lead to peritonitis, an infection of other tissues in the abdomen. Appendicitis is the most common cause of emergency abdominal surgery in children. It is slightly more common in boys and is rare in babies less than 1 year of age. Most cases occur between 8-16 years of age. The rate of perforation is higher in younger children (less than 5 years) because of their difficulty describing symptoms and difficulty examining them.

There is a wide range of symptoms and not all children have all symptoms. The most common symptoms include:

Pain that usually begins in the center of belly, around the belly-button, and then moves downward and to the right, near the area of the appendix. This usually becomes worse as time passes, when moving, taking deep breaths, coughing, sneezing and being touched in the area. The location of the pain is often hard for preschool children to describe.

Lack of hunger Nausea and vomiting Fever and chills Diarrhea or constipation Urinary symptoms such as urinating frequently and pain with urination

Diagnosis of Appendicitis
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A complete medical history and physical examination are performed. Also, some diagnostic procedures may be completed. Diagnostic procedures may include the following:

Blood tests - These are used to evaluate the infection or to determine if there are any problems with other abdominal organs such as the liver or pancreas. Urinalysis - This is done to diagnosis a bladder or kidney infection, both of which have symptoms similar to appendicitis. Abdominal ultrasound - This procedure uses sound waves to take pictures of the inside of the body. Computerized tomography (CT) - This procedure uses X-rays to take pictures of many different parts of the body. The machine takes pictures of very small sections of the body part being scanned.

Treatment of Appendicitis
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Non-perforated Appendicitis

Treatment for appendicitis is removal of the appendix (appendectomy). Patients receive antibiotics both before and after surgery. In some cases, laparoscopic surgery rather than open surgery is performed. This technique involves making a few small incisions in the belly and inserting a very small camera and surgical instruments. The pediatric surgeon then removes the appendix with the instruments. An open appendectomy involves one larger incision in the lower right side of the abdomen. Regardless of which surgical technique is used, if the appendix has not perforated, most children are able to go home from the hospital within 24-48 hours and are able to return to school in one week. Perforated Appendicitis If your child's appendix is perforated, an open surgery is often done. The child is then treated with a course of antibiotics, which is often completed at home. Perforated Appendicitis with Abscess At times, when the appendix has perforated and the infection has localized to one area, an abscess forms. Treatment of the abscess includes drainage of the infection and a course of intravenous (IV) antibiotics. Percutaneous (through the skin) drainage is done using ultrasound to help guide a small tube through the skin into the infected area in the belly. An appendectomy is then performed approximately 6-8 weeks after the infection has been treated.

After Surgery
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Non-perforated Appendicitis Your child may be sleepy and feel sick to his stomach when waking up after surgery. When he/she wakes up completely, a clear liquid diet is started. After they are able to take clear liquids without nausea or vomiting, they are allowed to eat regular foods. Encouraging your child to sit in a chair, walk, and take slow, deep breaths will help speed up recovery. In the operating room, a medicine called bupivacaine is generally given at the incision site to numb the area. Its effect lasts 6 to 8 hours. When necessary, oral or intravenous pain medication is also given. It is important to take medication for pain before the pain becomes severe, so if you think your child is starting to become uncomfortable, please let the staff know. There may be a small amount of bloodstained drainage from the wound. Perforated Appendicitis Your child may be sleepy and feel nauseous when waking up after surgery. A nasogastric (NG) tube may have been placed through your child's nose into the stomach to help empty stomach contents. This will be removed when all of the following occur:

The amount of fluid draining from the tube has decreased There are active bowel sounds (gurgling sounds made by the intestines) Gas or stool is passed

It may take up to several days before the nasogastric tube is ready to be removed. Food or fluids are not allowed until gas or stool is passed and the nasogastric tube is removed. Then, a clear liquid diet is started. If your child is able to take clear liquids without nausea or vomiting, he/she will be allowed to eat regular food. Your child will receive fluids and antibiotics through an IV line. Encouraging your child to sit in a chair, walk, and take slow, deep breaths will help speed up recovery. Once your child is no longer sleepy, he/she can get up and walk around the room as much as he/she wants.

It is important to take pain medication before pain becomes severe, so if you think your child is starting to become uncomfortable, please let our staff know. Either oral or intravenous (IV) pain medication will be given. There may be a small amount of bloodstained drainage from the wound. In some patients, the wound must be left open and covered with a dressing. The dressing will need to be changed regularly. Healing often occurs within three weeks.

Hospital Stay
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A child with non-perforated appendicitis is generally in the hospital for one to two days following surgery. A child with perforated appendicitis is usually in the hospital for four to five days. The child must stay in the hospital until they are:

Eating Passing gas No longer having high fevers Able to walk in the hallway Pain is managed with oral pain medications

Before the child is ready to go home, parents will be instructed about the antibiotics the child will need to receive at home. These antibiotics are sometimes given through a special intravenous (IV) line, and are sometimes given orally.

At-Home Care After Surgery

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The wound site must be kept clean and dry for at least two days after surgery. Your child's wound may have one of several types of dressings in place.

If your child has a clear top bandage over his/her incision, this is usually removed in 2-5 days. If your child has Steri-Strips, underneath the top bandage, allow these to fall off on their own. If your child has Steri-Strips only, allow these to fall off on their own. If your child has a glue-like covering over the incision, there is nothing that needs to be removed. Allow the glue to flake off on its own. If your child's wound was left open, you will be instructed on changing the bandages at home.

You child may take a shower two days after surgery. No tub baths should be taken for one week. Some children with non-perforated appendicitis require a 1 week absence from school. Your child may return to school sooner if he/she feels well enough. Children with perforated appendicitis may require a longer recovery time at home, typically 10-14 days, before returning to school. Gym class, sports, and climbing games are generally not permitted for two to four weeks after surgery. Your child should not do any heavy lifting for 2 weeks or participate in any formal weight lifting programs for 4 weeks after surgery. If your child had a perforated appendix, make sure he/she takes all of the prescribed antibiotics. The day you arrive home from the hospital, you should call your pediatric surgeon's office to schedule a follow-up appointment. Your child's pediatric surgeon should be called if any of the following problems occur:

Your child's temperature is above 101.5 F (38.6 C), even if it drops below this after acetaminophen is given. Your child has significant bleeding from the incisions Your child has extreme swelling at the incision sites. It is normal for there to be a small amount of swelling present for a couple days after the procedure.

Your child's incision looks infected. Symptoms of an infection include redness, significant swelling, pus (cloudy, yellow drainage) draining from site, increased tenderness or pain at site Pain is not relieved by medication. Your child vomits or develops diarrhea after being discharged from the hospital.

Post-Surgical Risks
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In some cases (3% to 11%), wound infection may develop. When this occurs, the wound must be opened and drained. The child is then treated with antibiotics. With good wound care, healing occurs within a few weeks. In some cases (1% to 2%) of perforated appendicitis, an intra-abdominal abscess (infection inside the abdomen) may develop. Depending on the size and location of the abscess, one of several treatment approaches may be used:

Treatment may consist of antibiotics alone. Treatment with percutaneous (through the skin) drainage may be combined with antibiotic treatment. Percutaneous drainage uses ultrasound to help guide a small tube through the skin into the infected area in the belly.

Treatment with surgical drainage may be combined with antibiotic treatment.