Acute appendicitis is one of the most common causes
of abdominal pain in childhood. This diagnosis must be considered
in all age groups but is more common between the ages of 4 and 15
years. The function of the appendix is unknown. However, in rabbits
and other animals the cecum is similar in shape to the appendix
and plays a role in digestion of food. The middle, inside portion
of the appendix may be irregular and somewhat narrow because of
the presence of lymph nodes in the wall of the appendix.
In most patients the appendix is located in the
right lower area of the abdomen. However, since the appendix is
a fingerlike projection, it may be in various locations in the right
upper area of the abdomen under the gallbladder, in the pelvis,
across the top of the bladder, and behind the large intestine. (Figure
|Figure 1: McBurney's point is located one
of the distance along a line from the front of the right pelvic
bone and the belly button.
Appendicitis most often results from blockage
by feces which has formed a stone (a fecalith) or, less commonly,
from enlarged lymph nodes caused by a viral infection. Once a blockage
occurs, bacteria located within the appendix grow. The pressure
in the appendix increases and the appendix becomes swollen. Eventually
the blood vessels to the appendix close and the appendix dies.
perforation will occur. (Figure 2).
|Figure 2: An appendix which has died, but is
not yet ruptured is shown during a laparoscopic appendectomy. Note the
enlarged, swollen appendix (white arrow) with a relatively normal
appendix where it attaches to the large intestine (black arrow).
Acute appendicitis usually begins with pain, frequently localized
to the area around the belly button. This is commonly followed by
loss of appetite: most children with appendicitis show no interest
in their favorite foods. Nausea and vomiting usually are seen next.
In time the pain eventually shifts to the right lower area of the
abdomen. In some patients, the appendix lies behind the first part
of the large intestine and in those patients the shift of pain to
the right lower area of the abdomen may be absent. The pain in
is continuous and generally does not get better. The pain is usually
present even when the patient is lying still. Occasionally a child
complains of right lower abdominal pain while walking, or refuses
to stand up or walk. Obtaining accurate information from an infant
or a very young child (<3 years old) may be a problem because
communication is difficult in this younger age group which leads
to a high rate of perforated appendicitis among these children.
Most children with appendicitis have a low-grade fever of 38°
to 39° C. However, it is unusual for patients with appendicitis
to present with a temperature above 39° C. When the temperature
is this high, an illness due to a virus should be considered.
The examination must include a careful abdominal and rectal
A youngster who is ill and in pain is often frightened by an unfamiliar
environment such as an emergency room. Examination under these
can be extremely difficult. Observation of the child will often
detect signs suggestive of appendicitis: the patient usually lies
quietly on the side with the knees drawn up. The patient with
moves slowly and carefully, avoiding any sudden movements: sudden
movement causes the appendix to irritate the inside of the abdomen
and to cause pain. The abdominal examination should be initiated
anywhere but the right lower quadrant with that area left for last.
Potentially unpleasant parts of the examination such as evaluation
of the throat with the use of a tongue blade or looking at the tympanic
membranes with an otoscope or performing a rectal examination should
be left for last. Careful examination of the neck, throat and chest
are important to identify other potential causes of abdominal pain
other than appendicitis.
The child can be asked to #8220;point with one
finger at the spot where it hurts the most" which is usually
found in the right lower area of the abdomen at McBurney's point.
(Figure 3). Gentle pushing on the
abdomen may identify tenderness in the right lower area of the abdomen
which is suggestive of appendicitis. Talking to children about pets,
siblings, or school while examining the abdomen may distract them
and allow a better examination. The stethoscope may be used to push
on the abdomen in young patients that believe that the stethoscope
is being used for listening. By watching for changes in the patient's
facial expression one may get an idea of how much the abdomen hurts.
Having a patient raise the hips and buttocks off of and then drop
them onto the examining table may elicit pain consistent with
A patient with appendicitis will rarely get off the examining room
table and jump up and down more than once and will have pain when
doing so. Holding a hand above a child's head and challenging him
or her to jump and touch it is irresistible to most children except
those in whom pain is produced. As mentioned previously, watching
how the patient moves on and off the examining table is also
|Figure 3: The appendix is a finger-like
that can extend down, toward the middle, upwards toward the
liver, or behind the first portion of the large intestine which
is called the cecum.
A rectal examination should be performed in most
patients unless the diagnosis is clear. The rectal examination may
identify constipation, which may be a cause of abdominal pain. A
tender area or a mass to the right on rectal examination suggests
appendicitis. In most teenage girls, a routine pelvic examination
is not necessary. Instead, the uterus, cervix, and even the ovaries
can be partially assessed during the rectal examination.
Laboratory tests are not especially helpful in the diagnosis of
early appendicitis. Approximately 90% of the patients with appendicitis
will have a white blood cell count that is high (between 10,000
to 15,000 per cubic millimeter); looking at the urine may be of
importance to identify a bladder infection or the presence of blood
in the urine which may be caused by a kidney stone. However, an
abnormal urine may also be observed in patients with appendicitis
if the appendix is near the bladder or ureter (tube which runs between
the kidney and bladder). In teenage female patients a urine pregnancy
test should be obtained.
A chest x-ray should be performed if there is a concern for pneumonia.
An abdominal x-ray might show the presence of an appendix stone
(fecalith) in the right lower area of the abdomen that suggests
that appendicitis may be present. Unfortunately, a fecalith is only
seen on x-ray in a few patients (15%). Ultrasound examination is
especially useful in teenage girls in whom gynecology conditions
such as an ovarian cyst are being considered. The typical finding
of appendicitis on ultrasound is a round, tender, stiff, blind-ending
structure that is greater than 6mm (quarter inch) in diameter and
sitting next to the first part of the large intestine which is called
the cecum. Computed tomographic (CT) scans play a role in the diagnosis
of appendicitis. Contrast (dye) is administered by mouth or through
the rectum such that it fills the cecum and, hopefully, the appendix.
One advantage of giving the contrast by the rectum rather than by
mouth is that the test can be performed much more rapidly. The CT
may show an enlarged, swollen appendix which often presents as a
"target sign#8221; (See Figure
4) A reaction in the area surrounding the appendix may also
be seen. CT evaluation appears to increase the physician#8217;s
ability to diagnose appendicitis. However, there are a group of
patients that clearly have appendicitis in whom a CT scan may be
wasteful and expose the child unnecessarily to radiation. As such,
the scan is most useful in patients in whom the diagnosis of
|Figure 4a: CT scan showing appendicitis. The
typical #8220;target sign#8221; of the appendix is shown in
the right lower abdomen of the upper scan (black arrow).
|Figure 4b: An enlarged, swollen
is shown by the white arrow in the lower scan.
Performing an operation by placing a scope into
the abdomen (laparoscopy), looking at the appendix, and doing an
appendectomy is the final diagnostic test in the patient with
pain and concern for appendicitis.
Although appendicitis is a common childhood condition, arriving
at the diagnosis may be difficult in up to half of the patients,
especially in infants, very young children, mentally retarded children,
patients initially hospitalized for other conditions, and teen-age
girls in whom various gynecologic problems may also present with
lower abdominal pain. One third to one half of patients with ruptured
appendicitis have already been seen in a physician's office or an
emergency room and are sent home with an incorrect diagnosis. A
careful menstrual cycle history often yields important diagnostic
clues. In addition, observation of a discharge from the vagina,
tenderness of the uterus or cervix, and lower abdominal pain on
both sides while pressing on the abdomen may suggest infection of
the ovaries and fallopian tubes. Twisting (torsion) of either a
normal ovary, an ovarian cyst, an ovary with a tumor, or a pregnancy
in the fallopian tube are also diagnostic considerations. In addition,
mid-monthly cycle ovulation may be a cause of concern because of
the pain (#8220;mittelschmerz#8221;). Infections of the intestines
due to a virus (gastroenteritis) with vomiting, watery diarrhea,
and high fever is a frequent cause of abdominal pain in young
Other conditions that may cause abdominal pain
in childhood include Crohn's disease, intestinal bacterial infection,
pancreatitis, perforated ulcer, gallstone or gallbladder problems.
Abdominal pain may also be caused by constipation, urinary infection,
kidney stones, and a number of other conditions (Table
In children less than 3 years of age, viral illnesses
and ileocolic intussusception (where the last part of the small
intestine moves up into the large intestine) are two of the more
common conditions which can be confused with appendicitis. In children
in whom the immune system is decreased (often patients with leukemia)
the right colon may get sick and swollen as a result of bacteria
invading the intestinal wall (typhlitis) and may be the cause of
severe right lower abdominal pain which may be difficult to distinguish
from appendicitis. The CT scan in patients with typhlitis may
thickening of the right side of the large intestine.
Table 1: Other causes
of abdominal pain which may be confused with appendicitis
|Gastroenteritis (viral, bacterial)
|Inflammatory bowel disease
|Mesenteric adenitis (bacterial, viral)
|Pelvic inflammatory disease
|Ruptured ovarian cyst
|Ruptured tubal pregnancy
|Torsion of normal ovary or ovarian cyst or
|Solid/hollow organ injury
|Trauma to a previously unsuspected mass
tumor, lymphoma, etc)
|Hemolytic uremic syndrome
|Torsion of appendix epiploica
|Torsion of omentum
Children with appendicitis usually fit into one of three groups.
The first are patients who present with an obvious case of
The second group of patients are those who clearly do not have
Finally, the third and most perplexing group are those children
with abdominal pain in whom the diagnosis is unclear. Here tests
including ultrasonography or CT may be required. In most patients
a decision as to whether appendicitis is likely or unlikely can
be made based on the symptoms, the examination, and if required,
an ultrasound or CT. If appendicitis is likely, an operation is
typically performed. If it is not likely, then most children can
be followed closely from home. Occasionally admission for observation
and serial examination is required.
The time interval between onset of symptoms and
rupture of the appendix can be shorter or longer, but in general
appears to be about 36 to 48 hours. Ruptured appendicitis occurs
in about one out of three patients admitted to most children's
Patients with ruptured appendicitis may be treated with antibiotics
followed by an appendectomy approximately 6 weeks later. Patients
with ruptured appendicitis tend to appear more ill, more often have
fevers, have a higher white blood cell count, have tenderness over
most of the abdomen, and have a longer period of symptoms. However,
even a combination of these symptoms does not help a lot to tell
the difference between ruptured and non-ruptured appendicitis. CT
may help to tell whether the appendix is ruptured or non-ruptured,
but the CT is not always correct. The surgeon must simply make a
judgment as to whether the child has #8220;ruptured” or
In instances of early appendicitis, the child
should receive intravenous fluids, antibiotics, and medication for
pain relief. Once antibiotics are administered, there is often a
reduction in pain and tenderness in many children. As such, in most
instances, antibiotics and pain medications should not be given
until the diagnosis of appendicitis has been made. Once antibiotics
are given, the infection in the appendix usually begins to get better
so that the need for immediate operation is also removed. As a result,
most appendectomy cases can wait until the daylight hours.
Appendectomy is accomplished at many centers via
a laparoscopic approach. The costs of the operation are greater
with laparoscopy than with an open operation, but the hospital stay
is shorter such that the overall costs are about the same. A
oepration can be performed in the same time that it takes to perform
an open appendectomy. One benefit, other than that the scar is smaller,
is the ability to completely see the other structures inside the
abdomen should the appendix appear normal. The laparoscopic operation
can be performed through using three or two #8220;ports#8221;
(Figure 5). With a three port operation, ports are
the belly button, the left lower abdomen and the right mid-abdomen.
A space is created between the appendix and the blood vessels going
to the appendix (the mesentery) near where the appendix joins the
large intestine. A stapler which divides and seals is first fired
across the blood vessels and then across the appendix itself. The
appendix is then removed. With the two port technique a port is
placed through the belly button and through the right lower abdomen.
The appendix is grasped and brought up through the port site as
the port is removed. An appendectomy is then performed outside of
the body as the blood vessels and the appendix are tied off with
sutures. The appendix is then removed. This technique is best used
when an early appendicitis is present or a normal appendix is found.
|Figure 5: Laparoscopic appendectomy
A) dividing the blood vessels going to the appendix using a
stapler followed by B) removal of the appendix using a
In some cases, an open appendectomy is performed
through a longer right lower abdomen incision (Figure
6). Antibiotics are continued after the operation only in patients
with ruptured appendicitis. Patients can usually start eating following
the operation and, in most cases of non-ruptured appendicitis, are
discharged in the first 24 hours.
|Figure 6: (A), An incision is made in the
lower abdomen. (B) , The muscle is opened. (C), The transverse
the first part of the large intestine, the cecum, is identified.
(D), The swollen appendix is seen and the blood vessels going
to the appendix are tied off. (E), A suture is placed in the
cecum around the bottom of the appendix. (F), The bottom of
the appendix is crushed tied off. The appendix is removed and
(G) the remaining portion of the appendix is dunked down into
the cecum using the suture tied in #8220;E#8221;.
When the appendix has ruptured, antibiotics should
be given to treat infection. Pain medication is administered. When
ready, the patient may be taken to the operating room for appendectomy.
However, in many cases of ruptured appendicitis, the approach of
interval appendectomy is applied: patients are first treated with
antibiotics to allow the infection to go away. Abscesses (pus pockets)
are drained out using the CT to guide placement of a needle into
the abscess (Figure 7) Antibiotics
are continued until the infection is gone. A peripherally-inserted
central catheter (PICC) may be placed into a vein and the patient
sent home on intravenous (IV) antibiotics once the child is eating
a diet and pain is controlled on medication taken by mouth. Nutrition
given into the IV may be necessary until adequate nutrition can
be taken by mouth. Appendectomy is then performed after 6 to 8 weeks.
The complications appear to be less with this approach of waiting
before doing the appendectomy when the appendix has ruptured.
|Figure 7: CT scan demonstrating the findings
of a pus pocket (abscess, see arrow) in the right lower abdomen
of a child with perforated appendicitis.
DEATHS AND COMPLICATIONS
The number of cases where children have died from appendicitis has
decreased over the past 3 decades to the point where it is now almost
never the cause of death. The availability of excellent antibiotics
along with the availability of CT scans have made deaths from
almost unheard of and the incidence certainly <1%. Infection
of the incision after an appendectomy is a fairly rare complication
(3%). Abscesses (pus pockets) are also fairly uncommon (<5%)
and can usually be managed by draining the pus with a needle placed
while watching the CT, drainage through the rectum, or continued
antibiotic administration in the case of multiple, small pus pockets.
There is a 3% to 5% risk of small bowel obstruction (blockage) after
appendicitis and appendectomy. Currently, >90% of children operated
upon for appendicitis indeed have the disease.
CHRONIC (LONG TERM) APPENDICITIS
Although whether chronic appendicitis exists is controversial, most
surgeons have managed patients with chronic abdominal pain that
resolved with appendectomy. In some cases, patients have noted
right lower abdominal pain and, in fact, the appendix which is
removed has chronic changes consistent with bouts of appendicitis.
Some surgeons have suggested that when the appendix does not fill
or only partially fills with barium during a barium enema or when
barium does not drain from the appendix after a few days following
a barium enema, suggests that chronic appendicitis may be present.
Laparoscopy with appendectomy has provided a means for evaluating
the appendix in the child with persistent lower abdominal pain.
Articles and graphics adapted from O'Neill: Principles of Pediatric
Surgery. © 2003, Elsevier.