Acute appendicitis
Acute appendicitis is the commonest cause of abdominal pain in childhood requiring surgical intervention (Fig. 13.5). Although it may occur at any age, it is very uncommon in children less than 3 years old. The clinical features of acute uncomplicated appendicitis are
Symptoms
anorexia
vomiting (usually only a few times)
abdominal pain, initially central and colicky (appendicular midgut colic) but then localising to the right iliac fossa (from localised peritoneal inflammation)
Signs
flushed face with oral fetor
low-grade fever 37.2-38°C
abdominal pain aggravated by movement
persistent tenderness with guarding in the right iliac fossa (McBurney's point).
In preschool children:
the diagnosis is more difficult, particularly early in the disease
faecoliths are more common and can be seen on a plain abdominal X-ray
perforation may be rapid, as the omentum is less well developed and fails to surround the appendix, and the signs are easy to underestimate at this age
With a retrocaecal appendix, localised guarding may be absent, and in a pelvic appendix there may be few abdominal signs.
Appendicitis is a progressive condition and so repeated observation and clinical review every few hours are key to making the correct diagnosis, avoiding delay on the one hand and unnecessary laparotomy on the other.
No laboratory investigation or imaging is consistently helpful in making the diagnosis. A neutrophilia is not always present on a full blood count. White blood cells or organisms in the urine are not uncommon in appendicitis as the inflamed appendix may be adjacent to the ureter or bladder. In some centres, laparoscopy is available to see whether or not the appendix is inflamed. Appendicectomy is straightforward in uncomplicated appendicitis.
Complicated appendicitis includes the presence of an appendix mass, an abscess or perforation. If there is generalised guarding consistent with perforation, fluid resuscitation and intravenous antibiotics are given prior to laparotomy. If there is a palpable mass in the right iliac fossa and there are no signs of generalised peritonitis, it may be reasonable to elect for conservative management with intravenous antibiotics, with appendicectomy being performed after several weeks. If symptoms progress, laparotomy is indicated. If an abscess is confirmed on abdominal ultrasound, operative drainage and appendicectomy will be required.
