All You Need to Know About Appendicitis
When should 'my tummy hurts!' make us worried about appendicitis?
Appendicitis is the most common reason for emergency surgery in children. About 8 percent of Americans suffer appendicitis during their lifetime. While appendicitis can occur in adults, the majority of cases occur in children between the ages of 6 and 16 (about 80,000 kids per year in the United States).
What is the appendix?
It’s a small finger-shaped organ that is attached to the end of the large intestine. It’s not clear why we have this appendage. There is evidence to suggest that early humans needed it to aid in digestion, but today the appendix has no known function. Appendicitis occurs when this organ becomes infected.
Kids have belly pain all the time for a wide variety of reasons: gas, too much ice cream, stress or viruses (“G.I. bugs”). Unlike other causes of abdominal pain in children, pain from appendicitis is unrelenting. It doesn’t come and go. Appendicitis is progressive, evolving from mild, achy pain to more severe over a period of 24-48 hours. Pain is typically the first sign, preceding other possible symptoms, such as nausea, vomiting, loss of appetite and low-grade fever.
Appendicitis pain starts in the middle of the belly and migrates to the right lower abdomen where the appendix resides. Movement worsens the pain. Children with appendicitis tend to hold still. They don’t want to walk, sit up, twist or turn. Classically, they complain about bumps in the road on the car ride to the hospital. When a child with appendicitis is lying down and relaxed, a gentle push on the lower right side of the abdomen always causes pain — called “right lower quadrant tenderness” by the doctors.
OK, now I’m worried about appendicitis. What should I do?
The first step is call your pediatrician’s office. Their team listens to the symptoms you share and can make a decision. Sometimes a quick visit to the pediatrician’s office can rule out appendicitis. If it’s outside of normal business hours or the suspicion for appendicitis is high, you may be directed to an urgent care or emergency department.
Here in Charlotte, we are fortunate to have two excellent pediatric emergency rooms, one at Levine Children’s Hospital (at Atrium Health Carolinas Medical Center) and one at Hemby Children’s Hospital (at Novant Health Presbyterian Medical Center). Each of these facilities is staffed by pediatric emergency physicians and nurses who exclusively care for children. Our recommendation is to have your child evaluated at one of those facilities, rather than an outlying urgent care or suburban emergency department where pediatric expertise may or may not be present. Though it might be a 15-minute further drive, your child will receive the best, most specialized care. And if it turns out your child does, in fact, have appendicitis, a time-consuming and expensive transfer to a children’s hospital is not required.
How is appendicitis diagnosed?
The diagnosis of appendicitis takes into account the story of the child’s illness, the characteristics of the child on physical examination, laboratory values obtained with a blood draw, and the results of radiologic studies, like ultrasound or CT scan. Most children with appendicitis do not require a CT scan for diagnosis.
How is appendicitis treated?
The standard treatment for typical appendicitis is a short, simple operation to remove the appendix before the appendix ruptures, which rarely happens until symptoms have lasted over 72 hours. Although the thought of an operation is scary, it needn’t be thanks to laparoscopy, or minimally invasive surgery. With very small, specialized tools and scopes, pediatric surgeons can remove an infected appendix with a few small incisions. The average procedure time is less than 30 minutes, and most children go home within six to 12 hours of surgery. Yes, often the same day!
After an appendectomy, kids have some achy discomfort from the operation that diminishes over three to five days, and athletic activities are limited for one to two weeks. The risk of any major complication following appendectomy for typical appendicitis is very low (less than 1 percent). Studies have been performed to determine if some children with appendicitis can be safely treated with antibiotics alone and not surgery. Complication rates in children treated without surgery are unacceptably high compared to children treated with surgery, so laparoscopic appendectomy remains the standard treatment for children with typical appendicitis.
In about 20 percent of cases, the appendix is perforated at the time of diagnosis, which means there is a small hole in the wall of the appendix. This is also known as a ruptured or burst appendix. When it occurs, the infection from inside the appendix leaks out into the abdomen. Children experiencing this condition usually have a longer recovery and are best treated with an extended course of antibiotics.
Many children with perforated appendicitis receive surgery at time of diagnosis, but sometimes, if the appendix has been perforated for an extended period of time, the best treatment is initially just antibiotics, followed by interval appendectomy after the infection resolves. Interval appendectomy is usually out-patient surgery performed eight to 12 weeks after the initial diagnosis.
For many parents, appendicitis is their first exposure to pediatric surgery. They may not know what to ask when a surgeon is referred to them. Remember that it is your right to choose the surgeon who operates on your child, and you should feel very confident in your pediatric surgeon’s abilities. To ensure the best outcome, look for a board-certified pediatric surgeon. Then ask as many questions as you need to feel comfortable.
Dr. Graham Cosper is a board-certified Pediatric Surgeon with Pediatric Surgical Associates in Charlotte. The surgeons of Pediatric Surgical Associates have made important contributions to the improvement of appendicitis management in recent years, publishing data in the surgical literature on multiple subjects, including the minimization of CT scan radiation, more efficient diagnosis, better antibiotic stewardship, and streamlining the recovery and discharge process for children with appendicitis.
For more information on keeping your child safe and well, visit pedsurgical.com.