Appendicitis in children
The content of the article:
- Causes of appendicitis in children and risk factors
- Forms of the disease
- Symptoms of appendicitis in children
- Diagnosis of appendicitis in children
- Treatment of appendicitis in children
- Potential consequences and complications
- Forecast
- Prevention
Appendicitis is an acute (less often chronic) inflammatory process, localized in the appendix (appendix vermiformis, vermiform appendix), which is an appendage of the cecum.
Appendicitis - an inflammatory process in the appendix
Acute appendicitis in children occurs very often. Over 75% of emergency surgical interventions in pediatric surgery departments are caused by this pathology.
Appendicitis in children often proceeds under the guise of other diseases, so not only surgeons, but also specialists of other profiles (pediatric gynecologists, gastroenterologists, urologists, therapists) have to deal with it.
The main feature of the course of the inflammatory process in the appendix in childhood is its rapid development, as a result of which destructive changes in the appendix wall occur very quickly, conditions are created for the development of inflammation of the peritoneum (peritonitis of appendicular origin).
Appendicitis in children of the first years of life is rare (5% of cases). As they grow older, the incidence increases, with its peak occurring at school age.
Causes of appendicitis in children and risk factors
The main cause of appendicitis in children is obstruction (blockage) of the lumen of the appendix with further bacterial invasion. Obstruction can be caused by:
- congenital anomalies (torsion, bending) of the appendix;
- inflammatory strictures;
- hyperplasia of lymphoid tissue;
- helminths;
- foreign bodies;
- fecal stones (coprolites).
Mechanical blockage of the lumen of the appendix provokes hyperproduction of mucous secretion by cells of the mucous membrane. As a result, the pressure in the appendix gradually increases and the tension of its walls increases, the blood supply worsens, the phenomena of venous stasis increase, and the active development of bacterial microflora begins.
After 10-12 hours from the onset of the pathological process, the inflammatory process spreads beyond the walls of the appendix, leading to irritation and inflammation of the peritoneum. If the obstruction is not resolved, then the increasing deterioration of the arterial blood supply causes the development of tissue ischemia and the onset of necrosis of the entire thickness of the walls of the appendix.
The next stage in the development of the inflammatory process is the perforation of the wall of the appendix with the release of fecal and purulent contents into the free abdominal cavity. On average, the full cycle of development of appendicitis in children lasts no more than 24–36 hours.
In some cases, appendicitis in children ends with spontaneous recovery, but this is possible only if the wall of the appendix has not been perforated.
In the first two years of life, inflammation of the appendix in children is practically not observed. This is explained by the fact that the peculiarities of nutrition at this age create the best conditions for the outflow of liquid contents from it. In addition, in children of the first years of life, lymphoid tissue is still poorly developed in the appendix, which also reduces the risk of its inflammation. By the early school age, it fully matures, which leads to an increase in the incidence.
Poor nutrition is a predisposing factor for appendicitis in children.
An important role in the development of appendicitis belongs to its own microflora of the appendix and intestines. In addition, the infection can enter it by the lymphogenous or hematogenous route from any other source of inflammation in the body. This is confirmed by the fact that appendicitis in children often develops against the background of sinusitis, follicular sore throat, otitis media, measles, or an acute respiratory viral infection. Some infectious diseases, for example, amebiasis, tuberculosis, yersiniosis, typhoid fever, can become an independent cause of appendicitis in children.
The predisposing factors for the development of appendicitis in children are:
- intestinal dysbiosis;
- gastroenteritis;
- helminthiasis (most often ascariasis);
- chronic constipation;
- improper diet (overeating, the content in the diet of a significant amount of light carbohydrates and insufficient fiber).
Forms of the disease
Morphological classification distinguishes the following forms of appendicitis in children:
- catarrhal (simple);
- destructive;
- empyema of the appendix.
The destructive forms include phlegmonous and gangrenous appendicitis in children, which, in turn, can occur with or without perforation.
Depending on the activity of the inflammatory process, appendicitis in children can be acute, subacute or chronic.
Symptoms of appendicitis in children
The clinical manifestations of appendicitis in children are varied and depend on the following factors:
- features of the anatomical location of the process (right or left iliac region, retroperitoneal, subhepatic or retrocecal space);
- morphological stage of development of the inflammatory process;
- the age of the child;
- the presence of concomitant pathology.
The first and earliest symptom of appendicitis in children is abdominal pain. In most cases, pain initially occurs in the umbilical or epigastric region, and after a few hours it shifts to the right iliac region. With the pelvic arrangement of the appendix, pain is localized in the suprapubic region, with the subhepatic - in the right hypochondrium, and with retrocecal - in the lumbar. Older children not only show the location of pain, but also describe its nature. Babies react to this pain by resisting palpation of the abdomen, pulling their legs up to the abdomen, sleep disturbances, crying and anxiety.
The first symptom of appendicitis in children is abdominal pain
Other signs of appendicitis in children are:
- refusal to eat;
- vomiting (repeated in babies, in older children it occurs 1-2 times);
- stool disorders (constipation or, conversely, diarrhea mixed with mucus in the feces).
Against the background of acute appendicitis in children, the body temperature rises to 38–40 ° C. The scissors symptom is characteristic, which consists in a discrepancy between the increase in body temperature and the heart rate. The symptom is most pronounced in school-aged children.
With the pelvic localization of the appendix, one of the symptoms of appendicitis in children is pollakiuria (frequent urination).
Against the background of catarrhal appendicitis in children, the tongue remains moist, and plaque appears in the root area. With the phlegmonous form of the disease, the tongue is moist, completely covered with a white coating. With gangrenous appendicitis in children, the tongue is dry, completely coated.
Chronic appendicitis in children is much less common than in adults. It is characterized by a periodic increase in body temperature to subfebrile values with the simultaneous appearance of abdominal pain.
Diagnosis of appendicitis in children
Diagnosis of appendicitis in children is carried out on the basis of the results of a physical examination, laboratory and instrumental examination.
When palpating the abdomen, the child reveals a protective tension in the muscles of the anterior abdominal wall, a sharp soreness in the right iliac region, positive symptoms of Voskresensky, Shchetkin - Blumberg, indicating irritation of the peritoneum. In young children, abdominal palpation is most often performed during physiological or medication sleep. The muscles of the anterior abdominal wall and children in the first years of life are still poorly developed, so it is almost impossible to determine the presence of their increased tension in the usual way. In this case, electromyography of the muscles of the abdominal wall is justified.
Also, in the diagnosis of appendicitis in children, ultrasound is used, during which an accumulation of free fluid in the right iliac fossa, an expanded vermiform appendix (over 6.0 cm in diameter) is detected.
To diagnose appendicitis in children, abdominal palpation is performed
In the general analysis of blood in children with acute appendicitis, leukocytosis is revealed (the number of leukocytes reaches 10-15x10 9 / l), a shift of the leukocyte formula to the left. In the general analysis of urine, albuminuria, hematuria, leukocyturia can be observed.
In diagnostically difficult cases, a rectal digital examination is shown, during which soreness and overhanging of the anterior wall of the rectum are revealed. Teenage girls who have reached childbearing age must undergo an express pregnancy test and refer them to a pediatric gynecologist for consultation.
If it is impossible to carry out an unambiguous interpretation of the results obtained, then radiography or computed tomography of the abdominal cavity is used as additional methods of instrumental diagnostics.
In some cases, laparoscopy is used. When the diagnosis is confirmed, diagnostic laparoscopy becomes therapeutic.
In children, as in adults, the diagnosis of chronic appendicitis is made by excluding any other pathology that can occur with similar symptoms. In this case, the program of laboratory and instrumental diagnostics includes:
- bacteriological and general analysis of feces;
- feces for worm eggs;
- analysis of feces for dysbiosis;
- sigmoidoscopy;
- Ultrasound of the abdominal and pelvic organs;
- excretory urogrophy;
- esophagofibrogastroduodenoscopy (FEGDS).
With acute appendicitis in children, differential diagnosis with the following diseases is required:
- right-sided lower lobe pneumonia or pleurisy;
- mesentery;
- coprostasis;
- ascariasis;
- irritable bowel syndrome;
- dysentery;
- gastroenteritis;
- torsion of the ovarian cyst;
- ovarian apoplexy;
- adnexitis;
- renal colic;
- pyelonephritis;
- pancreatitis;
- acute cholecystitis.
In children, many diseases are accompanied by the development of an abdominal syndrome (hepatitis, tonsillitis, flu, scarlet fever, measles, hemorrhagic vasculitis, rheumatism), therefore, if appendicitis is suspected, a thorough examination of the mucous membranes and skin, pharynx is performed.
Treatment of appendicitis in children
If you suspect appendicitis, the child is hospitalized, further examination is carried out in a surgical hospital. When acute pain in the abdomen appears, it is strictly forbidden to give laxatives, antispasmodics or pain relievers, put a cleansing enema or apply a heating pad to the stomach until the diagnosis is established.
Confirming the diagnosis of appendicitis in children is an indication for an emergency operation. Currently, specialists prefer laparoscopic appendectomy, as the most minimally traumatic surgical technique, in which the risk of postoperative complications is minimal. With perforated appendicitis and the development of peritonitis, appendectomy is performed by an open method.
Surgical treatment of appendicitis in children
Preoperative preparation of children with destructive forms of acute appendicitis lasts no more than 2-4 hours. The child is prescribed antibiotics of a wide spectrum of action, detoxification therapy, correction of violations of water and electrolyte balance is carried out.
Potential consequences and complications
Acute appendicitis in children can lead to the development of serious complications:
- perforation of the wall of the appendix;
- periappendicular infiltrate;
- peritonitis;
- appendicular abscess;
- sepsis;
- intestinal obstruction.
Forecast
With timely diagnosis and surgical treatment, the prognosis is generally favorable. The mortality rate is 0.1–0.3%.
After suffering phlegmonous or gangrenous appendicitis, adhesive disease often develops.
Prevention
To prevent the development of appendicitis, it is important to organize proper nutrition for the child, monitor the regular emptying of the intestines, identify and treat acute and chronic diseases, including helminthic invasions.
Parents should remember that appendicitis in children develops rapidly and can be atypical, therefore it is very important to consult a child with a specialist if any ailments (fever, dyspeptic disorders, abdominal pain) appear. This allows you to timely diagnose the disease and carry out its treatment before complications develop.
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Elena Minkina Doctor anesthesiologist-resuscitator About the author
Education: graduated from the Tashkent State Medical Institute, specializing in general medicine in 1991. Repeatedly passed refresher courses.
Work experience: anesthesiologist-resuscitator of the city maternity complex, resuscitator of the hemodialysis department.
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
