The clinical picture of acute appendicitis is extremely diverse and depends on the age of the child, the location of the process, the morphological stage of inflammation.
The earliest sign of appendicitis is pain, which in the classical case is localized in the epigastric or paraumbilical region, and then shifted to the projection of the appendix (usually the right iliac region). With retrocecal location of the appendix, pain is determined in the lower back, with subhepatic location – in the right hypochondrium, with pelvic – in the suprapubic area. Older children easily point to the localization of pain. The prevailing symptoms of appendicitis in a young child are anxiety, crying, sleep disturbance, pulling the legs up to the stomach, resistance to physical examination.
Appendicitis pain syndrome is almost always combined with refusal to eat. Pathognomonic sign of appendicitis is vomiting: single or double in older children or multiple – in children. Children with appendicitis may experience stool retention; in young children, as a rule, the stool becomes more frequent and fluid with an admixture of mucus (diarrheal appendicitis), and therefore dehydration can quickly occur.
Body temperature rises to subfebrile or febrile values (38-40 ° C). For children of the older age group, the symptom of “scissors” is typical, manifested by a discrepancy in temperature and pulse. Increased urination (pollakiuria) is usually observed in the pelvic localization of the appendix.
With catarrhal appendicitis, the child’s tongue is moist, with a coating in the root area; in case of phlegmonous appendicitis, the tongue also remains wet, but its entire surface is lined with white bloom; with gangrenous appendicitis – the tongue is dry and completely covered with white bloom.
Acute appendicitis may be complicated by process perforation, peritonitis, periappendicular infiltration or appendicular abscess, intestinal obstruction, sepsis.
Chronic appendicitis in children is less common than in adults. It is accompanied by recurrent bouts of pain in the right iliac region with nausea and fever.
Diagnosis of appendicitis in a child
Recognition of appendicitis requires physical, laboratory, and, if necessary, instrumental examination of the child.
Palpation of the abdomen in a child is accompanied by muscle tension and a sharp painfulness of the iliac region, positive symptoms of peritoneal irritation (Shchetkin – Blumberg, Voskresensky). In young children, the examination is performed during physiological or drug sleep. If it is difficult to diagnose, a rectal digital examination is performed, which reveals the overhang and soreness of the anterior wall of the rectum, the presence of infiltration, and other pathology is ruled out.
In general, a blood test is determined by leukocytosis of 11-15×10 9 / l and the shift of the leukocyte formula to the left. A general urinalysis study can detect reactive leukocyturia, hematuria, albuminuria. In girls of childbearing age, a pregnancy test and a consultation with a pediatric obstetrician-gynecologist are included in the examination program.
- During ultrasound examination of the abdominal cavity in children, it is possible to detect an expanded (more than 6 cm in diameter) worm-shaped process, the presence of free fluid in the right iliac fossa; perforation of the appendix shows periappendicular phlegmon. In younger children, electromyography of the anterior abdominal wall is used to identify protective muscular tension.
When ambiguities in the interpretation of clinical and physical data, the child may need to perform radiography or CT scan of the abdominal cavity. In chronic appendicitis in children with a differential diagnostic purpose, fibrogastroduodenoscopy, escretory urography, pelvic ultrasound, pelvic rhythmoscopy, coprogram, feces analysis for dysbacteriosis and helminth eggs, bacteriological examination of feces can be performed. Diagnostic laparoscopy, as a rule, goes to the treatment.
Differential diagnosis in cases of suspected appendicitis in children is performed with acute cholecystitis, pancreatitis, pyelonephritis, renal colic, adnexitis, ovarian apoplexy, torsion of the ovarian cyst, gastroenteritis, dysentery, irritable bowel syndrome, ascariasis, anomalous syndrome, an extract, and an unpleasantly, in an inoperable syndrome. To exclude diseases associated with abdominal syndrome (rheumatism, hemorrhagic vasculitis, measles, scarlet fever, influenza, tonsillitis, hepatitis), a careful examination of the skin and throat of the sick child is required.
Treatment of appendicitis in children
If an appendicitis is suspected, immediate hospitalization and examination of the child by specialists is necessary. In no case should you put a heating pad on your stomach, put a cleansing enema, give painkillers and laxatives.
The presence of acute and chronic appendicitis in children of any age serves as an absolute indication for surgical treatment. In pediatrics, preference is given to low-impact laparoscopic appendectomy, which reduces postoperative recovery time.
In cases of destructive appendicitis, preoperative preparation should not exceed 2-4 hours; at the same time, antibiotics are administered to the child, and infusion therapy is carried out. In cases of complicated appendicitis, an open appendectomy is performed in children.
Great preventive importance is the correct diet, monitoring the regular emptying of the intestines of the child, the treatment of chronic inflammatory diseases. It should be remembered that the course of appendicitis is always rapid and often atypical, therefore, for any indisposition (abdominal pain, dyspeptic disorders, fever), consultation with a pediatrician is necessary.
Causes of appendicitis in a child
Appendicitis is a consequence of obstruction of the appendix and subsequent bacterial invasion. The cause of obstruction of the appendix can be formed or trapped in the lumen of the process of coprotae (fecal stones), foreign bodies or parasites, hyperplasia of lymphoid follicles, inflammatory strictures, congenital anomalies (bends, torsion) of the vermiform process.
Mechanical obstruction and overproduction of mucus create an increased pressure in the lumen of the appendix, which is accompanied by edema of the appendix mucosa and an increase in the tension of its walls. In turn, this causes a decrease in perfusion of the appendix, venous congestion and reproduction of the bacterial flora. After 12 hours, transmural inflammation develops and peritoneal irritation occurs. With unresolved obstruction, the arterial blood supply to the appendix is disturbed in the future, with the occurrence of tissue ischemia and necrosis of the entire appendicular wall. The next stage may be perforation of the appendix wall with access to the abdominal cavity purulent and fecal contents. Full development of appendicitis takes less than 24-36 hours.
Children up to 2 years old fall ill with acute appendicitis relatively rarely, which is explained by the peculiarities of their nutrition and the anatomy of the appendix, favoring its emptying. One of the reasons for the rare occurrence of appendicitis in children of this age is the weak development of lymphatic follicles in the appendix. By the age of 6-8 years, the follicular apparatus is fully matured, and at the same time the frequency of appendicitis increases.
In the development of appendicitis in children, the leading role is played by the intestinal microflora and the vermiform process. Often there is a hematogenous and lymphogenous infection, since there is a connection between the development of appendicitis and ARVI, measles, otitis, follicular angina, sinusitis.
Some infectious diseases (typhoid fever, yersiniosis, tuberculosis, amebiasis) can cause appendicitis on their own. Predisposing and provoking factors can be overeating, a diet with low fiber content and high sugar content, constipation, helminthiasis (ascariasis in children), gastroenteritis, and dysbacteriosis.
Classification of appendicitis in a child
According to the morphological classification, a simple (catarrhal), destructive appendicitis and empyema of the appendix are distinguished. In turn, destructive appendicitis can be phlegmonous or gangrenous (in both cases – with or without perforation). Appendicitis in children does not always lead to perforation of the appendix; in some cases, there are cases of spontaneous recovery.
The appendix in children can be located in the right or left iliac region, subhepatic, pelvic or retrocecal space. Recent studies have shown that children can develop both acute and chronic recurrent appendicitis.
Appendicitis in children – acute (less often subacute, chronic) inflammation in the appendix (appendix). Appendicitis in children occurs with abdominal pain, single or double vomiting, rapid stool, temperature reaction, decreased activity, anxiety. Diagnosis includes palpation of the abdomen, rectal finger examination; general blood and urine test; Ultrasound, radiography or CT scan of the abdominal cavity; diagnostic laparoscopy. Detection of appendicitis requires an appendectomy, preferably by laparoscopy.
Acute appendicitis is the most common urgent disease in pediatric surgery (75% of emergency operations). With appendicitis in children one has to face not only pediatric surgeons, but also pediatricians, pediatric gastroenterologists, pediatric gynecologists.
In childhood, inflammation of the appendix of the cecum develops rapidly, which causes an increase in destructive changes in the appendix in a relatively short time. When appendicitis in the child in the inflammatory process is often involved in the peritoneum, leading to the development of appendicular peritonitis.
The peak in the incidence of appendicitis in children (over 80% of cases) occurs at school age, in preschool children the disease occurs in 13%, in toddlers – in 5% of cases.