Appendicitis in Kids

How many times do parents hear this cry from their children? How is a parent supposed to react? More than likely, the child is hungry, ate too much or is constipated. But what if – that one time – a parent does not take their child’s stomach ache seriously and it turns out to be something much more severe, such as appendicitis?
“Mommy, my tummy hurts!”
By Priscilla N. Shartle
Having a good understanding of appendicitis and how it differs from the run-of-the-mill stomach ache is important to avoid unnecessary visits to the emergency room, a delay in diagnosis or, more importantly, a misdiagnosis when your child really does have appendicitis.
Appendicitis is the inflammation of the appendix, a narrow tube that branches off the large intestine at the lower right-hand side of the abdomen. The appendix has no apparent function in the body, but if an inflamed appendix is not treated it can rupture and spread infection throughout the abdomen causing a potentially dangerous condition called peritonitis.
Obstruction of the appendiceal lumen, the inside of the appendix, causes appendicitis. Sources of obstruction include:
• Feces, parasites or growths in the appendix that clog the appendiceal lumen
• Enlarged lymph tissue in the wall of the appendix caused by infection in the gastronomical track or elsewhere in the body
• Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
• Trauma to the abdomen
With children, according to Dr. Julie Munson-Jackson of Memorial Health Partners in Ooltewah, the blockage can be caused by small stool or piece of food the size of a popcorn kernel.
If your child complains of a stomach ache, Munson-Jackson urges parents to pay close attention to where the pain is. “Parents should be familiar with the warning signs of appendicitis and take the necessary action by taking their children to see a doctor or the emergency room,” she says.
Symptoms usually begin with pain in the belly button area that gradually worsens and often moves toward the right side of the abdomen. Sometimes the pain can be elsewhere in the abdomen, especially in small children.
A pediatric surgeon at T.C. Thompson Children’s Hospital, Dr. Joseph “Pete” Kelley says that approximately 48 percent of patients come in after the appendix has ruptured. Kelley says that the location of the pain in a child can depend on the location of his/her appendix. “If (the appendix is) tucked behind the cecum, the child might have a stomach ache down toward the pelvic area, and pain in the legs or hips or trouble going to the bathroom might be the symptom,” he says. “Pain is 100 percent universal in every child that comes in.”
“When a child comes in with a stomach ache, it’s important to separate a virus from appendicitis,” says Dr. Paul Hendricks, an emergency medicine physician at Memorial Hospital. “If we do the work-up and determine the child needs to be admitted, we transfer them to Children’s Hospital.” According to Hendricks, one of the key elements in diagnosing kids with appendicitis is just watching them – how they walk and move or where they complain of pain.
Transferring children to T.C. Thompson Children’s Hospital is common for most of the hospitals in the Chattanooga area. The facility sees about 250 children with appendicitis a year – about one child per day. In fact, it is considered the most common pediatric emergency surgery.
One of the problems for parents in identifying appendicitis is that the symptoms mimic the symptoms of the common virus: stomach ache, cramps and not feeling well. However, with appendicitis the pain localizes about 12 hours later and within 24 to 36 hours, the appendix ruptures. Because of the threat of a ruptured appendix, the condition is considered an emergency and treatment should be sought immediately.
Surgery to remove the appendix is called an appendectomy. Currently there are two common methods of removing the appendix. The older technique, known as a laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The other more common method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions.
A third and newer option was outlined in the April 2006 Journal of Pediatric Surgeons by the University of Tennessee College of Medicine, Chattanooga Unit. This surgery is called a video-assisted transumbilical appendectomy (see www.jpedsurg.org/search/quick.) Similar to laparoscopic surgery, this procedure goes through the belly button, but requires only one port or surgical opening, therefore leaving no scar.
“More and more pediatric surgeons across the country are choosing to use this technique,” says Kelley.
Choosing not to operate on a child’s ruptured appendix is becoming more common too, according to Kelley. “The ruptured appendix is first treated with an IV antibiotic at the hospital,” he says. “The child then goes home and for two weeks takes oral antibiotics. Four to six weeks later, the child returns to the hospital where we remove the appendix in outpatient surgery.” By then the infection is gone.
This new approach to treating a ruptured appendix came about because pediatric surgeons recognized that operating on a ruptured appendix can lead to complications. Antibiotic therapy seems to avoid the dangers of those complications.
Of course, a non-ruptured appendix is removed immediately and children are often able to go home the same day. “Kids typically do just fine,” says Kelley.
Appendicitis is more common in children than adults. Although there is no way to prevent appendicitis, with sophisticated diagnostic tests and antibiotics, most cases are identified and treated without complication.
So parents, when your child says he or she has a stomach ache, pay attention. Learn the classic symptoms of appendicitis, and be glad that Chattanooga is home to some of the finest pediatric medical professionals and facilities in the country.
Priscilla Shartle has lived in Chattanooga for nearly 10 years. She is a graduate of Louisiana State University and is the current president of the Chattanooga Writers Guild. She has four children and three grandchildren. She and her husband live on Signal Mountain.