What is the Appendix as an Organ, What is its Function?

The appendix, commonly known as the ‘blind intestine’, is a piece of intestine located at the junction of the small intestine and the large intestine, approximately 5-6 cm long and 2-3 mm in diameter in adults, but in children, the size of which varies depending on age and person, with a blind lumen.

Its function is not fully known, but it is thought to contribute to our immune system, especially the intestines.

 

Images: Anatomical location of the appendix

What is appendicitis?

It is an infection or inflammation of the appendix.

Is appendicitis seen in children?

Although appendicitis can be seen in all age groups, this rate is slightly higher in childhood. The incidence in childhood is 0.4%, the most common age group is between the ages of 6-10, and the incidence gradually decreases after the age of 35.

What Causes Appendicitis?

As mentioned before, the appendix is ​​an organ with a lumen. Appendicitis generally develops due to obstruction of the lumen, but in some patients, appendicitis can also be seen without obstruction of the lumen. As a result of this obstruction, the natural intestinal secretions in the appendix cannot be expelled and first the appendix wall becomes edema, then its blood supply begins to deteriorate and the inflammatory process called inflammation begins. At this stage, the child only has symptoms such as abdominal pain around the navel and loss of appetite. As the inflammatory process progresses, the appendix tissue begins to swell and the developing infection spreads to its entire wall. At the same time, the nutrition of the appendix is ​​severely disrupted. During this process, the child's abdominal pain becomes severe and settles in the lower right part of the abdomen. During this period, the patient's fever may rise and vomiting may begin. As the process continues, the intestinal content spills into the abdomen through the hole formed in the wall of the appendix, whose blood supply is disrupted, and a process called "peritonitis" begins. This process varies from person to person from the beginning, but lasts approximately 6-12 hours. If surgical intervention is not performed during this very dangerous process, the infection spreads rapidly throughout the body and may result in the patient's death.

 

What are the Pathologies that Cause Appendix Lumen Obstruction?

These reasons can be in the form of internal obstruction and external pressure, which are; Hardened poop, which we call fecalith, indigestible food pieces, foreign bodies, lymph node enlargement, lymphoma and other tumors, parasites, etc.

Is Appendicitis Familial or Genetic?

No, it is not.

Is Appendicitis Seen in Young Children and Babies?

Yes, it is seen, and even newborn babies can have appendicitis. Approximately 15% of total appendicitis is seen in those under the age of 5, and 2% in those under the age of 2.

The frequency of appendicitis in the general population is approximately 10-15% and is more common in people between the ages of 5-30.

Adult men are more likely to get appendicitis than women. This ratio is 1.5/1. However, it is equally likely to be seen in both girls and boys during childhood. The most common period is young adulthood.

What are the Symptoms of Appendicitis in Children?

The main clinical symptoms of acute appendicitis are abdominal pain, nausea and vomiting, loss of appetite, high fever and limited movement due to pain. The difference between appendicitis pain and most other abdominal pain is that its intensity does not decrease, does not come and go, and even increases gradually. When the appendix bursts, pain and stiffness in the entire abdominal wall, or a ‘wooden belly’, occur.

It should be noted that if your child has appendicitis, all the classic symptoms listed above may not be present. Since the appendix, which resembles a finger-shaped protrusion, can extend to many different places, it can cause different findings, and especially under the age of 3, with the addition of communication difficulties, there may be delays in diagnosis and treatment.

Clinical Symptoms in General;

• Abdominal Pain
• Loss of appetite
• Nausea
• Vomiting after pain
• Restriction of movement
• Swelling of the abdominal area
• Constipation or diarrhea accompanied by gas
• Difficulty in passing gas
• Fever usually does not exceed 38 °C
• Pain in the rectum area
• Painful urination

Abdominal pain; The most well-known symptom of appendicitis is abdominal pain and is the first symptom. Abdominal pain is initially around the navel and cannot be localized exactly, then settles in the lower right part of the abdomen after an average of 4-6 hours. The pain is followed by loss of appetite, nausea and vomiting.

The pain may initially be colicky, that is, as if something is stabbing, then blunt as if hit with a fist, the pain sometimes becomes continuous, does not even allow sleep, but there may be a temporary improvement when the appendix ruptures. The pain increases with movement and even coughing, so the patient does not want to move and even walks sideways. When he lies down, he cannot lie flat on his back and he lies on his side and pulls his feet towards his stomach.

There are two things to remember about pain, first, each child's pain threshold perception is different, second, the appendix may be anatomically located differently, for example, when it is located behind the cecum, which we call retrocecal, the pain perception may be different and diagnosis may become difficult.

 

Picture: Appendicitis Patients' Postures

Constipation

Another of the most obvious features of appendicitis is the occurrence of constipation together with appendicitis pain. In other words, if there is a problem with the appendix, the person cannot go to the toilet; in fact, the patient is not constipated; they poop but cannot do it or they do it in small amounts.

Anorexia (Loss of appetite)

It is present in 90-95% of patients, but it does not attract much attention. It occurs before the pain. When children ask if they are hungry, they say no, even if they have not eaten anything for a long time, they do not want to eat even their favorite food when you tell them.

Nausea, vomiting

It is present in 75% of patients. Vomiting is not severe. If there is severe vomiting, other causes should be considered. Vomiting occurs after the pain. If vomiting occurs first and then pain, this is usually not acute appendicitis. The cause of vomiting is peritoneal irritation. Vomiting initially contains stomach contents and later bile.

Fever

All patients have a fever, the fever is around 38 °C, but in delayed cases it can be much higher, even over 40 °C. Fever may not be present only in patients with systemic diseases or those using antipyretic drugs.

Rapid heartbeat

There is mild tachycardia, but if there is a tachycardia of 120-140 / minute, it means there is a complication.

What is the Most Common and Important Clinical Finding of Appendicitis?

It is a stomachache. There is no appendicitis without abdominal pain.

Should Appendicitis Come to Our Mind First in Abdominal Pain?

Appendicitis should definitely be considered in abdominal pain in children. However, the most common causes of abdominal pain in children are gastroenteritis (intestinal infection), urinary tract infection, parasite, upper respiratory tract infection and finally constipation. It should not be forgotten that only 5-10% of abdominal pain in children is due to a surgical cause. For this reason, it is not thought about much and because it is not thought about, diseases are missed, in other words, diagnosis is not made and when it is not made, serious complications are encountered.

What Should Be Considered for Correct Diagnosis When Abdominal Pain is Seen in Children?

The patient's age, the onset and characteristics of the pain, the location of the pain in the abdomen, the spreading characteristics of the pain, whether there are other accompanying complaints, whether there have been such complaints in the past, whether there are similar complaints in the family, environmental conditions are important and should definitely be questioned.

In Which Cases Should a Surgical Cause Be Considered for Abdominal Pain?

Sudden onset abdominal pain, especially if the abdominal pain is very severe or does not subside at all, very widespread or localized and severe abdominal pain, accompanied by bilious vomiting, abdominal distension, if the abdominal pain increases with movement and there is loss of appetite, if there is a history of previous trauma, if the cause of the abdominal pain cannot be explained, if there is jaundice, a surgical cause should definitely be considered.

How is Appendicitis Diagnosed in Children?

Despite all technological developments, appendicitis is still diagnosed today with history and physical examination. However, a number of tests are used to support the diagnosis and distinguish it from other diseases.

In standing X-rays, foreign bodies, especially fecaliths, scoliosis related to posture can be seen and other findings can be detected.

 

Images: Fecalith and scoliosis appearance in standing X-rays

There may be high white blood cell count in blood test, there may be urinary tract infection findings in urine test, care should be taken and not be confused.

With abdominal ultrasonography, the diameter of the appendix exceeding 6 mm, the presence of free fluid around the last part of the large intestine, the thickness of the intestinal wall and the appearance of infection in those areas are helpful in diagnosis. Ultrasound is also important in distinguishing ovarian pathology in girls and urinary system pathologies in all children, care should be taken.

Computerized tomography, which is very effective in adults, does not have the same importance in the younger age group due to the thinness of children. However, in obese children, it can show the existing pathology very clearly because fatty tissues can provide better images.

Which Diseases Should Be Considered in the Differential Diagnosis of Appendicitis in Children?

Although appendicitis is common in childhood, diagnosis can be quite difficult in half of the patients. Diagnosis becomes difficult especially in those under the age of 3, those with mental disabilities, those hospitalized for another disease, and young girls who may have abdominal pain due to gynecological reasons. It should not be forgotten that one third to half of cases with ruptured appendicitis are children who have been seen by a doctor before.

In young girls, mid-menstrual cycle pain, pregnancy, ovum rotation, ovum cyst; intestinal infections in childhood, pancreatitis, constipation, kidney stones, urinary tract infections, parasites; infections, pneumonia, intestinal obstruction (small intestine passing into large intestine) in younger children can cause abdominal pain that can be confused with appendicitis.

When the causes of abdominal pain are listed one by one, dozens or even more reasons can be listed. Instead, here, we will list which system diseases can cause abdominal pain under general headings and which should be considered in the differential diagnosis of appendicitis.

• Gastrointestinal system diseases
• Biliary system and liver, pancreas diseases
• Urinary tract diseases
• Gynecological causes
• Blood diseases
• Respiratory tract infection causes
• Ear infections
• Medications used
• Metabolic diseases

This group of diseases will be examined more broadly under the title of causes of abdominal pain.

Can Gas Pain Be Confused with Appendicitis Pain in Children?

Patients and their relatives may confuse them. However, a specialist physician will not confuse them. At least gas pain starts suddenly and there are painless periods in between, whereas the pain never goes away in appendicitis. For example, if you ask the mother how she slept last night and she says she woke up 1-2 times but slept comfortably other than that, it is not appendicitis pain, because with appendicitis pain, the mother could not sleep at all at night and always groaned in pain.

What are the Difficulties in Diagnosing Appendicitis in Children?

Diagnosing appendicitis is difficult, especially in children under two years old. Because all the system infections listed above can cause abdominal pain and the patient cannot express herself. On the other hand, the clinical findings of appendicitis in this age group include signs of infection in all systems. Common symptoms are restlessness, general deterioration, difficulty in feeding, pain, loss of appetite, abdominal distension, bilious vomiting and fever. Inflammation of the abdominal wall, which we call cellulitis, and swelling in the scrotum may be seen in the right lower quadrant wall. Since it is difficult to obtain a sufficient history and physical examination from the patient, the diagnosis is usually made after complications develop. In patients under the age of two, 93% perforation has occurred when the diagnosis is made.

There may also be difficulties in diagnosing appendicitis when the patient has an atypical history and the appendix is ​​in a different location. In addition, when the patient has another disease together, the findings may be hidden if the patient takes analgesics, antibiotics and corticosteroids.

Important Note!

In order not to make a wrong diagnosis and not to miss it, patients who cannot be fully diagnosed and young babies who are considered to have appendicitis should definitely be hospitalized and the patient should be examined at intervals, especially while sleeping, and preferably evaluated by the same specialist.

In addition, painkillers should never be given to patients whose diagnosis is not definite by their families and physicians.

What is the Treatment Method for Appendicitis in Children?

The definitive treatment method is to remove the infected appendix and clean the abscess that has formed. This surgery, which is called appendectomy in medicine, has two methods today: open and laparoscopic.

Before the surgery, the patient is not fed orally, antibiotics and painkillers are started. Serum is given intravenously, and if necessary, a urinary catheter and nasogastric tube are inserted.

Open appendectomy; The diseased tissue is removed with an incision made in the right lower abdomen and the area is thoroughly cleaned. Patients with open appendectomy stay in the hospital longer, have longer pain, have more early and late complications, and are not preferred today, but laparoscopy may not be suitable for some patients, so open appendectomy is performed.

 

Figures; How Open Appendectomy is Performed and Appendix Appearance

Laparoscopic appendectomy; Appendectomy is performed with the help of a camera inserted from the navel and two instruments inserted from the right and left.

Thus, the recovery period of surgeries performed with minimal tissue damage is significantly shortened and there are almost no post-surgical scars. Complications seen in classical surgical practice are also minimized. Patients return to their daily activities in a shorter time.

Those who recommend open appendectomy prefer it primarily due to its shorter operation time and easy applicability. Laparoscopic appendectomy has advantages such as faster wound healing, shorter hospital stay, less post-operative pain and better cosmetic results compared to open surgery.

 

Figures: Demographic Views of Laparoscopic Appendectomy

How Does the Post-Operative Process Progress?

Depending on the severity of the disease after the surgery, the patient needs to receive antibiotic treatment for a while. Which antibiotic to take and for how long depends on the severity of the disease. This treatment is usually carried out in the hospital with antibiotics administered intravenously. The patient starts walking approximately 6 hours after the surgery. Patients whose bowel movements return to normal, whose fever decreases and who can easily be fed orally are discharged home.

The post-operative period is closely related to the period in which the surgery is performed. While the patient can often be discharged within 1-2 days in laparoscopic appendectomies performed in the early stages, this period can be up to a week in delayed, burst stages and open appendectomies. However, each child may react differently.

What are the Post-Operative Complications?

Depending on the inflammation status of the appendix and the inside of the abdomen, various complications may develop after the surgery. These include wound site infections, intra-abdominal abscesses, and intestinal adhesions. When appendicitis is diagnosed and treated early, the rates of these complications are quite low. In addition, infertility may be observed in girls at an advanced age due to uterine adhesions.

Appendectomy is the most frequently performed surgical procedure worldwide. The mortality rate after surgery has recently decreased to 0.5% with the increased effectiveness of antibiotics and improved diagnostic methods. Skin infections after appendectomy are seen at a rate of 3% and can be easily treated. Intra-abdominal abscesses, especially those seen after a burst appendix, can also be easily treated by draining them under tomography or ultrasound. Small bowel adhesions, which can be seen after appendectomy, can also be seen at a rate of 1-3%. All of these complications may require a second surgery.

What to do if abdominal pain reoccurs and fever occurs a few days after surgery?

In such a case, intra-abdominal abscess formation and early intestinal adhesion should be considered first. A doctor is consulted again and the necessary treatment is arranged, in such a case, a second surgery may be required.

*** The information provided here and the content of the website are arranged for the purpose of informing visitors, especially families. No information should be considered as advice by visitors and should not lead to any decision or action. The patient should definitely be examined by a pediatric surgeon on the subject, and a decision should be made by consulting him/her and consulting his/her personal knowledge.