Acute appendicitis in children: pediatric surgery

Acute appendicitis in children is quite common in medical practice. This disease requires urgent surgical attention.

The clinical course of inflammation in children is somewhat more complicated than in adults, which, in fact, complicates the diagnosis during the examination of an admitted patient.

These patterns are expressed quite often in children under 3 years of age. This fact is explained by the difference in anatomical and physiological characteristics in the development of the child.

A bit of history

For the first time, Reginald Fitz in 1886 described information about the clinical history of acute appendicitis.

After examining the patient, the doctor suggested treating the inflammation with appendectomy.

A year later, in the United States, Tomos Morton became the first surgeon who was able to diagnose appendicitis and perform the first appendectomy successfully.

In 1889, Mr. Wurnay described the clinical findings of acute appendicitis, assigning the point of maximum pain. It was named after the name of its creator.

Anatomical signs of the appendix

The appendix of the cecum should be understood as the appendix, which is located in the lower pole.

At the time of birth, it looks like a pyramid with its upper part upside down. In childhood, the appendix does not occupy its position, as it is observed in adults.

Over the years, the lateral walls of the cecum grow. The phase of rapid growth is observed from 11 to 16 years old.

If the growth of the cecum is suppressed, then appendix hypoplasia is observed. Also, doctors record cases of agenesis of the appendix.

Pediatric surgery has dealt with cases of appendix doubling. The base of the organ in such cases is located at the junction of the three lines with the colon.

The appendix has an elongated muscle layer, a circular epithelium, as well as a colon epithelium, which gradually passes to the cecum.

The location near the appendix in 95% of cases is intraperitoneal, but it is impossible to say for sure in any case.

In 30% of cases, the end of the organ is located in the pelvic region, in 65% - retrocecal. There is also 5% - retroperitoneal location of the appendix. If there is an incomplete bowel turn, then the appendix may show signs of inflammation of unusual localization.

As for the length, it varies within 10 cm. When a person is born, there are only a few submucous lymph nodes in the appendix, but at the age of 12-20 years their number reaches 200 pieces.

After 30 years, on the contrary, there is a decline; at the age of 61, only traces of their former presence remain.

Prevalence of appendicitis in children

Most often, acute appendicitis in children occurs in developed countries. 75% of cases require emergency operations.

The risk factors include the fact that the diet of children has a low fiber content, as well as an excess of sugar.

Cases of family predisposition, as well as the influence of infection of agents, are not excluded.

The risk of disease is 7% out of 100. Adults are also included in this category. In children, the peak incidence occurs at the age of 10-12 years.

This is explained by the fact that at this time, children develop lymphatic follicles. After this stage, the risk of getting sick decreases. But it is worth noting that the disease can overtake a person in adulthood.

The lowest incidence rate is found in infants. As for the gender division, boys suffer from appendicitis 2 times more often than girls of the same age.

Speaking about the mortality rate, it is worth noting that world statistics indicate data at a rate of 1%.

Pathogenesis of acute appendicitis in children

Today, 2 theories are known that explain why acute appendicitis occurs in children. These are: neurovascular theory and stagnation.

Neurovascular theory

It consists in the fact that acute appendicitis is the cause of a disturbance in the activity of the gastrointestinal tract, as well as failures in viscero-visceral impulses.

All this is reflected in the vascular trophism of the appendix of the cecum itself. When a spasm of smooth muscles and the vascular system occurs, there is a violation of the nutrition of the walls of the appendix, necrosis.

There is also a change in the permeability of the mucous membrane for microflora, which provokes the development of the inflammatory process.

Stagnation theory

Explains the development of an acute form of appendicitis in the younger generation by the obstruction of the appendix with intestinal contents.

At the same time, the pressure in the lumen of the appendix rises, and therefore the outflow of limf is disturbed. All this leads to edema and swelling of the appendix tissues.

Violation of venous outflow under conditions of high pressure inside the lumen of the organ leads to ischemia of the mucous membrane, as well as invasion of the existing microflora.

Pathology of appendicitis in children

Catarrhal inflammation of the appendix is ​​accompanied by a hyperemic and edematous serous membrane. Microscopically, defects of the mucous membrane, which is covered with leukocytes and fibrin, will also be determined.

Phlegmonous inflammation of the appendix in children is manifested by purulent inflammation of the layers of the organ. It will be hyperemic, thickened in the walls, fairly tense, and also have a fibrin coating.

Infiltration of the microcirculatory nature of all layers of the appendix is ​​determined. In the mucous membrane, there will also be elicitation, rejection and suppuration.

Gangrenous inflammation of appendicitis in children is characterized by destructive defects in the wall of the appendix, which will be thickened.

It will have purulent fibrinous overlays, as well as a dark gray tint. If the pathology is examined microscopically, it is possible to establish necrosis of the walls of the appendix.

Symptoms of acute appendicitis in children

It is very important to know how the acute form of appendicitis manifests itself in children. The child's condition is accompanied by pain in the abdomen.

They can subside and reappear. As for localization, it is mainly the navel or the epigastric region.

Gradually, the pain can move to the right iliac region. Even during sleep, such sensations can excite a child.

Vomiting also occurs in children. There may be several reflex attacks, but there is no relief after it.

It is also worth trying the temperature. With acute appendicitis, a child may have a body temperature of 38 degrees.

The discrepancy is possible within one degree. It is also recommended to check your heart rate. It will become more frequent by 8-10 beats per minute.

The chair will be broken, the child will not be able to go to the toilet. If you palpate the muscles of the abdominal wall, you can feel their tension.

On palpation of the right side of the iliac region, the child may feel an increase in pain, this confirms acute appendicitis in accordance with Filatov's symptom.

If deep palpation is carried out and the hand is removed from the abdominal wall, the pain can also become stronger, this is a positive Shchetkin-Blumberg symptom, confirming the diagnosis.

Of course, you cannot engage in self-diagnostics, you need to immediately take the child to the hospital.

Diagnosis of acute appendicitis in children

The course of the pathology and physical examination play an important role during the diagnosis of the patient's body. Laboratory examinations will also be useful in this case.

General blood analysis

Leukocyte formula will shift to the left. But 10% of cases have no failures in blood tests.

The disadvantage of this method is non-specificity. The thing is that leukocytosis is possible in the case of other inflammatory processes in the body.

General urine analysis

A change in the norm in urine is observed in 25% of patients. Deviations are expressed in the form of hematuria, leukocyturia, albuminuria.

This is due to reactive inflammation of the urinary tract, which is located next to the appendix.

But if there are more than 25 leukocytes in the urine, then this indicates the course of pyelonephritis in the body.

If the examination is carried out in girls of childbearing age, a urine or blood pregnancy test should be included in the examination.

X-ray

This examination will be useful if the doctor cannot understand the exact diagnosis. Looking at the picture, you can determine the presence of fecal matter.

They are found in 10-20% of patients with appendicitis, which indicates the need for surgery.

Ultrasound

Helps to find an enlarged process with fluid in the lumen, if it is not palpable from the outside.

During perforation of the appendix, doctors pay attention to the presence of an abscess process or periapendicular phlegmon.

The disadvantages of this method are that with obesity or the presence of gas in the intestines, it is difficult to determine the appendix.

CT scan

CT scan will be performed with intravenous contrast if there is ambiguous data in the interpretation of the clinical picture of pathology.

The data will indicate a thickening of the walls of the cecum or appendix. Plus, an appendicular abscess can be identified.

The use of this study in the diagnosis of appendicitis in childhood is not widely known, since there are limitations due to increased radiation exposure to the growing body.

Additional tests

As additional tests, blood tests for C-reactive protein or interleukin are prescribed. They are able to confirm the presence of inflammation in the child's body.

Abdominal laparoscopy may also be done. If the doctor has doubts about the diagnosis, he hospitalizes the patient in the department of surgery at the hospital.

There, the patient will be under the supervision of a doctor for no more than 10-12 hours. At this time, the surgeon consults with related specialists. If it is impossible to exclude a case of acute appendicitis in a child, surgical intervention is prescribed.

It is not always easy for a doctor to correctly assess the data of atypical acute appendicitis in children during the first examination.

First of all, this is due to the fact that the clinic of acute appendicitis can be stimulated by other diseases.

In addition, pain in the abdomen is not always the result of inflammation of the appendix of the cecum.

School-aged children have a tendency to hide the pain, fearing that they need surgery. Cases are not excluded when, on the contrary, they aggravate their feelings.

All this is of great practical importance. The fact is that some doctors perform an operation on children to remove appendicitis for extended indications, i.e. preferring overdiagnosis of appendicitis. It should be noted that it is not always justified.

Some difficult cases of diagnosis involve a digital rectal bimanual examination.

This method gives a chance to determine the presence of complications or to clarify the diagnosis. This is especially important in the case of girls in pre-puberty or puberty.

Cases of torsion of the ovarian cyst, pain with an unidentified menstrual cycle, follicular and luteon cysts are not excluded.

Examination using the rectal passage for acute appendicitis in children makes it possible to establish soreness of the rectal wall on the right and in the front, as well as in some cases when the arch overhangs from the right parts.

Research data and constant pain on palpation in local areas in combination with other symptoms become the reason for the diagnosis of acute appendicitis in a patient.

Differential diagnosis of acute appendicitis in children

Diagnosis presents serious difficulties, due to the fact that in childhood acute appendicitis in clinical manifestation simulates many other pathologies, most of which do not need surgical intervention.

This is especially true among atypical variants of the location of the appendix.

There are many somatic and surgical diseases, both in the abdominal cavity and outside of it, which are disguised as acute appendicitis in childhood.

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