| disease | Acute Appendicitis in Children |
| alias | Acute Children Appendicitis |
Acute appendicitis in children is a common acute abdominal condition in pediatric abdominal surgery. Children account for about 10% of patients across all age groups. The peak incidence occurs between 6 and 12 years of age, while it is relatively rare in children under 5 years old and even less common in infants under 1 year old. This may be related to the development of the appendix in young children, where the opening of the appendix into the cecum is wider and funnel-shaped, making obstruction less likely and thereby reducing the chances of acute appendicitis. Some scholars report that the incidence of pediatric appendicitis is related to seasons, with higher rates occurring in early spring (March and April) when upper respiratory infections are more frequent, as well as in July and August when gastroenteritis is prevalent.
bubble_chart Clinical Manifestations
1. Abdominal pain: Due to difficulties in obtaining medical history and describing symptoms, a typical history of migratory abdominal pain is often unavailable. The range of abdominal pain is relatively broad, and sometimes abdominal pain is not the initial symptom.
2. Gastrointestinal symptoms: These are often prominent and severe. Vomiting is frequently the first symptom, with a high intensity and prolonged duration. Severe vomiting and inability to eat may lead to dehydration and acidosis. Diarrhea may sometimes occur, while severe constipation is rare. Diarrhea is caused by intestinal inflammation stimulating excessive peristalsis.
3. Systemic symptoms: These are more severe. Fever appears early and can reach 39–40°C, even accompanied by chills, high fever, convulsions, and spasms. This is due to the instability of the thermoregulatory center in young children and the intense inflammatory response.
4. Tenderness and muscle guarding: The tender point is often located above McBurney's point. In infants and young children, the cecum is positioned higher and is more mobile, so the tender point tends to be more medial and superior. Due to the thin abdominal wall and poor cooperation in children, assessing muscle guarding is challenging. Careful, gentle, and thorough examination is required, with comparative checks in different areas.
5. Abdominal distension and fullness with diminished bowel sounds: Due to early peritoneal exudation and gastrointestinal dysfunction, abdominal distension and diminished bowel sounds are particularly noticeable.6. Upper respiratory symptoms: Upper respiratory infections are more common in children and may be a predisposing factor for acute appendicitis. Therefore, children often present with upper respiratory symptoms before developing clinical manifestations of acute appendicitis.
Pediatric acute appendicitis has the following characteristics:
1. Weak immune defense in children:
Due to insufficient humoral immunity, complement deficiency, and poor neutrophil phagocytosis, coupled with unstable thermoregulation, children are prone to high fever, more pronounced leukocytosis than adults, and more severe toxic symptoms.
2. Clinical symptoms in older children resemble those in adults:
Children under 6 years old often lack the classic symptom of migratory right lower abdominal pain. Abdominal pain and localized signs are often inconsistent, leading to a high clinical misdiagnosis rate, reportedly as high as 63%.
3. Rapid progression to suppuration and perforation: {|111|} Children have abundant lymphatic tissue in the appendix, a thin appendiceal wall, and sparse muscle layers. Severe lymphatic edema after inflammation can cause appendiceal obstruction and impaired blood supply, leading to perforation. The younger the child, the higher the perforation rate. Perforation often results in diffuse peritonitis, with difficulty forming localized abscesses due to underdeveloped omentum and rapid perforation. Suppurative appendicitis can perforate within 14–24 hours of onset. {|112|}
Children aged 6 and older can describe the location and nature of abdominal pain and cooperate with physical examinations, making diagnosis relatively easier. However, for younger children who cannot accurately express the nature of abdominal pain or cooperate with physical exams, diagnosis can be more challenging. The following points should be noted during diagnosis:
1. If a child presents with fever and abdominal pain, the possibility of appendicitis should be considered, and necessary examinations and observations should be conducted. Children who cannot be ruled out for appendicitis should be hospitalized for close monitoring. When the child is asleep, gently shake and pat their body—if they show resistance or cry, remain vigilant and conduct repeated examinations.
3. A rectal examination has practical value in differentiating between enteritis, dysentery, and intussusception and should not be omitted during diagnosis.
bubble_chart Treatment Measures
Given some characteristics of acute appendicitis in children, early diagnosis and timely treatment are required, and appropriate indications should be selected.
1. For catarrhal or early mild suppurative appendicitis with a short onset time, conservative treatment may be considered initially.
2. For appendiceal masses and periappendiceal abscesses, non-surgical therapy is generally preferred.
3. Severe suppurative appendicitis and gangrenous appendicitis should be treated surgically.
4. Obstructive appendicitis (including fecaliths, ascariasis, and adhesive stenosis) should be treated surgically.
5. Perforated appendicitis with peritonitis should be treated surgically as soon as possible.
For special types of patients, such as infantile ascariasis appendicitis and ectopic appendicitis, surgical indications should be relaxed. Preoperative preparation includes the use of antibiotics and fluid infusion. For children with symptoms lasting about 48 hours, preoperative assessment of dehydration, acidosis, and hypokalemia should be performed, followed by targeted treatment for 2–4 hours before surgery.
The surgical incision is typically a McBurney incision. For cases where the tender point deviates from McBurney's point, the incision can be made at the most tender location. For cases with diffuse peritonitis or adhesive intestinal obstruction, a right lower quadrant exploratory incision is often chosen. Some pediatric surgeons in domestic children's hospitals advocate for electrocautery treatment of the appendiceal stump without purse-string suturing, but the results show no significant difference compared to purse-string suturing. The indications for peritoneal drainage are more relaxed in children than in adults. For diffuse peritonitis, periappendiceal abscess, or cases where the appendiceal stump is not reliably treated, a cigarette drain should be placed. For children with periappendiceal abscesses, close observation of symptoms and signs, along with laboratory tests and B-ultrasound examinations, should be conducted after admission. If the condition progresses, surgical treatment should be performed immediately. The goal of surgery is drainage. For gangrenous appendicitis, ascariasis, or fecaliths with minimal encapsulation and adhesion, removal should be attempted, but forceful separation of adhesions should be avoided. For children whose appendix is not removed, routine appendectomy should be performed six months later. More than half of children with complicated peritonitis have mixed infections of Gram-negative bacilli and anaerobic bacteria, and antibiotics such as ampicillin, gentamicin, and metronidazole can be selected. For cases with severe toxic symptoms, amikacin or cephalosporin antibiotics may be used. For critically ill children with prolonged disease, postoperative attention should be paid to correcting dehydration, acidosis, and hypokalemia.
In the differential diagnosis, special attention should be paid to distinguishing it from acute gastroenteritis, intestinal ascariasis, intussusception, dysentery, acute mesenteric lymphadenitis, primary peritonitis, and Meckel's diverticulitis.
