APPENDICITIS APPENDECTOMY
Category: Pediatric Surgery
Abstract : Appendicitis Included in this group because is caused by obstruction of the appendiceal lumen, most commonly by fecaliths. When obstruction occurs, secretions from the appendix accumulates and acutely distends the lumen. The pressure eventually produces arterial obstruction leading to infarction. Bacteria initially invade the mucosa and produce intramural infection. Other causes include pinworm in
Appendicitis Included in this group because is caused by obstruction of the appendiceal lumen, most commonly by fecaliths. When obstruction occurs, secretions from the appendix accumulates and acutely distends the lumen. The pressure eventually produces arterial obstruction leading to infarction. Bacteria initially invade the mucosa and produce intramural infection. Other causes include pinworm infestation, carcinoids and lymphoid hyperplasia.
Initially periumbilical pain secondary to distension of the lumen of the appendix occurs. Pain impulses from the wall of the distended appendix are carried by visceral afferent sympathetic fibers through the celiac ganglion to T10 and then referred to the umbilical area in the tenth dermatome. Later the pain shifts to the right lower quadrant of the abdomen, where it localizes. The shift in location is an important diagnostic sign and indicates the formation of irritating exudate around the inflamed appendix that stimulates the pain receptors of the peritoneum locally. Anorexia, nausea and vomiting follow the onset of abdominal pain.
Physical findings include an obviously ill-appearing child who usually will walk slowly and bent over. Motion, heel tap, or bouncing on the heels will elicit pain in the right lower quadrant. Point tenderness in the right lower quadrant (or the persistence of right lower quadrant pain) is the most reliable physical finding. There is usually rebound and referred pain to the right lower quadrant, indicating peritoneal inflammation. Fever is usually present.
Laboratory findings are an elevated white blood cell count in most instances. Very high WBC's > 18,000 may indicate perforation. Urinalyses is generally clear, but occasionally RBC's or WBC's may be associated with the inflamed appendix adjacent to the bladder or ureter. Radiographic findings may include ileus, appendicolith (pathognomonic finding), splinting, abdominal wall edema, and only very rarely, free air.
Initial treatment is rehydration to establish adequate urinary output. Any evidence of possible perforation should mandate the use of appropriate antibiotics. Once adequate then surgical intervention proceeds quickly. Most patients are approached through a right lower quadrant horizontal muscle splitting incision. Removal of the appendix, irrigation and, when localized abscesses are identified, institution of drainage.
Appendicitis is usually diagnosed from signs, symptoms, results of simple laboratory tests a/o simple abdominal films. After simple abdominal films an appendicolith (coprolith, fecalith, retained barium or foreign body) is sometimes found in the symptomatic child with right lower quadrant pain or less commonly in an asymptomatic situation. In the child WITH SYMPTOMS of low abdominal pain this finding should be followed by appendectomy. Appendiceal fecaliths and calculi play a role in the pathogenesis of appendicitis and are associated with perforation and gangrene. In the ASYMPTOMATIC situation a prophylactic appendectomy is NOT justified when an appendicolith, retained barium or another foreign body within the lumen of the appendix is identified. A normal appendix will expel the appendicolith or barium in a variable period. The parents should be informed that appendicitis may develop and that the child should seek a physician if abdominal symptoms develop. A note should appear in the record explaining this conversation.
A word on incidental appendectomy: Removing a normal appendix incidentally during a surgical procedure done for reasons other than abdominal pain is associated with a small but definite increase in adverse postoperative outcome. In this respect incidental appendectomy has been found to increase the incidence of postoperative septic complications (wound infection). It is neither cost-effective as an estimated 36 incidental procedures would be needed to prevent one case of appendicitis. As any procedure it increases adhesion formation from surgical manipulation in the right lower quadrant fossa. In potentially contaminated primary procedures the addition of incidental appendectomy does not increase operative morbidity or mortality. Incidental appendectomy is indicated in procedures where a potential diagnostic pitfall can occur such as Ladd procedure for malrotation, diagnostic laparoscopy for right quadrant pain and surgically reduced ileo-colic intussusception.
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