Acute appendicitis
Acute appendicitis is the
commonest abdominal emergency in children, affecting approximately one-sixth of
the population. Acute appendicitis begins with obstruction of the lumen of the
appendix, often by a faeco-lith, and this causes vague central abdominal pain.
After about 6–12hr an inflammatory process involves the full thickness of the
wall of the appen-dix. After a further 24–36hr the appendix will become
gangrenous and perforate. Irritation of the peritoneum results in more severe
abdominal pain localized to the right iliac fossa.
•
Pain
is aggravated by movement.
•
Child
may prefer to lie still with knees flexed.
•
Mild
fever is usual.
•
Peritoneal
irritation results in involuntary spasm in the muscles of the abdominal
wall—‘guarding’.
The mortality from appendicitis is
virtually zero. However, substantial morbidity is incurred by delayed
diagnosis. The diagnosis of appendicitis is clinical and laboratory
investigations are generally not helpful.
•
The
‘classical’ symptoms and signs of acute appendicitis are seen in about 60% of
cases.
•
Of all
children admitted to hospital with abdominal pain only about 30% will have
acute appendicitis. Not all of these cases are obvious at the initial
assessment (probably only 50–70%); if there is any doubt, child should be
admitted to hospital for observation.
•
Urinalysis
is abnormal in about 1/3 children with acute appendicitis: pyuria and even
bacteriuria may be present. The temptation to start antibiotics for a
presumptive diagnosis of UTI should be avoided unless there are symptoms of
dysuria.
•
The
WCC is normal in 10–20% of children with appendicitis.
US:
if there is clinical doubt, US is
the investigation of choice. The overall
accuracy of US in the diagnosis of acute appendicitis is around 90%.
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