Appendicitis

What is appendicitis?

Appendicitis is an irritation, inflammation, and infection of the appendix (a narrow, hollow tube that branches off the large intestine). The appendix functions as a part of the immune system and is believed to help serve as a reservoir for bacteria that colonize our intestine. During human evolution, the appendix has become less important in this capacity and therefore is not felt to be a vital organ. Appendicitis is one of the most common causes of emergency surgery in childhood and occurs when the appendix becomes infected by the bacteria that normally live in it.

What causes appendicitis?

Appendicitis occurs when the interior of the appendix becomes inflamed leading to infection from bacteria that normally live inside the appendix. The cause of the inflammation is not often known but can be associated with blockage of the appendix opening into the intestine, changes in the bacteria that normally live in the appendix, and a patient’s genetic makeup. With time, the inflammation and swelling of the appendix increases, cutting off the blood supply to the appendix and it starts to die. This leads to further swelling and irritation as blood flow is needed for a body part/organ to remain healthy. Eventually, holes develop in the walls of the appendix and it can “burst” (rupture, perforate) allowing stool, mucus, and other substances to leak through and get inside the belly. An infection inside the abdomen is called peritonitis and occurs when the appendix perforates (commonly referred to as complicated appendicitis).

How often does appendicitis occur?

Most cases of appendicitis occur between the ages of 6 and 20 years. It is less common in children under 5 years and very rare in newborns and infants, but the rate of perforation is high in this group since young children are unable to tell exactly how they feel and "where it hurts."

Appendicitis occurs slightly more often in boys than girls.

About 75,000 - 80,000 children age 17 years or less develop appendicitis annually in the United States.

Why is appendicitis a concern?

An irritated appendix can turn into an infected and ruptured appendix, typically within 24- 36 hours from the start of symptoms. A ruptured appendix is much more complicated to treat and, if not treated, can be life threatening.

What are the symptoms of appendicitis?

The following are the most common symptoms of appendicitis. However, each child may experience symptoms differently. Symptoms may include:

• Pain in the abdomen which:

o May start in the area around the belly button and move to the lower right-hand side of the abdomen but may also start in the lower right-hand side of the abdomen.
o Usually increases in severity as time passes.
o May be worse with moving, taking deep breaths, being touched and coughing or sneezing.
o May spread throughout the abdomen if the appendix ruptures.

• Nausea and vomiting.
• Loss of appetite.
• Fever and chills.
• Changes in behavior.
• Diarrhea or constipation.

When should your child's physician be called?

Since an infected appendix can rupture and be a life-threatening problem, please call your physician immediately if you think your child has appendicitis.

How is appendicitis diagnosed?

In addition to a complete medical history and physical examination, diagnostic tools and procedures for appendicitis may include:

• Pediatric Appendicitis Score (PAS): Since abdominal pain is a very common complaint in pediatric patients, we use a clinical tool to help us evaluate for appendicitis. The PAS relies on information obtained from your child’s symptoms, exam, and basic laboratory results. The PAS tool has been validated in pediatric patients and shown to be reliable to help identify pediatric patients at low-risk and high-risk for appendicitis. Most patients who fall into the high-risk group based on the PAS score do not require additional imaging or tests and we typically recommend treatment for appendicitis.

• Imaging: Some patients will present with atypical signs or symptoms or have an intermediate PAS score such that we are not able to definitively make a diagnosis of appendicitis based on the PAS score alone. These patients may benefit from either longer observation or imaging.

o Abdominal ultrasound – An ultrasound (US) is a diagnostic imaging technique which uses high-frequency sound waves and a computer to create images of blood vessels, tissues and organs. Most pediatric specialists agree that an US should be the first-line imaging study used in pediatric patients who are being evaluated for appendicitis. This is because of its low-cost and absence of exposure to radiation to your child. For US to be useful it requires technicians and radiologists who are experienced in performing and interrupting pediatric ultrasounds for appendicitis.
o Computed tomography scan of the abdomen and pelvis (Also called a CT or CAT scan.) - A diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat and organs. CT scans are more detailed information than an US or standard x-rays but also are associated with exposure to radiation. CT scans performed at Children’s Wisconsin use specialized equipment, techniques and protocols customized to each child, lowering the exposure of radiation to the lowest possible amount.

• Blood tests - to evaluate the infection, or to determine if there are any problems with other abdominal organs, such as the liver or pancreas.
• Urinalysis - to detect a bladder or kidney infection, which may mimic the symptoms of appendicitis.

Treatment for appendicitis:

Specific treatment for appendicitis will be determined by your child's physician based on the following:

• The extent of the problem.
• Your child's age, overall health and medical history.
• The opinion of the surgeon and other providers involved in the child's care.
• Your child's tolerance for specific medications, procedures, or therapies.
• Your opinion and preference.

Surgery versus Medical treatment of appendicitis:

Medical Treatment:

For decades surgery to remove the appendix was the only treatment for appendicitis. More recently, we learned that antibiotics alone may be appropriate treatment for acute or early appendicitis in some patients. Several studies in pediatric patients have demonstrated that a highly-select group of pediatric patients with acute appendicitis can be treated with antibiotics alone with a 90% success rate. Over the course of a year, a small percentage of patients will develop similar symptoms such that at 1 year after the initial treatment for appendicitis with antibiotics alone, 70 - 80% of patient still have their appendix, have no residual symptoms and do not require surgery. Importantly, very few patients treated initially with antibiotics and who ultimately required surgery developed more complicated appendicitis. We believe that for some patients, antibiotics alone may be very effective treatment for acute appendicitis and may offer a less invasive and less costly treatment alternative to surgery. There are a few caveats that must be emphasized when considering medical treatment for acute appendicitis:

o Not all patients with acute appendicitis are candidates for medical management without surgery. All patients being considered for non-operative treatment require evaluation by a surgeon, blood work, and imaging (ultrasound or CT scan) to adequately select patients for this treatment.
o Currently, medical management requires admission to the hospital for IV antibiotics and observation by a surgeon for at least 24hrs.
o Patients are released from the hospital after 24hrs if their symptoms are improving to complete a one-week course of antibiotics taken by mouth.

Surgical Treatment:

While medical treatment of appendicitis is an option for some patients, the majority of patients require surgery. When we perform an appendectomy, for most patients we recommend a minimally invasive approach. This procedure uses one or more small incisions and a camera called a laparoscope to look inside the abdomen during the operation. Under anesthesia, the instruments the surgeon uses to remove the appendix are placed through several small incisions and the laparoscope is placed through another incision. This method is commonly used for both acute and complicated appendicitis. The major benefit to the patient in performing a laparoscopic appendectomy is less pain and smaller scars.

In a small number of patients mostly with complicated appendicitis, we may recommend a larger incision or convert to a larger incision during surgery. The reason this may be necessary is that the infection and inflammation caused by complicated appendicitis can cause the intestines to abnormally stick to each other, other organs and the abdominal wall making a laparoscopic appendectomy less feasible. In order to safely remove the appendix, we may not have adequate visualization with the laparoscope that an “open approach/ large incision” will allow. While this open approach is associated with a larger scar and possibly increased pain after surgery, the outcomes between laparoscopic and open appendectomy are roughly equal.

What to Expect After an Appendectomy?

First, and most important, pediatric patients should expect to return to a normal life with no change in their diet or function of their intestines after removal of the appendix. The recovery for acute appendicitis and complicated appendicitis, however, is different.

Post-operative Care After Acute Appendicitis:

Most patients following a laparoscopic appendectomy for acute appendicitis can expect to stay in the hospital 4 - 24 hours after surgery. They are typically allowed to eat a normal diet immediately after the operation and are only limited if they experience nausea related to the anesthesia or pain medication. No additional antibiotics are given to patients. Children will experience some discomfort and/or pain from the surgery which will improve over the next few days. The pain will be minimized with a combination of treatments. Your surgeon will place numbing pain medicine in or near the incision during surgery and the anesthesiologist will use IV narcotics and non-narcotic medications during and immediately after surgery. Once patients are out of the Recovery Room, we recommend scheduled Non-steroidal Anti-Inflammatory Drugs (e.g. Ibuprofen) and Acetaminophen as well as an ice-pack over the incision to help reduce the pain. These treatments are very effective for most patients and extremely safe. If used on a scheduled basis for 48hrs, this regimen will eliminate or at least minimize the need for any narcotic pain medications. Patients are ready for discharge when they are able to walk independently and able to adequately take medication by mouth, again typically 4 - 24 hours after surgery. Most patients can return to school within 1-2 days after release from the hospital. Most patients can expect to return to normal physical activity including sports without restrictions in less than 2 weeks.

Post-operative Care After Complicated Appendicitis:

Patients who undergo an appendectomy for complicated appendicitis typically remain in the hospital for a minimum of 3 - 5 days. These patients take longer to recover because of the infection inside the abdomen caused by the perforated appendix. The surgery removes the appendix, but the infection needs to be treated with IV antibiotics. These patients may continue to feel sick to their stomach, have nausea and occasionally vomiting for 1 - 2 days after surgery. Therefore, your surgeon may recommend that he/she not eat until that is improved. During that time, they are treated with IV fluids, and given IV antibiotics and IV pain medications. Patients are released from the hospital when they have not had a fever for at least 24 hours, are eating a fairly normal diet, and are able to take medications by mouth. Most often, patients are given antibiotics by mouth at the time of discharge to continue to treat the infection at home. Most patients can return to school within a few days of release from the hospital and will be cleared to return to normally activities including sports within 2 - 4 weeks of surgery.

Are there Complications That Can Occur After Surgery?

As stated above, we expect all patients to return to normal activities, diet, and health after an appendectomy. There are some complications from appendicitis that do occur and are more frequent in complicated as compared to acute appendicitis:

• Infection: About 5% of patients with acute appendicitis and 15% with complicated appendicitis will require additional treatment for an infection within a few weeks after an appendectomy. These include an infection with in one of the incisions or inside the abdomen. Wound infections typically present with redness, swelling, and drainage from the incision. Infections inside the abdomen present very similarly to the symptoms of appendicitis: pain, vomiting, fevers, and abdominal bloating. Treatment may include additional antibiotics, placement of a small drain into the infected fluid by Radiology, and in rare cases additional surgery.

• Constipation: Roughly 15% of pediatric patients return to the Emergency Department or preferably to our Pediatric Surgery Clinic within one month of surgery with pain related to constipation. Constipation is very common after surgery and made worse by the use of narcotic pain medication. We typically manage this proactively by minimizing narcotics when alternatives for treating pain are available and effective, encouraging patients to drink water to stay hydrated, and take stool softeners. This can typically decrease the risk of constipation after surgery, but some patients may require an enema if they become constipated despite these measures.

• Injury to adjacent structures during surgery: While this is very uncommon, it does occur most often during an operation for complicated appendicitis. Should this occur, your surgeon will take measures to treat the problem and discuss the injury immediately after surgery.

• Recurrent appendicitis: This is uncommon (much less than 1%) after the appendix is removed with surgery but can occur if the entire appendix is not removed. With medical treatment of acute appendicitis, about 10% of patients fail to improve in the first 24 hours and undergo surgery. Another 10 - 20% will present within the next year with similar symptoms and need to undergo surgery to remove the appendix.

Why Should My Child Be Treated at Children’s Wisconsin?

All Pediatric Specialists: Every physician, nurse, and staff at Children's has received additional training in order to take care of your child. Children's is the only hospital in our region where this is true. Pediatric Surgeons undergo a two-year fellowship training after completion of adult general surgery training in order to specialize in performing surgery on pediatric patients. Similarly, our anesthesiologists have completed additional specialized training to be pediatric anesthesiologists. Children's is the only hospital in Wisconsin to be verified by the American College of Surgeons as a Level 1 Children’s Surgery Center.

Experience matters: Each year at Children's we perform 350 - 400 appendectomies in children, more than any other hospital in Wisconsin. Experience translates into better outcomes, whether your child has acute or complicated appendicitis, is less than 1 year of age or older than 17 years. We are also one of the few hospitals in Wisconsin to offer non-operative management for acute appendicitis.

Imaging: Children's has Pediatric Radiologists, similar to our Pediatric Surgeons, who have undergone additional training in pediatric radiology. Our Pediatric Radiologists and radiology technicians are available 24/7. We are one of the few hospitals in Wisconsin that can offer ultrasound 24/7, and thus are less reliant on performing CT scans in the off hours for patients who might have appendicitis. In those children who do require CT scan, the CT machines at Children's expose our patients the least amount of radiation possible.

Focus on minimizing narcotics – An appendectomy is one of the most common surgeries in the pediatric population, and for many children it will be their first exposure to surgery and narcotic pain medication. We are focused on treating your child’s pain using a combination of treatments that will both adequately treat the pain they experience but also minimize their exposure to narcotics. Over the last few years with this approach, our patients who undergo an appendectomy have reduced their use of post-operative narcotic pain medications by 50%.

Focus on providing Quality and Value – Treatment for appendicitis is expensive and we try to ensure we provide our patients with the highest quality with the best value. This includes trying to reduce costs by:

• Utilizing less expensive imaging (US rather than CT) when necessary and appropriate. When necessary, radiation exposure is minimized by using pediatric protocols, which are different than adult protocols for CT imaging.
• Offering non-operative management with antibiotics when appropriate.
• Choosing not to use expensive tools in the operating room to perform the appendectomy when less expensive tools that are equally efficacious are readily available to us.
• Finally, the cost of treatment for appendectomy is dependent on the frequency of complications – particularly re-admissions for treatment of those complications. We participate in the Pediatric National Surgical Quality Improvement Program by the American College of Surgeons which allows us each year to measure our outcomes and complications from appendectomy and compare them to other hospital in the United States in order to ensure we provide the best care for your child.