1057
DIAGNOSIS
AND
TREATMENT:
APPENDICITIS
IN CHILDHOOD
Marc I. Rowe, M.D.
From the Section of Pediatric Surgery, The University of Chicago,
Department of Surgery, Chicago, Illinois
INTR0I)UCTORY NOTE: A discuss-ion of me common problem of pediatrics regularly appears as the last article preceding the “Experience and Reason”
section. Each of these short papers is intended to present current practice in regard to diagnosis or therapy or both. The Editor appreciates the enquiry which resulted in this month’s concise presentatian, and will welcome suggestions for other desirable topics.
5 RECENTLY AS 1958, 258 children died
in this country as a result of
appen-dicitis. Most of these deaths occurred in
young children with perforation. Correct
early diagnosis of acute appendicitis and
precise and vigorous management of
chil-dren with advanced appendicitis can
pre-vent these deaths. Particular attention
should be paid to the pre-school child with
abdominal pain. The historical and physical findings which are generally called classical
are more common in older children. The
in-traluminal pressure of the obstructed
ap-pendix of the young child is built up to the
same order as in the adult, but the
intra-vascular pressure is lower and the bowel
vall thinner. This results in the rapid
de-velopmcnt of necrosis. These two
factors-difficulty in diagnosis and a fulminating
course-lead to a high incidence of
pen-foration in children. Combining the
sta-tistics of four large series of 551 children,
age 4 years and under, with appendicitis,
429 or 77% were found to have perforated
appendixes. This high incidence of
perfona-tion has not decreased oven the years.
THE EARLY DIAGNOSIS OF APPENDICITIS
Abdominal pain is the prime symptom of
appendicitis. Its character and location
de-pend on the anatomic position of the
in-flamed appendix and the stage of
develop-ment of the disease process. The young
child is often not able to verbalize his
complaint of abdominal pain or localize
accurately the area of his abdominal
dis-comfiture. Fretfulness, crying, disturbed
sleep, and resistance to handling are often
the first indications that something is wrong.
Anorexia and vomiting are common
ac-companiments of many childhood illnesses.
However, the presence of a good appetite
casts some doubt on tile diagnosis of
ap-pendicitis. The familiar history of pain first,
followed by vomiting is often not elicited
in the pre-school child. The pain may not
be appreciated by the parents and vomiting will then appear to be the first symptom.
Slight fever is common with simple
ap-pendicitis. High fever in the first 24 hours
leads one to consider other sources of
in-fection, while later on high fever suggests
perforation. Changes in the bowel habit,
although common, are not helpful.
Consti-pation is more frequent, but diarrhea is not
unusual. Dysuria is seldom present with
appendicitis but, when present, or if a few
white blood cells or red blood cells are
found in the urine, this suggests the
prox-imity of the inflamed appendix or abscess
to the bladder or right ureter.
A white blood cell count of over 10,000
is found in over 90% of the cases of simple
appendicitis. Like high fever, a count of
over 20,000 early suggests another source
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1058 APPENDICITIS
of infection, while high leucocytosis later
on may indicate perforation. A shift to the
left of the polymorphonuclear cells,
al-though not specific for appendicitis, is a
constant finding. Changes in the white
blood cell count during the course of
ap-pendicitis are so variable as to be of little aid in evaluating the individual case.
Localized abdominal tenderness,
prefer-ably in the right lower quadrant, is the
most constant and significant finding in
acute nonperforated appendicitis. A patient,
gentle, unhurried abdominal examination
after the child’s confidence has been gained
makes it possible to locate the point of
maximal tenderness. With the young or
overly defensive child one must rely more
on changes in facial expression, shifts in
position and attempts to push the
examin-ing hand away, than on verbal response in
localizing tenderness. Spasm of the muscula-tune of the right side is a helpful finding,
but may be absent when the appendix lies
low in the pelvis or in a paracecal or
retro-cecal position. Infants frequently show no
muscular resistance. Rebound tenderness
referred to the right lower quadrant upon
release of pressure on the left side of the
abdomen is very suggestive of appendicitis in the older child. It is difficult to elicit and
interpret in a young or uncooperative
pa-tient. The occasional unmanageable child
can he sedated with a rapid acting
barbit-nate without masking tenderness or spasm.
A gentle rectal examination done with
the child lying on his back, knees drawn
up, shows tenderness or a mass in over 80%
of the cases. Unless the child’s cooperation
has been gained and the examination is
done gently and slowly with constant
ob-servation of changes in facial expression and in movement, little is learned.
X-rays of the abdomen have not been of
aid in the non-perforated cases but may be
valuable in the complicated or advanced
ones. A calcified appendolith, though rarely seen, is almost always associated with acute
appendicitis. When it is found, the
diag-nosis is made.
To avoid operating on normal appendices
one must often wait for such convincing evi-dence that delay is frequent and resultant perforation invited. To avoid this, one must willingly accept an incidence of at least one
normal appendix in five. The present risk of
operation for the non-inflamed appendix is
so slight that unwarranted delay in the child
with suggestive signs and symptoms of
ap-pendicitis is not justified. The majority of
historical, physical, and laboratory findings in appendicitis are so variable that one is left with simple criteria for diagnosis and opera-tion-a history of abdominal pain, localized
abdominal tenderness (preferably in the
right lower quadrant). and no gross inconsis-tencies in the history, physical examination,
or laboratory studies.
MANAGEMENT OF APPENDICEAL
PERITONITIS
Thirty-five to forty-five percent of chil. dren with appendicitis present with
perfora-tion, and virtually all the deaths and the
majority of the complications occur in this
group. The Ochsnerization program of
de-laying operation to await “walling off” of
the perforated appendix has no place in
therapy during childhood. The child suffers
a more fulminating disease and localizes
intra-abdominal infection less efficiently
than the adult. Although undue delay in
op-eration for peritonitis due to the perforated appendix is dangerous, precipitate operation without proper preparation is equally poorly
tolerated. Correction of hypovolemia,
re-duction of body temperature,
decompres-sion of the gastrointestinal tract, and initi-ation of antibacterial therapy are followed promptly by operation.
Protein and electrolyte rich fluids are
lost as a result of peritonitis. Starvation and fever increase the degree of hypovolemia. Shock is invited if surgery is undertaken
before losses are replaced. Plasma is
ad-ministered rapidly in volumes of 10 cc to
20 cc per kilogram, followed by
administra-tion of a sodium chloride solution.
Potas-sium is withheld until the patient voids.
Proper fluid replacement is best controlled
ARTICLES 1059
observation of intake and output records,
and graphic charts of the vital signs. A
return toward normal blood volume is
usu-ally heralded by improved peripheral
cm-dulation, a falling pulse, and the passage
of urine. Central venous pressure
monitor-ing is valuable when large volumes of fluid
must be administered rapidly to resuscitate
the desperately ill infant or child. Venous
pressure of 8 to 10 cc of water is a safe
level to maintain in the pediatric patient.
Correction of dehydration usually leads
to a fall in fever. Further reduction can be
accomplished by tepid sponges and electric
fans. Morphine sulfate intravenously
re-duces shivering and provides for proper
sedation and analgesia. A temperature
be-low 102#{176}F reduces the anesthetic risk. A
nasogastnic tube placed on intermittent
suction prevents gastric retention and
fur-ther abdominal distention. The
semi-Fow-len’s position eases respiration and allows
gravitation of pus away from the
dia-phragm.
Preoperative parental antibiotics should
he given in large doses. There is no general
agreement as to which antibacterial agent
is most effective in the treatment of
pen-tonitus due to the perforated appendix.
Penicillin and streptomycin, broad spectrum
antibiotics, and antibiotics combined with
the sulfa drugs have all been recently
em-ployed vith success. What is most
impor-tant is broad coverage of the bacterial
spectrum, begun as soon as the diagnosis
is made and continued for a sufficient period
in the postoperative phase. The drugs
should be administered parenterally in
doses which will maintain a therapeutic
blood level.
Preoperative preparation can usually be
accomplished in 2 to 4 hours. Occasionally
as long as 6 hours may he required for the
seriously ill child. Once toxicity has been
re-duced unnecessary delay can result in a
re-newed climb of pulse and temperature as
the optimal moment for operation passes.
If, as rarely happens, a patient fails to
re-spond to this program, immediate surgery
to drain the pus under pressure is indicated.
PERFORATED APPENDICITIS WITH LOCALIZED ABSCESS FORMATION
Thirty to forty percent of the cases of
perforated appendicitis present with local-ized abscess. Drainage of the abscess should
be done as soon as the preoperative
prepa-ration has taken effect. Particularly in the
small child, the abscess may not be well
walled off and with delay there is the
dan-ger of intraperitoneal rupture. Occasionally a child is seen with a small, obviously
sub-siding abscess; in this instance there is no
urgency. Conversely, a seriously ill child
with an abscess should have a rapid
drain-age as the most effective therapeutic
mea-sure.
In most pediatric centers in this country,
the appendix is removed whenever possible
at the time of drainage. This reduces
mor-bidity and the necessity for a second
opera-tion. With any large series there are the
occasional patients who are initially treated by incision and drainage alone. This is done when a patient is desperately ill or when, in a well localized abscess, the appendix is not palpated and the surgeon feels that to insist
on appendectomy would result in massive
soiling of the general peritoneal cavity.
These children should all return for
inter-val appendectomy, in 2 to 3 months, lest
another bout of appendicitis supervene.
COMMENT
There is room for improvement in the
di-agnosis of appendicitis. This is especially
true in the pre-school child, in whom the
incidence of perforated appendicitis has
not been appreciably reduced over the past
30 years. Abdominal pain and localized
ab-dominal tenderness are the most constant
and reliable guides to the diagnosis.
Almost all the morbidity and mortality of
appendicitis is seen in the patients with
perforation. Vigorous preoperative
prepa-ration, gentle rapid surgery and meticulous
postoperative care remain the key to
im-proved results. The child with an abscess as
the result of a perforated appendix should
have prompt drainage and, when possible,
