How to detect appendicitis in toddlers

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BY DR BENJAMIN NJIHIA

A ‘stomach ache’ is one of the common reasons a parent may bring their child for evaluation by a doctor. It may be due to constipation or bloating, but sometimes it may be associated with more serious conditions. If a child’s pain begins in the belly-button area and spreads to the lower right abdominal area, it may be the result of appendicitis, an inflammation of the appendix with subsequent infection. The appendix is a finger-like extension from the caecum, the first portion of the large intestine.

Appendicitis is the most common reason for emergency surgery in children. Up to 8% of children seen with abdominal pain will have the condition.  It mostly occurs in children between the age of ten and 20 years and has even been reported in children as young as several months old.

Most cases of appendicitis will occur due to a blockage of the appendix inner lining (lumen) by fecal matter, undigested food materials, or swelling of the lymph glands around its opening to the large intestine. More specific, though rarer, causes may include viral infections and intestinal worms.

Appendicitis occurs in school going age children who report abdominal pain initially around the navel, but within hours may localise to the right lower abdomen. They might also convey loss of appetite as the pain persists and parents may notice that the child has fever. Movements such as jumping, or coughing often worsen the pain and the child will prefer to lie still in bed. Their breathing becomes shallower than normal and abdomen distended especially if the appendix has ruptured.

Many appendicitis cases present differently and the younger the patient, the more challenging it is to diagnose because the child cannot explain their symptoms.

To help in the diagnosis of appendicitis, the doctor often takes blood to the laboratory to assess for signs of inflammation, or infection. It is the sum of signs, symptoms and laboratory findings that will guide the clinician to make the diagnosis of appendicitis. The blood tests taken may indicate an infection.  However, there are many potential sources where this can arise from and therefore laboratory findings cannot be the only determining factor.

Where there is doubt as to the diagnosis, the doctor may order an ultrasound, or CT scan of the abdomen.  Due to radiation exposure from this test, a paediatric surgeon may be called in to assess the child prior to requesting the investigation.

Due to the pain associated with appendicitis, the patient must be given relief medicines such as paracetamol and an anti-inflammatory drug. Antibiotics are also used to counter the infection.  Some cases of appendicitis may be resolved with this treatment, but may recur in approximately one in five patients. This may be carried out on the caregivers’ request, but only for children with early appendicitis and older children who can adequately describe how they are feeling.

The standard treatment is surgery to remove the appendix. In early appendicitis, the appendix is removed through a two to four centimetres incision in the right lower abdomen. If the doctor suspects that the appendix has ruptured, or become gangrenous, they may opt to go through a midline incision.  Keyhole surgery (laparoscopy) can also be used. For all these surgeries, the child will be under general anaesthesia.

The incision will heal within two weeks and the child is allowed to walk, attend school and do mild chores. Heavy exercise, sports and strenuous activities are deferred for six weeks. 

The common complications are infection of the surgical area, or pus collecting within the abdomen, especially if the appendix had already perforated. Surgical removal of the appendix does not otherwise affect the health of the child and they will grow healthy with no ill effects due to its absence.