Appendicitis is a condition of inflammation of appendix.
The condition is classified as an emergency, in many incidences, required the removal of the appendix.
Early diagnosis is easily treated with 100% recovery.
If burst, or perforate, spilling infectious materials into the abdominal cavity can be life threatening.
And depending to each patients condition, treatment of appendicitis perforate, may opt for conservative treatment by means of an intravenous antibiotic therapy to solve acute abdomen pain, planning a routinary interval appendectomy (IA) after some months or an immediate appendectomy(4).
Examples are quoted directly from the joint study led by the Institute for Maternal and Child Health - IRCCS Burlo Garofolo
[Patient 1. immediate appendectomyThis 5-year old girl showed the following symptoms: 5 days fever, abdominal pain and vomit. Leukocytes and PCR was 18 × 103 and 16 (mg/dl) respectively.
US showed a perforated appendicitis associated with an inflammatory mass.
We decided to perform an immediate video-assisted appendectomy through a subumbilical incision for the laparoscopic operative trocar insertion.
We found a subhepatic necrotic appendix surrounded by an abscess.
To dissect and extract the appendix, it was necessary to enlarge the subumbilical incision and create a second access in the left iliac fossa. Nasogastric tube (NT) and vesical catheter (VC) were placed. Surgery time was 165 min.
Oral feeding started on day 4. Hospital stay was 9 days.
She was treated with a triple antibiotic therapy (ampicillin/sulbactam 50 mg/kg every 8 h, metronidazole 10 mg/kg every 8 h, tobramycin 5 mg/kg in a single dose) for 9 days.
In the postoperative stage, an infection of the subumbilical wound was observed.
Patient 2: immediate appendectomy
This 4-year old girl reported having abdominal pain and fever for 3 days. Leukocytes and PCR was 24 × 103 and 20 mg/dl respectively.
US showed a thickening of the appendix with a pericecal effusion without a secure image of abscess.
An immediate video-assisted appendectomy was performed through a single enlarged subumbilical incision.
We found a necrotic appendix with an inflammatory mass involving the right tube and ovary.
The tube wall was very fragile and during the procedure a tubal lesion led to a partial tube removal. NT and VC were placed. Surgery time as 70 min.
Oral feeding started on day 3. Hospital stay was 10 days. Our standard triple antibiotic therapy was continued for 10 days.
In the postoperative stage, a subumbilical wound infection was observed](4).
Dr. Edoardo Guida and colleagues said, " In the case of a perforated appendicitis with an abscess and coprolith is an initial conservative case management followed by a routine interval appendectomy performed not later than 4 months after discharge"(4).
Therefore, to rule out perforated appendicitis, you must understand the signs and symptoms of below and act accordingly
1. Abdominal pain and upper respiratory tract infection
Although appendicitis is the condition that most commonly requires emergent abdominal surgery in the paediatric population, less than 2% of the disease occurs in infants and it is even more uncommon in neonates.
There is report of a rare case of a 14-month-old child presenting with abdominal pain first diagnosed with upper respiratory tract infection and then admitted to Paediatric Surgery Department with a final diagnosis of acute appendicitis, according to the FONDAZIONE IRCCS CA’ GRANDA – Ospedale Maggiore Policlinico(1).
2. Symptoms of vomiting, fever, pain, anorexia, diarrhea, abdominal tenderness, peritonitis, temperature 38.0 degrees C or more, abdominal distension, Leukocytosis, small-bowel obstruction (SBO), contrast enemas and perforated appendicitis.
According to some researchers, if you experience of all these symptoms persistently over 3 days or more, you may be in the early stage of appendicitis. Please check with your doctors right the way.
The average duration of symptoms was 3 days, with 4 or more days in 9 children. Eighteen children were seen by a physician before the correct diagnosis was made; 14 were initially treated for an upper respiratory tract infection, otitis media, or a urinary tract infection.
The most common presenting signs were abdominal tenderness (27), peritonitis (24), temperature 38.0 degrees C or more (21), abdominal distension (18), Leukocytosis (<12.0 x 10(3)/mm(3)) was found in 18, tenderness was localized to the right lower quadrant (RLQ) in 14 and was diffuse in 10.
The most common presenting signs were abdominal tenderness (27), peritonitis (24), temperature 38.0 degrees C or more (21), abdominal distension (18), Leukocytosis (<12.0 x 10(3)/mm(3)) was found in 18, tenderness was localized to the right lower quadrant (RLQ) in 14 and was diffuse in 10.
Abdominal radiographs demonstrated findings of a small-bowel obstruction (SBO) in 14 of 21 patients, a fecalith in 2, and a pneumoperitoneum in 1. Contrast enemas were performed in 6 children, 5 of whom had a phlegmon or an abscess. Perforated appendicitis was found in all 27 patients. An appendectomy was performed in 25 and a RLQ drain was placed in 18(2).
3. An abdominal mass, guarding, rebound tenderness, rigidity, diffuse or focal tenderness, diarrhea, emesis, fever, pain, and anorexia
According to the Children's Hospital of Philadelphia, the common physical signs of an abdominal mass, guarding, rebound tenderness, rigidity, and diffuse or focal tenderness and common symptoms are diarrhea, emesis, fever, pain, and anorexia with the most common presenting symptom was abdominal pain (94%); the most common sign was abdominal tenderness (95.8%)(3).
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3. An abdominal mass, guarding, rebound tenderness, rigidity, diffuse or focal tenderness, diarrhea, emesis, fever, pain, and anorexia
According to the Children's Hospital of Philadelphia, the common physical signs of an abdominal mass, guarding, rebound tenderness, rigidity, and diffuse or focal tenderness and common symptoms are diarrhea, emesis, fever, pain, and anorexia with the most common presenting symptom was abdominal pain (94%); the most common sign was abdominal tenderness (95.8%)(3).
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and Krishnamurthy N. Beeregowda(