appendicitis

The appendix is a particularly useless appendage of the colon. It is a narrow tube that hangs like a string off the first part or proximal end of the colon and serves no useful function we know of (except to employ surgeons, as the joke goes). It is maybe as big in diameter as a baby's pinky finger if it is healthy. It is the remnant of the larger cecum (first part of the colon) of herbivorous animals such as rabbits, etc.

Ordinarily, fecal debris sort of sloshes in and out of the appendix, and as long as the normal flushing mechanism works, there is not a problem. Over time, a chunk of crud can accumulate in this little tube, and if it stays there long enough, can calcify into a little stone, called a fecalith. This traps fecal material in the appendix, and it cannot be normally expelled.

This is where the trouble starts. Germs in the trapped stool material start to multiply and invade the tissue of the appendix. There is inflammation, swelling, and death of the tissue of the wall of the appendix. Eventually, the inflammed and pus-filled appendix will leak germs into the abdominal cavity. The infection that ensues is generally fatal if untreated.

Symptoms often start rather vaguely, with pain around the umbilicus (belly button) - where just about every kid points when he says his tummy hurts. As the disease progresses, though, the pain will classically move down into the lower right side, becoming more intense. The child may begin to limp from irritation to the large muscle that runs from the lower spine and raises the leg - the psoas muscle - because the inflammed appendix lies right on top of it in the abdominal cavity. Classically the pain progresses to nausea, and eventually to fever as the appendix ruptures and serious infection starts in the abdomen (peritonitis).

Cure is straightforward - surgical removal and antibiotic treatment of any infection present in the abdominal cavity. The incision is small, and usually heals very rapidly in children. (Selected cases can even be done laparoscopically.) Detection is not always so straightforward, because early symptoms can be vague and somewhat misleading.

Diagnosis in younger toddlers under age two or three is especially difficult, and even the most experienced surgeons report that the majority of very young patients have perforated the appendix by the time surgery is done.

Fortunately, post-operative antibiotic therapy has advanced to the point where the length of stay in the hospital for these patients is really about the same as for those with non-perforated appendices.

A new approach to the management of a perforated appendix known as interval management involves delaying surgery for perforated appendices, instead treating aggressively with antibiotics in the hospital and later at home. When the inflammation around the appendix is reduced, a single insertion laparoscopic appendectomy can be done through the umbilicus for a "scarless" procedure, often done as an outpatient and with very quick recovery time.

Appendicitis is definitely a perfect example of an illness you do not want to attempt to diagnose yourself. Call your doctor immediately if your child shows any suspicious signs of abdominal pain that is intensifying and moving to the lower right side. See also intussusception.

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