What Are the Signs of Appendicitis in Children?

Pediatric appendicitis, also called pediatric acute appendicitis, is a common acute abdomen in children. It is more common in children over 5 years old. Although the incidence is lower than that of adults, it is more serious than adults. Diffuse meningitis has a high rate of complications, appendix perforation, and even death, so it must be taken seriously. The younger the age of appendicitis in children, the less typical the symptoms are. Perforation, necrosis, and diffuse peritonitis occur within a short period of time. If the diagnosis and treatment are not timely, it will bring serious complications and even death, so it should be paid attention to.

Pediatric appendicitis

Introduction to Pediatric Appendicitis

Children make up about 10% of patients of all ages. The peak incidence is from 6 to 12 years old. It is rare in children under 5 years old, and the incidence is lower in children under 1 years old, which may be related to the appendix's fertility. At this stage, the appendix has a wide opening in the cecum, showing a valve-like shape, which is not easy to form obstruction Therefore, the chance of developing acute appendicitis is also small. Some scholars report that the incidence of pediatric appendicitis is related to the season, and the incidence of appendicitis is also high in the seasons of upper respiratory tract infections in early spring in March and April and the seasons of stomach and enteritis in July and August. ^[1]

Causes of Pediatric Appendicitis

The cause of pediatric acute appendicitis is still unclear, and it is multifaceted, mainly due to the interaction and mutual influence of factors such as appendix obstruction, bacterial infection, blood flow disorders and nerve reflexes. The specific reasons may be the following:

Causes of Pediatric Appendicitis

The cause of the disease is more complicated. At present, only the factors are known:

1.Bacterial infection

Bacteria reach the appendix through damaged mucosa and blood circulation, causing acute inflammation. As above, pharyngitis, tonsillitis and so on. Upper respiratory tract infections and tonsillitis in children make the appendix wall hypertrophic and obstruct blood flow, which can also be the cause of appendicitis;

2.Appendix obstruction

Appendiceal obstruction such as fecal stones, foreign bodies (fruit cores, tapeworms), twisted appendix, stenosis of the lumen of the lumen, etc., the retention of secretions leads to increased intraluminal pressure, vascular disturbance of the appendix wall, which is conducive to bacterial invasion and bacterial reproduction. A more common cause of acute appendicitis. If the appendix cavity is blocked for a long time, it will cause the blood circulation of the appendix itself to be impaired, which will cause tissue ischemia, which will cause perforation of the appendix.

3.Nerve reflexes

Children with cold, diarrhea, gastrointestinal dysfunction, etc. cause intestinal bacteria to invade the appendix and cause inflammation of the appendix; when gastrointestinal dysfunction occurs, it is often accompanied by appendic blood vessels and muscle reflex spasm, causing obstruction of the appendix cavity and impaired blood flow Causes inflammation.

Pathogenesis of Pediatric Appendicitis

Can be divided into 3 types:

1.Pyogenic (cellulitis) appendicitis

There are lesions in the serosa and mucosa, and purulent exudates are attached. Peritoneal infection and exudation can occur early and perforation can occur in severe cases.

2, catarrhal (simple) appendicitis

The lesions were limited to the mucosa. The main lesions were infiltration of polymorphonuclear leukocytes and hyperemia and edema of the mucosa.

3. Gangrene appendicitis

After infection, vasospasm and embolism occurred in the appendix, blood circulation disorder, extensive necrosis of the appendix wall, dark purple. There is not much exudation, but it quickly infiltrates the surrounding tissues and is prone to adhesion.

Catastatic appendicitis can be cured by conservative treatment, but if the appendix is not drained well, it can be secondary to infection and turn into suppurative appendicitis. Suppurative and gangrenous appendicitis should be treated early.

Pediatric Appendicitis Features

Pediatric acute appendicitis lesions are mainly exudative. There is peritoneal exudation in the early stage of inflammation, which increases rapidly. The inflammation quickly spreads to the appendix serosa and parietal peritoneum.

Children with acute appendicitis are more likely to have perforations because of their young age, relatively large appendix cavity, short omentum, thin appendix wall, prone to perforation, and poor ability to limit inflammatory lesions, which can lead to diffuse peritonitis. However, peritonitis is more prominent in infants and young children with appendicitis, not severe or not yet gangrene or perforation.

The cecum of children is relatively high, with high mobility, relatively free, and large variation in tenderness. ^[1]

Appendicitis symptoms in children

In children with fever and abdominal pain, the possibility of appendicitis should be considered, and necessary examinations and observations should be performed. Children with appendicitis cannot be ruled out and should be hospitalized for close observation. When the child falls asleep, shake and pat the child's body gently. If you show resistance or cry, you should be alert and repeat the examination.

1. Systemic symptoms are more serious

Severe, fever occurs early, body temperature is mostly 37.5 to 38.5 , which can reach 39 to 40 , the central temperature of children's body is unstable and inflammatory reactions are severe, and even chills, high fever, convulsions, and convulsions.

2. Abdominal pain

Due to the difficulty in querying and describing the medical history, a typical history of metastatic abdominal pain is often not available. The range of abdominal pain is wide, and sometimes abdominal pain is not the first symptom. Persistent abdominal pain begins in the upper abdomen or around the umbilicus and shifts to the right lower abdomen within a few hours. When the appendix is blocked, paroxysmal abdominal pain increases.

3. Gastrointestinal symptoms

Often obvious and prominent. Vomiting is often the first symptom, with severe vomiting and a long duration. Devotion and acidosis can occur due to large amounts of vomiting and inability to eat. Intestinal inflammation stimulates intestinal peristalsis too quickly and can cause diarrhea, which is rare in patients with constipation. After the perforation of the appendix, the symptoms of rectal irritation, such as frequent stools and acute rush, can be seen.

4. Tenderness and muscle tension

The tenderness point is usually above the Metz point. Repeated inspection can find obvious tenderness in the right lower abdomen, infants and young children with a high cecum location and high mobility, its tender point is inward and upper, children's abdominal wall is thin, and uncooperative, it is not easy to determine whether muscle tension. Children will be reluctant to move, prefer to lie on the right with their knees bent, and flex their waist while walking. It should be checked carefully, gently, and carefully, and contrasted up and down, left and right.

5, abdominal distension and bowel sounds weakened

Due to early peritoneal exudation, the function of the gastrointestinal tract is inhibited, so abdominal distension and bowel sounds weakened.

6, upper respiratory symptoms

The incidence of upper respiratory tract infections in children is high, and these diseases may be the cause of acute appendicitis in children. Therefore, children often have upper respiratory disease, and then the clinical manifestations of acute appendicitis.

7.Anal finger test

Digital anal examination is of important practical value to distinguish dysentery, enteritis, and intussusception, which cannot be simplified in diagnosis. The right wall of the rectum is sensitive, such as when the appendix perforates the pelvic pus, the edema and hypertrophy of the tissue around the rectum can be felt on digital examination, and there is obvious tenderness.

Disease characteristics

Pediatric acute appendicitis has the following characteristics:

1. Weak defense ability in children

Due to insufficient humoral immune function, complement deficiency and poor neutrophil phagocytosis, coupled with unstable body temperature regulation. As a result, high fever is prone to occur, leukocyte elevation is more obvious than that of adults, generally around 15,000, the neutrophil increases, and the symptoms of poisoning are also more severe.

2. The clinical symptoms of acute appendicitis in older children are similar to those in adults. Children over 6 years of age can voluntarily report the location and nature of abdominal pain, and it is easier to diagnose with the examination. Infants under 6 years of age often lack the typical symptoms of metastatic right lower quadrant pain, and abdominal pain and pain signs are often not fixed, so the clinical misdiagnosis rate is high, with 63% reported.

3, suppuration, perforated block

Pediatric appendix is rich in lymphoid tissue, the appendix wall is very thin, and there is less muscular tissue. Lymphedema is severe after inflammation, which can cause appendix obstruction and blood flow disorders, so it is easy to perforate. The younger the age, the higher the incidence of perforation, the greater omental hypoplasia, and the higher the incidence of perforation, more diffuse peritonitis is formed after perforation, and it is difficult for adhesions to form limited abscesses. Purulent appendicitis can occur in 14 to 24 hours after onset. ^[1]

Pediatric Appendicitis Examination

Pediatric Appendicitis Laboratory Examination

1.Urine and stool routine

The appendix is located near the ureter. There is a small amount of red blood cells in the urine, and there may be a small amount of pus in the stool when the condition is more serious.

2. Blood routine

Mainly manifested by the increase of white blood cells and neutrophils, but some children with appendicitis did not rise significantly.

The total number of white blood cells in suppurative appendicitis can increase to (10-12) × 109 / L; when there is an abscess or diffuse peritonitis, the white blood cells can reach more than 20 × 109 / L, the neutrophils are 0.85 0.95, and they have nucleus Shift left

It is generally believed that neutrophils increased to 0.85 or more, and the multi-reaction disease was severe, and poisonous particles were sometimes seen.

3, puncture fluid inspection

It is suitable for those who are difficult to diagnose or have symptoms of peritoneal inflammation.

Generally, the appendix of the right lower abdomen is punctured with a hypodermic needle, and the puncture fluid is examined by microscopy, bacterial smear, and biochemical examination.

Localized peritonitis with thin puncture fluid; early purulent appendicitis with microscopic examination of pustules; gangrene appendicitis, diffuse peritonitis, or abscesses around the appendix. The puncture fluid is pussy and viscous, or bloody and fecal odor. The film sees a lot of bacteria.

4. Serum C-reactive protein and fibronectin values

The value of plasma fibronectin decreased and the serum C-reactive protein increased significantly during the onset, which can be used as an auxiliary indicator to determine the degree of appendicitis before surgery.

Pediatric Appendicitis Imaging

1. Digital anal examination

It can be found that the right rectal wall is sensitive, such as when the appendix perforates pelvic empyema, the edema and hypertrophy of the tissue around the rectum can be felt on digital examination, and tenderness is obvious. There is inflammatory infiltration and thickening in the right front of the rectum, tenderness when there is an abscess in the pelvis, and an inflammatory mass is formed.

2.B-ultrasound

The normal appendix is 5 to 7 cm in length, 4 to 7 mm in diameter, and the cavity is very thin. Normally, it cannot be displayed by ordinary ultrasound. During inflammation, the appendix swells and thickens. The diameter is> 6 mm. , Rough mucous membranes, interrupted echo, or fluid in the appendix, pus, or fecal stones.

The B-mode display of the appendix image is based on pathological changes, and its specificity, accuracy, and sensitivity are high. It is a safe auxiliary examination method. The size of the abscess around the appendix can be diagnosed based on the increased width of the appendix cavity. B-ultrasound can also show the amount of exudate in the abdominal cavity of gangrenous appendicitis and the peristalsis of the bowel around the appendix, and it can also correctly diagnose the ectopic appendix.

(1) Simple appendicitis, the appendix cavity presents a low echo area, and the bowel movement is active

(2) Purulent appendicitis, the shape of the appendix is "U" or "C", the wall of the appendix is thick and uneven, part of the wall may be double-walled, and the size of the appendix cavity is enlarged, and some of them are Point-like strong echo, intestinal inactivation

(3) For those with perforation of the appendix, the image of the appendix is unclear, and the surrounding intestines are paralyzed, but it can be seen that a mass is formed in the right lower abdomen with a diffuse hypoechoic area and continues to the pelvis.

(4) Gangrene appendicitis, the curve of the appendix is changed to "C" shape, the wall of the appendix is dual, the cavity shows low echo areas with different strengths, and the intestine is inactive and paralyzed;

3.X-ray abdominal plain film

Suitable for patients with bloating. Although it lacks specificity, it helps to distinguish gastrointestinal perforation, intestinal obstruction, and necrotic enteritis.

Can show abnormal gas shadow in the right lower abdomen, the right abdominal wall line disappears, the psoas muscle shadow is blurred, and the lumbar spine is bent to the right. Appendix faecal stones can be seen in about 10% of cases.

4.CT examination

Can show the appendix and surrounding soft tissue and inflammation, manifested as a symmetrical thickening of the peripheral wall, the lumen is completely occluded or filled with water-like density of pus and expands, the fat around the cecum is blurred, and the density is increased.

5.Gut examination

Changes in intestinal electrogram are related to intraperitoneal inflammation and weakened intestinal function.

In children without peritonitis, the inflammation is limited to the appendix. Intestinal inflammation in the ileocecal region is directly stimulated, and the voltage at this site is lower than normal.

In children with peritonitis, as the inflammation progresses, the appendix is purulent, gangrene, and perforation occurs, the peritoneal inflammation exudate increases, and the intestinal electrogram of each part is lower than normal. However, there are no special changes in the severity of peritonitis by electrogram.

6, abdominal electromyography

Abdominal wall EMG amplitude can determine abdominal signs, muscle tension and its extent.

Appendix perforating peritonitis has persistent muscle tension, and the left and right ^[1] lower abdominal electromyographic amplitudes are significantly increased in the resting state.

The amplitude of myoelectric wave increased slightly when the suppurative appendicitis was at rest, and the amplitude of myoelectric wave increased obviously when the right lower abdomen was touched.

The increase of EMG amplitude was not obvious when the simple appendicitis was at rest.

Pediatric Appendicitis Identification

Pediatric acute appendicitis is a common acute abdomen in pediatric abdominal surgery. In differential diagnosis, special attention should be paid to acute gastroenteritis, intestinal roundworm, intussusception, dysentery, acute mesenteric lymphadenitis, primary peritonitis, and Meckel diverticulum. Identification of inflammation and other phases. It should also be distinguished from other acute abdomen:

Pediatric appendicitis is a disease confused with purulent gangrene and advanced appendicitis

1, ovarian cyst torsion

Female patient's right ovarian cyst was twisted and caused paroxysmal severe cramps in the right lower abdomen. The mass could cause abdominal muscle tension and tenderness due to blood circulation disorders and hemorrhage and necrosis. The diagnosis was based on digital rectal examination and double diagnosis of touching round pelvic mass.

2.Meckel's diverticulitis

The diverticulum is located within 20 to 100 cm from the ileum of the terminal ileum. The tenderness and muscle tension are relatively close to the midline when inflamed. If you have a history of blood in the stool, you should consider this disease. Preoperative examination is generally indistinguishable. If the appendix is normal during surgery, the ileum should be explored.

3, back to the blind tuberculosis

The patient is wasted throughout the body, often has low fever, usually has a history of chronic abdominal pain, often feels a mass, and can also have tuberculosis lesions in other parts of the body.

4. Acute necrotizing enteritis

He had a history of blood in the stool with diarrhea, often had a high fever at the time of admission, severe poisoning or shock, and tenseness in the right lower quadrant or whole abdomen. Exploring the laparotomy to confirm the diagnosis.

5.Primary peritonitis

More common in children 4 to 7 years old. The identification mainly depends on the abdomen puncture pus, thin and no odor. Microscopic examination for cocci, it is advisable to perform a laparotomy in time after diagnosis.

Pediatric Appendicitis and Early Simple Appendicitis

1. Acute gastroenteritis

Abdominal pain is mostly paroxysmal colic, abdominal tenderness is not fixed, abdominal muscle tension is not obvious. After a few hours, diarrhea and tenderness disappeared.

2. Acute mesenteric lymphadenitis

There is often a history of acute upper respiratory infections or acute tonsillitis. Abdominal pain is more extensive, and the right lower abdominal pain is also more obvious than other parts. But the tenderness is not limited and there is no abdominal muscle tension. Treated with antibiotics and observed for several hours, no progress or reduction in the condition.

Intestinal roundworm

Irregular abdominal pain caused by intestinal spasms, abdominal tenderness is not fixed, and no muscle tension.

4. Right lower lobar pneumonia or right pleurisy

Hold the right rib margin with your hand to protect the chest, and continue to compress the right lower abdomen with your other hand, and the abdominal muscle tension will gradually disappear. In addition, the patient breathed quickly and his nose flapped. Auscultation of the chest may reduce friction, snoring, and breathing. ^[1]

5, allergic purpura

Although there were abdominal pain and tenderness, there was no muscle tension. With subcutaneous bleeding spots, joint swelling and pain.

Pediatric Appendicitis Prevention

As the cause of pediatric acute appendicitis is not clear, in order to prevent the baby from suffering from appendicitis, the mother can pay attention to the following aspects:

1. Diet. Develop eating habits, pay attention to food hygiene, wash your hands before meals and after using the toilet. Eat a balanced diet and avoid overeating. Diet guides your baby to form good habits.

2. Exercise. Strengthen exercise to strengthen children's physique and prevent diseases such as measles, upper respiratory infections, and acute tonsillitis.

3. Daily activities. Do not eat while playing, avoid strenuous exercise immediately after a meal. Activities Do not allow your baby to jump, run and other strenuous exercises immediately after meals.

4, deworming. To prevent intestinal parasites, promptly follow the doctor's advice for deworming treatment. Deworming If your baby has intestinal parasites, you should go to the hospital in time.

Pediatric Appendicitis Complications

1.Adhesive intestinal obstruction

Occurred in patients with appendix perforation peritonitis or abscess. The reason is that inflammation causes adhesions between intestinal loop and mesentery, which can be complicated by intestinal obstruction.

In the early postoperative period (within 10 days), it is mostly caused by infection. Obstruction can be relieved by gastrointestinal decompression, conservative therapy, and active control of infection. Late stage (1 month later) requires open surgery. ^[1]

2.Residual abscess

Appendicitis peritonitis can cause residual abscesses that usually form 7 to 14 days after surgery.

Abscesses often occur in the pelvic cavity, and also occur in the intestinal space, submental or intrahepatic, and subspleen. No other places have occurred.

The clinical manifestations are a gradual rise in body temperature and an increase in white blood cells.

Those who are milder use anti-inflammatory and supportive therapies to make the pus absorb itself. If the abscess is large and the position is clear and there is tension, the puncture drainage or surgical incision drainage should be guided under the guidance of B-ultrasound.

3 , fecal fistula

Mostly due to severe lesions around the appendix or appendix stump, rare in children. Individually due to TB infection.

If the dressing fails to heal for several weeks, fistula resection should be performed.