Pediatric appendicitis, also known as pediatric acute appendicitis, is a common acute abdominal condition in children, with children over 5 years of age being the most common. Although the incidence is lower than that of adults, the disease is more severe than in adults. The high complication rate and appendiceal perforation rate of diffuse membranitis, which can even be fatal, must be taken seriously. The younger the age of pediatric appendicitis, the more atypical the symptoms are and the more perforation, necrosis, and diffuse peritonitis occur within a short period of time, which can bring about serious complications and even death if not diagnosed and treated promptly, and therefore should be taken seriously.
Children account for about 10% of patients of all ages. 6 to 12 years old is the peak incidence, less common in young children under 5 years old, and the incidence is even lower in children under 1 year old, which may be related to the fact that the appendix in young children is more widely opened in the cecum at this stage, and it is flap-shaped, so it is not easy to form an obstruction, so the chance of acute appendicitis is also small. Some scholars have reported that the incidence of pediatric appendicitis is seasonally related, with a high incidence of appendicitis in March and April, when there are many upper respiratory tract infections, and in July and August, when there is a high incidence of gastritis and enteritis.
Disease characteristics
Pediatric acute appendicitis has the following characteristics.
1. Weak defenses of the pediatric organism
Due to the deficiency of humoral immune function, lack of complement and poor phagocytosis of neutrophils, coupled with unstable thermoregulatory function. As a result, hyperthermia easily occurs, leukocyte elevation is more obvious than in adults, usually around 15000, neutrophilic nuclei increase, and toxic symptoms are more serious.
2, the clinical symptoms of acute appendicitis in older children are similar to those in adults. children over 6 years old can complain of the site and nature of abdominal pain, and with examination, the diagnosis is easier. infants and children under 6 years old often lack the typical symptoms of metastatic right lower abdominal pain, and the abdominal pain and painful signs are often irregular, so the clinical misdiagnosis rate is high, with 63% reported.
3.Septic, perforated block
Pediatric appendiceal lymphatic tissue is abundant, the appendiceal wall is very thin, the muscle layer tissue is little, after inflammation lymphedema is serious, it can cause appendiceal cavity obstruction, blood flow obstruction, so it is easy to perforate. The younger the age, the higher the incidence of perforation, the less developed the greater the omentum, and the higher the incidence of perforation, the more diffuse peritonitis is formed after perforation, and it is difficult to adhere to form a limited abscess. Perforation can occur in septic appendicitis from 14 to 24 h after the onset of the disease.
Differentiation
Pediatric acute appendicitis is a common acute abdominal disease in pediatric abdominal surgery. In the differential diagnosis, special attention should be paid to differentiate it from acute gastroenteritis, intestinal ascariasis, intussusception, dysentery, acute mesenteric lymphadenitis, primary peritonitis, and meconium diverticulitis. It should also be differentiated from other acute abdominal conditions.
Diseases confused with pyogenic gangrene and advanced appendicitis
1. Ovarian cyst torsion
In female patients, torsion of the right ovarian cyst causes paroxysmal severe colic in the right lower abdomen, and the mass can be caused by hemorrhagic necrosis due to impaired blood circulation, resulting in abdominal muscle tension and pressure pain. The differential diagnosis is a round mass in the pelvis on rectal palpation and duplex examination.
2.Meckel’s diverticulitis
The diverticulum is located in the terminal ileum within 20-100 cm from the ileocecum, and the site of pressure pain and muscle tension is relatively close to the midline when inflammation occurs, and the disease should be considered if there is a history of blood in the stool. Preoperative examination usually cannot identify it, and if the appendix is normal during surgery, the ileum should be explored.
3.Ileocecal tuberculosis
The patient is wasted, often with low fever, usually with a history of chronic abdominal pain, often with palpable masses, and other parts of the body may also have tuberculous lesions.
4.Acute necrotizing small bowel infection
History of diarrhea and blood in stool, often with high fever on admission, severe poisoning or shock state, right lower abdomen or whole abdomen pressure pain tension. Must open abdominal exploration, clear diagnosis.
5.Primary peritonitis
Most commonly seen in children aged 4 to 7 years. Differentiation mainly depends on the abdominal puncture pus, dilute and odorless, microscopic examination for coccus, diagnosis is still timely dissection is appropriate.
Diseases that can be confused with early simple appendicitis
1, acute gastroenteritis
The abdominal pain is mostly paroxysmal colic, the abdominal pressure is not fixed, and the abdominal muscle tension is not obvious. After a few hours, diarrhea appears and the pressure pain disappears.
2.Acute mesenteric lymphadenitis
There is often a history of acute upper respiratory tract infection or acute tonsillitis. The abdominal pain is more widespread, and the right lower abdominal pain is also more obvious than other parts. However, the pressure pain is mostly not limited, and there is no abdominal muscle tension. Treated with antibiotics and observed for several hours, the condition did not progress, or there was a reduction.
3.Intestinal roundworm disease
Irregular abdominal pain due to intestinal spasm, abdominal pressure pain is not fixed, and there is no muscle tension.
4.Pneumonia of the lower lobe of the right lung or right pleurisy
Protect the chest by pressing the right rib margin with the hand, and gradually and continuously compress the right lower abdomen with the other hand, the abdominal muscle tension will gradually disappear. In addition the patient breathes fast nasal flapping. There may be friction sounds on auscultation of the chest.
5.Allergic purpura
Although there is abdominal pain and pressure pain, but no muscle tension. It is accompanied by subcutaneous bleeding spots, joint swelling and pain.
Complications
1.Adhesive intestinal obstruction
Most often occurs in people with peritonitis or abscess of perforated appendix. The cause is the adhesion of intestinal loops and mesentery caused by inflammation, which can be complicated by intestinal obstruction.
The early postoperative period (within 10 days) is mostly caused by infection, and the obstruction can be relieved after gastrointestinal decompression, conservative therapy and active infection control. Late stage (after 1 month) requires open surgery.
2.Residual abscess
Appendiceal perforation peritonitis can occur as a residual abscess, which usually forms 7 to 14 days after surgery.
Abscesses mostly occur in the pelvic cavity, but also in the intestinal space, under the diaphragm or in the liver or under the spleen, and are not seen elsewhere.
The clinical manifestations are a decrease in body temperature followed by a gradual increase and leukocytosis. In mild cases, anti-inflammatory and supportive therapies are mostly used to allow the pus to absorb on its own. When the abscess is large in scope and clearly located with tension, it should be drained by ultrasound-guided localized puncture or surgical incision.
3.Fecal fistula
Most of them are caused by severe lesions around the appendix or appendiceal stump, and they are rare in pediatric patients. Individuals are due to tuberculosis infection.
If the fistula does not heal spontaneously after several weeks of drug exchange, fistulotomy should be performed.