Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (59 page)

Appendicitis

Appendicitis is the most frequent abdominal surgical emergency in children.
²⁸
As in adults, the classic presentation is mid-abdominal pain moving to the right lower quadrant, anorexia, vomiting, low-grade fever and localised tenderness with peritoneal signs in the right lower quadrant (see also
Chapter 9
). Presentation in children may be atypical, particularly in those under 5 years of age. Some authors have attempted to quantify the usefulness of specific findings in children using scoring systems. Clinical scoring systems such as the Alvarado Score and the Paediatric Appendicitis Score have been shown to be both sensitive and specific (
Table 12.3
).
^29
–
31

In the otherwise well, stable patient with an equivocal presentation, the diagnostic options include observation with serial examinations, or imaging with ultrasound or computed tomography (CT) (
Fig. 12.6
). There is a great deal of controversy as to which technique is more appropriate (see also
Chapter 5
). Ultrasound is clearly more operator dependent, but recent analyses have suggested that CT scans in childhood may be associated with an increased risk of radiation-induced malignancy later in life.
³²
Both have excellent accuracy.

Increasingly, surgeons are using a laparoscopic approach to appendicectomy in children. As in adults, the benefits of the laparoscopic approach include reduced postoperative pain and length of stay, in addition to a decrease in wound infection rate. There is some evidence that the rate of intra-abdominal abscess may be higher after laparoscopic appendicectomy in children with perforated appendicitis.
³³
The laparoscopic approach may also be beneficial in children who are muscular or obese, and in adolescent females, where the incidence of ovarian pathology as a cause for the symptoms is higher.

Approximately 40% of children present with perforation, and the incidence is over 65% in those aged 0–4 years old.
²⁸
In contrast to non-perforated appendicitis, these children usually present with prolonged symptoms, higher fever, higher white blood cell count and more diffuse peritoneal signs. Some children present with frank sepsis and diffuse peritoneal contamination; these children benefit from resuscitation, followed by immediate appendicectomy and peritoneal washout. Many children with perforated appendicitis present with a prolonged history and a localised abscess or phlegmon on imaging. This condition can be managed either by early operation or by non-operative management consisting of broad-spectrum antibiotics and image-guided drainage of any purulent collections. As in adults (see also
Chapter 9
), the need for a subsequent interval appendectomy several months later is controversial. The authors reserve the use of interval appendectomy for those with an appendicolith on imaging, since their risk of recurrent appendicitis is over 50%.
³⁴

Fluid and electrolyte management in children are made challenging by differences in total body water and compensatory mechanisms, as well as changes in physiology throughout childhood. Total body water is as high as 80% of body weight in neonates, and decreases to the adult level of approximately 60% by 1 year. Degree of dehydration can be estimated from the history and physical examination. Children with mild dehydration (1–5% of body fluid volume) show few clinical signs but frequently have a history of 12–24 hours of vomiting or diarrhoea. Those with moderate dehydration (6–10%) are often lethargic, have low urine output (usually evident as fewer wet nappies/diapers), weight loss, loss of skin turgor, sunken eyes or fontanel, dry mucus membranes and crying without tears. If severe dehydration (11–15%) is reached the child may develop cardiovascular or neurological instability. Children have very active peripheral vasoconstriction, so that blood pressure will be maintained until advanced intravascular volume depletion is reached with onset of hypotension, irritability or coma. However, tachycardia is an early sign that should be recognised and treated.
²¹

The urgency of fluid replacement depends on the degree of dehydration and the cause of the fluid loss. The goals of treatment are the restoration and preservation of cardiovascular, neurological and renal perfusion. In the event of dehydration resulting from an inflammatory condition that will require urgent surgical intervention, such as appendicitis, isotonic fluid (normal saline or Ringer's lactate solution) should be given in 20 mL/kg boluses until signs of cardiovascular compromise subside. For situations in which there is no urgency to do an operation, such as pyloric stenosis, the fluid deficit can be replaced more slowly. This has the advantage of avoiding sudden fluid shifts, and the possibility of cerebral oedema and seizures, which are particularly likely in neonates and infants. The commonly used protocol is to calculate the fluid deficit, and replace half over the first 8 hours and the other half over the subsequent 16 hours.

The principles of trauma management are the same for children as they are for adults (see also
Chapter 13
). Securing the airway and ensuring adequate ventilation are paramount prior to treating bleeding and circulatory collapse. Fluid resuscitation is based on the patient's size, keeping in mind the differences in physiological response to hypovolaemia mentioned in the previous section. As with adults, two boluses of crystalloid (20 mL/kg) should be given through large-bore intravenous lines as quickly as possible. If there is still suspicion for ongoing bleeding, blood products are administered in 20 mL/kg boluses.

The principles of managing penetrating trauma in children are also the same as in adults (see
Chapter 13
). However, children sustaining blunt abdominal trauma are more prone to solid-organ injury due to the low-lying nature of these organs with respect to the paediatric ribcage and the relative laxity of the abdominal wall. In general, injuries to the spleen, liver and kidney can be managed non-operatively regardless of the grade of injury and operations are rare for blunt abdominal trauma in children. The indications for laparotomy in a child with blunt abdominal trauma include: evidence of peritonitis on abdominal examination; free intra-abdominal air on imaging; inability to normalise haemodynamic status despite resuscitation efforts; a rapidly expanding abdomen associated with persistent hypotension; and the need for transfusion of more than one-half of a blood volume over 24 hours.

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