APPENDICITIS Clinical Features Although appendicitis can occur in children younger than age 2, the presentation is usually one of peritonitis or sepsis because of the delay in diagnosis.10 Over age 2, appendicitis becomes a more important part of the differential diagnoses of abdominal pain. The classic progression of symptoms associated with appendicitis applies equally to children and adults. The events involve early anorexia followed by the development of mild to moderate periumbilical pain and then vomiting and the movement of the pain to the right lower quadrant of the abdomen. The youngster should be observed walking into the examining room; in most instances, the child appears to be in discomfort as he or she moves along. This discomfort associated with motion can be exacerbated by asking the youngster to jump up and down before he or she lies down on the examining table. On inspection of the patient, the physician may find limited motion of the lower abdomen due to inflammation of the peritoneum and, depending on the duration of the symptoms, there may be abdominal distention. Palpation may reveal the presence of tenderness in the right lower abdominal quadrant. The position of the appendix may vary greatly, and thus tenderness on examination may vary. Guarding and rebound tenderness may or may not be present in this area. The longer the duration of the symptoms, the greater is the possibility of finding a right lower quadrant mass representing localized perforation with the development of an appendiceal abscess. A rectal examination should be performed to detect the presence of a low-lying, intrapelvic, acutely inflamed appendix or to palpate a mass. The child may have a mild fever and an elevated white blood cell count in the range of 11,000 to 20,000. When there is doubt in the overall symptom complex, an x-ray may reveal the presence of an appendicolith ( Fig 1,2,3-3).
Diagnosis Symptoms consistent with appendicitis together with the presence of an appendicolith warrant the clinical diagnosis of appendicitis and laparotomy. Intravenous fluids should be given and surgical consultation obtained. The following signs and symptoms make the diagnosis of acute appendicitis difficult:
1. The temperature may be normal.
2. The white blood cell count may be normal.
3. The child may not be anorexic and may actually request food.
4. A heavily built child may manifest minimal right lower quadrant tenderness and minimal tenderness on rectal examination.
5. Gastroenteritis is not infrequently associated with appendicitis. Thus, a child presenting with a several-day history of vomiting and diarrhea, perhaps even with siblings suffering from the same problem, should not have the diagnosis of appendicitis discounted on this basis. Intensification of pain in the presence of a history of gastroenteritis should suggest an acutely inflamed appendix secondary to gastroenteritis. 11
6. Appendicitis has been identified in children younger than 1 year of age and is not uncommon in the second year. The incidence of perforation in this age group is much higher because of the difficulty of making the diagnosis and the confusion with gastroenteritis.
Recently, ultrasonography has been a subject of interest in identifying patients with appendicitis. It is, however, operator dependent and has missed not only inflamed appendices but also ruptured appendices. Overall, it has good sensitivity and specificity. It is not yet a gold standard. 12
Treatment Once the diagnosis of appendicitis is strongly considered or confirmed, surgical consultation should be obtained and the child should be admitted to the hospital. The child should receive any appropriate supportive therapy. If the child is febrile, rectal acetaminophen may be given. The child should not receive any oral fluids or food. Start an intravenous line and administer fluid boluses if the child shows signs of sepsis or shock. Closely monitor the child's vital signs and give pain medication parenterally after consultation with the surgeon.
If the diagnosis is possible but not probable, surgical consultation should be considered and the child reexamined until either resolution of the illness or need for laparotomy is determined.
If a perforated appendix is suspected or the child appears septic, ensure that the patient is adequately oxygenated and ventilated, and hypovolemia is corrected. Ensure adequate circulation and urinary output. Start broad-spectrum antibiotics. Ampicillin, gentamicin, and clindamicin are possible regimens.
MECKEL'S DIVERTICULUM A Meckel's diverticulum can cause a variety of signs and symptoms, such as bleeding, peritonitis, intussusception, and intestinal obstruction. The presence of gastric mucosa in the diverticulum may give rise to an ulcer in the adjacent ileum, which may cause symptoms such as painless rectal bleeding. Bleeding is brisk and usually bright red. The ulcer may perforate and cause peritonitis. Isotope scanning reveals the presence of a Meckel's diverticulum containing gastric mucosa in up to 50 percent of the cases. A scan with normal findings does not eliminate the diagnosis.
Acute inflammation in a Meckel's diverticulum may simulate acute appendicitis or may initiate intussusception. Finally, the vitellointestinal remnant attaching the apex of a Meckel's diverticulum to the intraabdominal umbilical region may be the focus around which volvulus of the small bowel or an internal hernia develops, each of these giving rise to intestinal obstruction. Surgical consultation is necessary.
BLEEDING There are several systemic processes that can result in GI bleeding. Upper GI bleeding is usually the result of peptic ulcer disease, varices, or gastritis. Lower GI bleeding can be due to not only the previously mentioned diseases, but also due to infectious colitis, coagulopathies, ulcerative colitis, and Crohn's disease. Two other illnesses can cause abdominal pain and bleeding: Henoch-Schonlein purpura (HSP) and hemolytic-uremic syndrome (HUS)
In HSP, some children may present with joint pain, abdominal pain, or seizure. Usually, there is a petechial or purpuric rash on the buttocks and lower extremities. Many children have guaiac-positive stools but rarely present with bleeding unless there is associated intussusception. Treatment is usually symptomatic and on an outpatient basis unless the child appears ill or has a complication of the disease.
In HUS, there is usually a history of a gastroenteritis with or without bloody diarrhea up to 2 weeks before onset of illness. Toxigenic strains of Escherichia coli have been implicated as a possible link to HUS. Low-grade fever, pallor, hematuria, and hematochezia occur. The central nervous system can be involved. Hypertension occurs in up to 50 percent and seizures in up to 40 percent of cases. Acute bowel perforation, toxic megacolon, intussusception, renal failure, and pancreatitis can occur. These children should be managed by appropriate pediatric specialists or intensivists.
COLON POLYPS Single polyps or multiple or classic familial polyposis may give rise to painless hematochezia. Single polyps are usually benign (juvenile), with no propensity for malignant degeneration. Frequently, the parent describes what is obviously a prolapsed polyp, easily palpated on rectal examination. It is rare for bleeding originating from a polyp to be life threatening. Familial polyposis is rare and is a premalignant syndrome. The child should be referred to a pediatric surgeon.
OTHER CAUSES OF GASTROINTESTINAL BLEEDING Blood represents local irritation or erosion in the majority of children. What appears to be a small amount of blood on the stool or diaper of a healthy child is probably due to an anal fissure or could be related to food substances that have a red or melanotic coloration. A stool test for occult blood and a gentle rectal examination may be all that is needed in a healthy child.
On the other hand, if the child is sick- or ill-appearing or shocklike or has petechiae, one must consider vascular malformation, Meckel's diverticulum, intestinal duplication, or sepsis. In adolescents, one must consider stress ulceration, peptic ulcer disease, and inflammatory bowel disease. Sepsis, severe gastroenteritis, HSP, and HUS should also be part of the differential diagnoses.
In infants, a coagulation survey should be included in the evaluation if the child is ill or shocklike or has a family history of a clotting disorder. Also remember that GI bleeding could be the presentation of intussusception or volvulus. In neonates the differential diagnosis consists of many severe disorders, and consultation may be necessary to exclude them (Table 123-6).
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