ACUTE APPENDICITIS

Acute appendicitis is less common in Indian children than in western counterparts, probably due to high fiber diet. It is most common in 6-10 years age group, with male preponderance (3:2).

Etiopathogenesis: Acute appendicitis usually begins with obstruction of appendicular lumen by fecoliths/ worms/seeds, etc., leading to obstruction in mucus flow (mucocele) and secondary infection, followed by gangrenous necrosis of walls, perforation and peritonitis.

While perforation may be sealed by protective omen­tum (appendicular lump) in older children, generalized peritonitis is more common in younger children due to thinner and smaller omentum. Rarely, infection may reach appendix during hematogenous septicemia from distant sites.

Clinically, typical cases present with a specific sequence of symptoms: (a) abdominal pain, followed by (b) vomiting, followed by (c) fever, developing over 24-48 hours.

Characteristically, appendicular pain begins in periumbilical region and gradually migrates to right iliac fossa after 2-6 hours. Generalized pain indicates development of peritonitis. Constipation is common, though irritation of sigmoid colon or urinary bladder by inflamed appendix may cause diarrhea and dysuria, respectively.

Clinical examination may reveal:

• Tenderness at McBurney's point—the junction of lateral 1#8725;3^rd and middle 2#8725;3^rd of a line joining anterior superior iliac spine to umbilicus,

• Psoas sign, i.e. pain during flexion or hyperextension of the hip.

• Tender mass in right iliac fossa, composed of inflamed appendix, cecum, terminal ileum and omentum,

• Signs of generalized peritonitis.

Diagnosis rests on clinical suspicion with poly­morphonuclear lekocytosis and must be confirmed on USG, showing dilated (gt;6 mm) tubular, aperistaltic, thick-walled appendix, with/without intraluminal fluid or fecoliths.

Abdominal CT scan is indicated in doubtful cases to confirm the diagnosis as well as detect/localize the perforation or intra-abdominal abscesses.

X-ray abdomen is of little value in diagnosis of appendicitis per se, but may reveal calcified appendicolith, air-fluid level in cecum, signs of small bowel obstruction, and pneumoperitoneum.

Treatment depends on the stage of diagnosis, as follows:

• Non-perforated cases need immediate appendicec­tomy, preferably laparoscopic, after pre-operative stabilization.

• Perforated cases with appendicular mass or peritonitis must be managed conservatively for 7-10 days, followed by interval appendicectomy after 10-12 weeks.

Pre-operative stabilization and conservative manage­ment includes: (a) nasogastric decompression, (b) fluid/ electrolyte correction, and (c) antibiotics, including metronidazole for anerobic infections.

Prognosis: Overall mortality is lt;1% with surgery before perforation. Perforation is more common in younger children and carries poorer prognosis. Other complications include intra-abdominal abscesses, intestinal obstruction, and rarely, infertility due to obstruction of fallopian tubes.

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