‘Constipation in children could be appendicitis’

In this interview with MOTUNRAYO JOEL, a consultant paediatric surgeon at the University of Ilorin Teaching Hospital, Kwara State, Dr. Abdulrasheed Nasir, talks about appendicitis in children

What is appendicitis?

Appendicitis is an inflammation of vermiform appendix. It is the most common reason for emergency abdominal surgery in children. It causes pain in one’s lower right abdomen. However, in most people, pain begins around the navel and then moves. As inflammation worsens, appendicitis pain typically increases and eventually becomes severe.

Although anyone can develop appendicitis, most often, it occurs in people between the ages of 10 and 30. Standard treatment is surgical removal of the appendix.
Does appendicitis causes pain in the lower right abdomen?

Sometimes, it can be hard to tell what causes the pains. Younger children might not be able to say what they are feeling. Sometimes, the pain can be caused by another medical problem such as gastroenteritis (a tummy bug). If the doctor is not sure what is causing a child’s pain, he will admit them in the hospital and observe them, in case it is appendicitis. Sometimes, even if they are not sure of the exact problem, doctors decide to perform a small operation to look at the appendix to make sure that appendicitis is not causing the tummy pain.

What causes appendicitis?

Appendicitis results from obstruction of the lumen of appendix. The luminal obstruction can be caused by proliferation of lymphoid tissue in mucosa of the appendix; faecal concretion (faecoliths) – faecal matter serving as nidus for obstruction; cancers: colonic (large intestine) cancers and carcinoid tumors; parasites and foreign bodies—nails, bones and seeds etc

Are these causes different in children?

The causes of appendicitis differ from one person to another. For instance, cancer of the colon (large intestine) is not common in children. It also varies from one geographic location to another because of differences in diet and food hygiene. It is less common in developing countries than in western world.

What are the symptoms of this condition in children?

Appendicitis typically presents with pains around the umbilicus which will later be located to the right of the umbilicus. There is associated poor appetite and feeling of vomiting. However, symptoms of appendicitis vary, and not every child will have all the symptoms. In children younger than age two years, the most common symptoms are vomiting and a bloated or swollen abdomen. Toddlers with appendicitis may have difficulty eating and may seem very tired. Children may have constipation, but may also have small stools that contain mucus. Although infants and children younger than two years may also have abdominal pain and other symptoms, they are too young to effectively communicate their symptoms to adults, who may then miss the symptoms of appendicitis. Other symptoms of appendicitis may include the following: nausea, vomiting, constipation or diarrhoea, inability to pass gas, loss of appetite, abdominal swelling and fever.

How is it diagnosed?

The key to successful diagnosis of appendicitis is a careful history, thorough examination and analysis of selected laboratory studies. In experienced hands, ultrasound is helpful in the diagnosis of appendicitis with the findings of an enlarged, non-compressible appendix. Ultrasound is very important especially in adolescent girls to exclude other conditions that can be confused with appendicitis. These conditions include ovarian pathology and pelvic infection. Other conditions that resemble appendicitis in both girls and boys are gastroenteritis, mesenteric adenitis and pneumonia. Children often present with complications of appendicitis because their complaints are often ignored by parents under the pretext of hide and seek. Self-medication can also lead to delay diagnosis. Age is also a contributing factor in delay diagnosis. By the time a toddler can give sufficient information about abdominal pain or discomfort for parents to seek medical attention, it is almost always too late. More than half of children with appendicitis perforate before seeing a doctor, and 70 per cent before seeing a surgeon.

If not dealt with in time, what can happen to the child?

If not treated in time, the appendix will perforate or rupture leading to spillage of infected intraluminal content into the abdominal cavity causing generalised abdominal pain. Because an obstructed appendix is a good breeding ground for bacteria, the spilled content will result in generalised infection of the abdominal cavity. Delay treatment can also lead to dead (gangrenous) appendix.

Can babies develop appendicitis?

Appendicitis is very uncommon in babies, but it is possible. Appendicitis can be hard for a parent to diagnose, though. At first, it may seem a lot like stomach flu. The classic symptoms are abdominal pain, fever, and vomiting. (In rare cases, it can also cause diarrhoea.)

Your baby’s abdomen may be distended and sensitive to your touch, and he may bend over on his right side if his inflamed appendix irritates the muscles that lead to his leg. Older children may be able to describe the sometimes, telltale sign of abdominal pain that progresses from the belly button to the lower right abdomen, but at this age, there’s little your baby can do to help you understand what’s bothering him.

Can a child survive without an appendix?

Appendix is not essential for life, so one can survive without an appendix.

Are there certain foods that aggravate this condition in children?

No foods have been reported to increase the risk of appendicitis but variation in the rate of appendicitis has been linked to difference in foods especially high fibre foods.

Is appendicitis preventable?

No, appendicitis is not preventable. Early presentation and treatment is however desirable.

What is peritonitis?

Peritonitis is widespread inflammation of the peritoneum cavity. This is the membrane like structure lining the abdominal cavity. It is the consequence of spillage of infected intraluminal content of the intestine.

Appendicitis can rapidly evolve into a life-threatening or fatal infection of the abdominal cavity (peritonitis) if not treated immediately.

What causes peritonitis?

Infection of the peritoneum can happen for a variety of reasons. In most cases, the cause is a rupture (perforation) within the abdominal wall. Though it’s rare, the condition can develop without an abdominal rupture. This type of peritonitis is called spontaneous peritonitis.

Can appendicitis be treated with medicines, in children?

The appendix is a small tube extending from the large intestine, and infections and inflammation of the organ can be dangerous. The only absolute way to diagnose the condition is surgery. Hence, appendicitis is a surgical condition that is treated by surgical removal. Complication of appendicitis can be fatal, it is advisable that it should be surgically treated early in the disease to avoid unnecessary complication.

Are there long term consequences of appendectomy?

Removal of appendix has no known long-term consequence. However, like any other abdominal surgery, appendectomy can be complicated by intestinal obstruction from adhesion.

What is your health advice to parents?

Parental education and high index of suspicion by primary care physicians is necessary to reduce the menace of appendicitis in children.

When the appendix is blocked, it becomes inflamed and bacteria can overgrow in it. Blockage can be due to hard rock-like stool (called a fecolith), inflammation of lymph nodes in the intestines, or even infections like parasites. If the infected appendix isn’t removed, it can burst and spread bacteria. The infection from a ruptured appendix is very serious — it can form an abscess (an infection of pus) or spread throughout the abdomen (this type of infection is called peritonitis).