Appendicitis is one of the most common surgical emergencies, and it is one of the most common causes of abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million patient-days of admission.
It is Saturday afternoon, you are trying to get some work done, and your child has a tummy ache. It has only hurt for a few hours, and they are still playing, but the complaints continue. Lunch didn’t go well, but there isn’t a fever. Should you wait and watch?
Would it be better to drive to the Emergency Room and have the child examined? Insurance will cover most of the medical costs, but what about the time lost waiting for the exam? On the other hand, you don’t want to miss appendicitis if that is the problem.
Tummy aches are common, and most are not appendicitis, but how do you decide when you should worry? Appendicitis is the most common acute surgical disease in the abdomen. Uncommon under five years of age, its incidence peaks in the second and third decades of life. From around age 15 to 25, boys are affected more than girls, but at other ages, both sexes are affected equally.
The appendix is usually a useful structure that assists our bowel in defending itself from the variety of substances and bacteria we ingest. Unfortunately, it can become obstructed from thickened stool particles, enlarged lymph nodes, or ingested items such as seeds or intestinal worms.
Following blockage, the appendix swells with fluid, and trapped bacteria begin to multiply. The resulting infection causes more swelling, and the stretched appendix begins causing abdominal pain. With typical progression, the pain becomes worse, the appetite is disturbed, and low-grade fever may appear.
Surgical removal of the appendix at this time is curative and rapidly returns a sick person to healthy status. Untreated the infection and increasing pressure cause the organ to leak, and the person can become quite ill.
Surgery and recovery become more difficult, and the chance of complications is significantly higher.
What signs and symptoms are useful in order to avoid these complications?
From years of treating appendicitis, I’ve found three questions that have proven to be very helpful in arousing my suspicions that someone has acute appendicitis.
How long has it hurt, and is it getting worse?
Appendicitis doesn’t happen; it evolves. The abdominal pain frequently begins in an innocuous fashion, and the patient often feels that he has the “flu.” Over several hours (typically 4-8), the discomfort increases and may be felt more in one part of the abdomen than others.
The pain becomes more than an annoyance and frequently begins to interfere with activities such as play. Movement may cause an increase in the abdominal symptoms, and sleep may be disturbed. The pain, initially a nuisance, now can no longer be ignored.
Does it hurt all over the abdomen or mostly in one place?
Acute appendicitis tends to follow a common pattern. It is initially a diffuse discomfort that may center on the umbilical area. With time the pain increases and will usually localize to one place in the abdomen. This is most frequently the lower right side.
However, because of variations in the anatomic position or length of the appendix, it can be almost anywhere. Other places where you might feel the pain include the lower left side, the back on the right, or above the pubic bone. If you can gently push on your child’s abdomen and one area hurts more than the rest, appendicitis is a concern.
Is the appetite normal?
It is unusual for someone with appendicitis to have a normal appetite. For over 95 percent of patients, loss of appetite is the first symptom, and pain occurs later. Vomiting happens three-quarters of the time, usually after the abdominal pain has started. Most often, it occurs once or twice.
Diarrhea can happen; however, a more frequent complaint is the desire to pass gas or have a bowel movement. Unfortunately, successful passage of either one doesn’t relieve the increasing discomfort.
Diagnosing appendicitis is fairly easy if the appendix is located in the “usual” position. Unfortunately, it frequently is not, and acute appendicitis has been mistaken for many other illnesses, including abdominal flu, kidney stones, ovarian problems, and an inflamed colon.
This is a particularly difficult problem in the very young and in older adults. Their bodies do not react quite the same, and as a consequence, the rupture rate is typically 50 percent or more. Most older teens and adults have a more typical course, but many times, specialized testing such as a CT scan is needed to confirm the diagnosis and rule out other possible causes for the pain.
A ruptured appendix occurs when the pressure in the blocked appendix becomes so high that the circulation is disturbed, and gangrene ensues. The appendix leaks pus and bacteria into the abdominal cavity. If the leaking appendix can be contained by the body and the infection controlled, recovery can occur on its own.
However, if the containment process is ineffective, the pus spreads, and the person becomes dramatically ill with abdominal pain, fever, chills, and dehydration. Treatment consists of removing the appendix, draining the pus, and using antibiotics to prevent further spread of the infection. The person is usually sick for quite a while and recovery is slow.
A word about examining someone with abdominal pain
Perform your exam with the person laying down, preferably with their legs drawn up slightly to relax the abdominal muscles. Make sure that your hands are warm and that you push gently using the flat part of your hand, not your fingertips. Don’t prolong the exam.
If it hurts, try to get an idea where it is localized and then quit. Their belly hurts enough; don’t make it worse. If the initial symptoms don’t suggest appendicitis, I would recommend keeping the person on clear liquids for a few hours.
These are essentially flavored water and are represented by jello, broth, clear fruit juice, and sodas. Given frequently, in small amounts, they help prevent dehydration which will make any illness feel worse.
From a surgeon’s perspective, they keep the stomach free of solid food in the event that an operation is necessary.
Acetaminophen (Tylenol) or ibuprofen can be given to relieve discomfort. A few hours of observation should help you determine if the symptoms change and suggest that appendicitis is a possibility.
If it is Saturday afternoon and your child is complaining, remember the following guidelines. If they have (a) a history of abdominal pain which is getting worse, (b) pain which is localized to one particular area of the abdomen, and (c) an appetite disturbance, particularly loss of appetite, appendicitis is a real possibility, and further evaluation is indicated.
A professional physical exam accompanied by a determination of the white blood count and urine exam should help to confirm or deny your concern. If the diagnosis is difficult, expect that further tests may be done, including a CT scan or other specialized studies.
This article was written by James H. Redford MD for Prepper’s Will.
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