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Appendicitis and Surgeon's Juggle with Management Approach

Appendicitis is the most common acute abdomen which demands surgical attention. About one third of patients are below 18 years and peak is seen between 11 to 12 in pediatric age group. Still high index of suspicion is required in toddlers and under 5 years as they are at higher risk of presenting with Appendicular perforation and Intestinal Obstruction, if initial signs are missed/ ignored. Firstly because they are unable to express the signs precisely at presentation which are the most important clinical clinch and Secondly for fear of negative laparotomies they are misdiagnosed as gastroenteritis in absence of proper surgical opinion by primary Healthcare professionals.

Appendicitis

#Myriad presentations of Inflammed Appendix are:#

  • 1.ACUTE APPENDICITIS
  • 2. SUPPURATIVE APPENDICITIS
  • 3.APPENDICULAR PERFORATION
  • 4. APPENDICULAR ABSCESS
  • 5.APPENDICULAR LUMP
  • 6. GANGRENOUS/ NECROTIZING APPENDICITIS

To make it clinically relevant and useful ...We have

1. SIMPLE APPENDICITIS
2.COMPLICATED APPENDICITIS

Although the mortality rate for APPENDICITIS has dropped to nearly zero with advent of good antibiotic cover which caters the sepsis in complicated Appendicitis but, overall length of hospitalization and morbidity is increased if complication sets in By general consensus the treatment of Appendicitis is Appendectomy but the surgical technique Laparoscopic, Open, Laparotomy , use of drain, interval Appendectomy varies from clinical presentation of the child and surgeon' s preference.

Appendicitis is mostly diagnosed on clinical history and examination with typical

  • 1.Pain localized to Right iliac fossa: Pointing Sign
  • 2.Migratory pain : Shift from Umbilicus to Right iliac fossa
  • 3. Rebound Tenderness Roving sign
  • 4.Mass in Right iliac fossa supported by clinical evidence of nausea, vomiting, anorexia, fever and lab criteria of leukocytosis and shift to left.

Plain radiography may show Fecolith in 10 -20 % and Usg is highly sensitive 85 % and specific 90 % in hands of an expert sonologist with ofcourse good clinical correlation.CT though has become more widespread with sensitivity over 90 % and specificity over 80 % but there is no evidence that supports the routine use of CT in diagnosis unless there are valid clinical clues which justifies the use, to allay unnecessary radiation exposure for routine cases which can be picked up with clinical examination and good ultrasound.

APPENDIX WILL ALWAYS REMAIN OUR JUGGLE AND A DILIGENT APPROACH AT PRIMARY DIAGNOSIS WILL MAKE ALL THE DIFFERENCE.
Dr Shweta Pediatric and Neonatal Surgeon
Sarvodaya Hospital
Sector 8 , Faridabad