Acute appendicitis in children

Acute

From tba Department pital, Akron, Obio.

of Surgery,

Appendicitis FRANK T. LANSDEN,

M.D.,

Tbe Children’s

are based on experience patients.

Hos-

A

Volume 106. December 1963

Akron, Ohio

AGE

PPENDICITIS is the most common disorder of chiIdhood requiring emergency abdominaI surgery. The course of the disease may be attended with Iess morbidity than the common chiIdhood diseases, or it may assume crippling or even fata CompIications when unrecognized or improperIy treated. The morbidity and mortaIity from acute appendicitis have been decreased remarkabIy in the past two decades by the fairly genera1 acceptance of a satisfactory method of treatment for the disease [I]. Proper replacement of fluids and eIectroIytes and the judicious use of antibiotics and whoIe bIood are now routinely practiced in most communities. Although the mortaIity from acute appendicitis is now approaching that of simpIe, genera1 anesthesia, deaths stiI1 do occur [z]. AImost without exception, mortality is associated with perforation of the appendix or some complication thereof [?I. Patients with perforation continue to be pIagued with a high degree of morbidity and prolonged hospitalization. It is at once evident that any further reduction in the now existent mortality and morbidity can only be accomplished by earIier diagnosis with prevention of perforation. To compare the peculiarities of the disease and the resuIts of treatment in this community with national statistics, a review of patients subjected to appendectomy was undertaken. One thousand nine hundred sixty-two appendectomies were performed in the Children’s HospitaI, Akron, Ohio, from January rg5o through December 1959. Three deaths are recorded for an operative mortality of 0.15 per cent. One thousand consecutive patients operated on for acute appendicitis from 1954 through 1959 were subjected to critical statistica1 anaIysis. The foIIowing observations American Journal OJ Surgery.

in Children

rZND SEX

encountered

with these

DISTRIBUTION

The average age of a11 patients operated upon in this series was 9.8 years. The youngest patient was sixteen months of age and the oIdest seventeen years. The distribution of maIe to femaIe patients foIlowed cIoseIy to that reported by Gross [4], with a reIative preponderance of maIe (57 per cent) to femaIe patients (43 per cent). The reason for this increased frequency in male patients cannot be adequateIy expIained. Figure I graphicaIIy shows the progressive frequency of appendicitis with increasing age. The peak number of cases occurred at eIeven years of age with a gradua1 decIine thereafter to age fifteen, whereupon the number dropped off rapidly. At eIeven years of age the Iymphoid tissue of a chiId is Iikewise at its maxima1 growth curve. Since the appendix normaIIy contains Iarge numbers of Iymphoid foIIicIes, it is interesting to specuIate that the Iumen of the appendix is more narrow at this age and thus more easiIy obstructed by smaIIer fecaIiths. SEASONAL VARIATION A definite increase in patients was noted in the early spring and fall. The number of patients dropped off to a low figure in December only to return to the peak in January. Whether or not this may be due to the prevalence of infections of the upper part of the respiratory tract during these periods or to changes in diet or social activities is Ieft entireIy to conjecture. (Fig. 2.) SYMPTOMS

AND

DURATION

The most common symptom encountered earIy abdomina1 pain, usuaIIy periumbiIica1 with gradua1 IocaIization to the right Iower quadrant of the abdomen. This was followed was

938

Acute

Appendicitis

in Children

PERFORATED NONPERFORATED

J 5

AGE

NUMBER OF CASES *

601.

50 JAN

MAR

FE6

APR

MAY

JUNE

JULY

AUC

SEPT

OCT

NOV

DEC

MONTH FIG.

2.

Se:~~onai variation of I, I 2~.patients.

ciated with abscess or perforation of the appendix. A preceding infection of the upper part of the respiratory tract was noted in a third of the patients and five patients had pneumonitis at the time of operation. A temperature below 102~~. was almost universally present, while temperatures above 103~~. suggested perforation. Recurrent attacks of abdomina1 pain, prior

closely by vomiting in 68 per cent. of the patients. Thirteen per cent described onI> nausea coupIed with pain and 9 per cent experienced anorexia without nausea or vomiting. In IO per cent there was no history of vomiting or anorexia. Constipation nausea, \?-as a frequent companion in 28 per cent of the patients. Diarrhea was noted in I 2 per cent of all patients, but was most commonly found asso939

Lansden to surgery, were described by 21 per cent of the patients studied. The majority of these feII into the oIder age groups. It is of intcrcst to note that of this group of patients, 25 per cent had a normal appendix at operation. AS wouId he suspected, the duration of symptoms prior to admission to the hospital varied in accordance with the degree of pathologic condition found; the patients showing perforation or abscess formation accounted for the Iongest time interval of 71.4 hours. Those with a pathoIogic condition other than appendicitis followed with a time span of 45.3 hours. Simple, acute appendicitis without complication had produced signs and symptoms an average of 30.2 hours prior to admission. PHYSICAL

.4iiD

LABORATORY

FINDINGS

The most c0nstan.t positive physical finding was point tenderness in the right lower part of the abdomen. Rebound tenderness and tenderness on coughing were usuaIIy present in patients with a moderately advanced condition. Most chiIdren feIt best in the so-calIed “peritonitis position,” Iying on their sides with knees Aexed. ‘The rectal examination was helpful. in arriving at the diagnosis in jo per cent of the patients. It was frequentry omitted or deferred by the house officers. This omission is mentioned onIy tu be condemned, since practicaIIy aI1 patients with perforation or abscess formation require more carefu1 preoperative preparation than do patients with simpIe appendicitis. Since these conditions are usually detected by digita examination, its routine performance is indicated. Significant leukocytosis was present in 84 per cent of the patients and a relative increase in poIymorphonucIear leukocytes with a shift to the Ieft was noted in 88 per cent. More than haIf (58 per cent) of the patients found to have a normal appendix at operation had either an absence of Ieukocytosis, a shift to the Ieft or both. While it is true that the need for emergency operation dues not rest entirely upon interpretation of laboratory data, the absence of Ieukocytosis warrants more carefur consideration and a period of hospital observation prior to surgery. It is true that appendices do not usually “rupture” suddenIy, but rather perforate and soil the peritoneal cavity slowly. Roentgenograms of the abdomen were made preoperativeIy in a smaII number of patients,

and were found to be heIpfu1 in the diagnosis of rupture or abscess formation. Routine roentgenograms, as suggested by Boles, Ireton and CIatworthy [y], were not made. WhiIe helpful in seIected cases, it would seem that routine roentgenograms would be unwarranted. CoproIiths of the appendix were found in I per cent of the patients studied. This is a considerabIy Iowcr incidence than suggested by FeIson and Bernhard [6] in their early reports with the roentgenoIogic recognition of appendicea1 calculi. DURATION

OF HOSPITAL

STAY

Patients with simpIe appendicitis required an average hospitat stay of 5.3 days, whiIe patients with perforation aImost doubIed this figure (9,~ days)_ The average over-a11 stay was six days. The proIonged hospital course of patients with perforation was primarily the result of the high incidence of complications associated with this stage of the disease. PREPARATION

FOR SURGERY

The average hours eIapsing from admission until surgery was 6.7 hours for a11 patients combined. This impIies that at least some time was permitted for restoration of fluid and eIectroIyte baIance and regulation of the acceIerated metaboIic rate. Patients with simpie appendicitis were operated upon an average of f,r hours after admission, whiIe patients with perforation required 6.8 hours for preparation. It is interesting to note that in misdiagnosed cases (normal appendix), an average period of deliberation of 15.6 hours was required before operation was decided upon. OPERATIONS

Appendectomy

was accomplished in 99 per thus reAecting the present attitude that the appendix shouId be removed if possible at the primary operation. Drainage alone accounted for onIy 0.5 per cent of the operations performed. ‘two patients were reoperated fur obstruction or peritonitis, and eleven secondary pelvic abscesses were drained. Three patients were treated with antibiotics and observation, with remission of their symptoms. These patients were later operated upon eIectiveIy when the disease process was proved, (TabIe I.)

cent of the patients,

940

Acute -,-ABLE

Appendicitis

in Children TARL.E II

I

COMPLICATIONS

OPEKATIONS

abscess. Pelvic abscess. Intro-abdominal

56

Wound

28

ahsccss

‘3

Perincphric abscess. Wound disruption Bowc[ obstructic,n

OPERATIVE

FINDINGS

Acute appendicitis was found in 88 per cent of patients operated upon with a combined positive and negative error in the remaining 12 per cent. Eighteen per cent of all patients v-ere found to have gross or microscopic evidence of perforation with the majority percentage-wise falling into the pre-school age I.) Of the patients showing group. (Fig. perforation, 42 per cent had generaIized peritonitis whiIe 64 per cent showed some form of localization. EnIargement of the mesenteric lymph nodes was described in many of the patients having both acutely inflamed and normal appendices. Whether or not this represents a true disease entity in itself, or is merely a reflection of a toxic process within the gastrointcstinaf tract, is open to debate. POSTOPERATIVE

I I I

Grcinoid of thr appendi\ Tcratoma of the ovary Kuptured right rcctus muscle

I I I

Primary peritonitis. Pathologic ovarinn cyst. Acute snlpingitis Wilms tumor.. Pinworms

COMPLICATIONS

ANTIBIOTICS

Antif,iotics were administered to 46.4 per cent of all patients treated. Ninety-seven per cent of all patients with perforated appendices rcceivctf drugs as did 35 per cent of the patients having simple acute appendicitis. .4 comf>ination of penicillin and streptomycin was the most commonly administered drug \vith broad spectrum antibiotics running a close second. No sulfa preparations were used. The routes of administration were varied according to the particular case. Gmpfications occurred in a11 groups, but were seen fess frequently in patients with simple acute appendicitis when no antibiotics lvere used. The complication rate in the nonperforated cases was eight times as great in patients receiving prophyIactic antibiotics. hlany of these patients were discharged from the hospital only to be readmitted with wound abscesses that had apparentIy been suppressed somewhat by antibiotics during their hospital stay. 94’

;I 3

I 43

AND

MORTALITY

As wouId be expected, the frequency of complications was highest in those patients whose appendices had perforated. The complications encountered in this series are Iistecl in Table II. Among the intra-ahtfomin:~I abscesses there was only one subphrenic af>scess. The over-all incidence of complications was IO per cent. There were three deaths in 1,962 appendectomies or o. I 5 per cent mortality. The fast death occurred in November 1953. No deaths have occurred in the fast 1,273 patients. ASSOCIATED CONDITIONS ‘l’he conditions fisted in Tnbfc III were cncountered during operation for acute appendicitis. Only one incidental carcinoid of the appendix was noted. The single case of Wilms’ tumor had produced symptoms of pain in the right Iowcr quadrant presumably- caused by infarction with metastases in the vicinity of the right part of the ureter. The remaining cases were largely due to gynecologic pathologic condition. Meckel’s diverticulum was encountered in only four patients, but admittedly was not searched for in a11 patients. Pinworms (Oxyuris vermicularis) were reported in 4.3 per cent of the pathologic specimens. HaIf the cases reported were in otherwise normal appendices. In no instance was it evident that the organisms were responsibIe for the disease present. No specific inflamma-

Lansden tory or IocaI reactions were present to suggest pin worms as an etioIogic factor in acute appendicitis. It is obvious that the incidence of infestation with 0. vermicularis is higher than 4 per cent among chiIdren and that many of the parasites are overIooked unIess carefuIIy and deIiberateIy searched for in IongitudinaI sections of the appendix [7]. SUMMARY I.

OF CONCLUSIONS

Acute appendicitis in chiIdren is rare within the first two years of life with a progressive incidence to the earIy teenage years. 2. Norma1 Iymphoid hyperpIasia of the appendix may be an etiologic factor in appendicitis in chiIdren. 3. The Iargest percentage of perforations of the appendix occurs in the pre-schoo1 age group with a proIonged history of abdomina1 pain prior to admission. 4. A seasona variation in the disease exists with a greater incidence during periods of changing weather and socia1 activities. 5. It is more common in maIe than femaIe children. 6. The most common presenting symptoms are abdomina1 pain, vomiting and Iow-grade temperature. 7. LocaI tenderness over the appendix associated with Ieukocytosis and a reIative increase

in poIymorphonucIear Ieukocytes with a shift to the left is usuaIIy indicative of acute, suppurative appendicitis. 8. A history of diarrhea and temperature above 103’~. suggests perforation and abscess formation. 9. While antibiotics are helpfur in the treatment of complications occurring with perforations of the appendix, they have no pIace in the treatment of simpIe acute appendicitis without complications. vermicuIaris) do not 10. Pinworms (0. appear to be an etiologic agent in appendicitis. REFERENCES

I. CANTRELL,J. R. and STAFFORD, E. S. The diminishing mortakty from appendicitis. Ann. Surg., 141: 749, 1955. 2. BEECHER. H. K. and TODD. D. P. A studv of the deaths ‘associated with anesthesia and surgery. Ann. Surg., 140: 2, 1954. 3. ABEL, W. G. and ALLEN, P. D. Acute appendicitis in chiIdren. Ann. Surg., 132: 1093, 1950. 4. GROSS, R. E. The Surgery of Infancy and Childhood, p. 253. PhiIadeIphia, ig54, W. B: Saunders Co. 4. BOLES. T. E.. IRETON. R. J. and CLATWORTHY. H. W. Acute appendicitis in chiIdren. Arch. Surg., 79: I

447.

‘959.

6. FELSON, B. and BERNHARD, C. M. The roentgenoIogic diagnosis of appendicea1 calculi. Radiology, 49: 178. ‘947. 7. RECTOR, L. E. Factors influencing the reported inci-

dence of appendicea1 Med., 23: 369, 1943.

942

oxyuriasis.

Am.

.I.

Trop.