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Acute appendicitis refers to an inflammation of the appendix. The appendix is a small, blind-ending structure outpouching from the cecum (the first part of the large intestine). It is regarded as a vestigial organ because its purpose is unknown. What causes the inflammation is a subject of contention. The most common theory is that of obstruction of the hollow part of the appendix. The obstruction may be due to a fecalith (hardened, calcified stool), infection, parasite or tumor. Irrespective of the cause of the obstruction, there is increase in pressure in the appendix, decreased blood flow to the tissues of the appendix, and bacterial growth, all resulting in inflammation.
Presentation: Although appendicitis affects both adults and children, the ages between 10 and 19 years record the most cases. The clinical picture that parents experience at home before going to the clinic or emergency room as well as what the doctor finds when he examines the patient may also differ. Many of us know that appendicitis causes abdominal pain which often starts around the belly button. The pain quickly moves down to the right lower part of the abdomen within a few minutes to hours.
Children with appendicitis do not always experience symptoms like loss of appetite, nausea, vomiting, abdominal swelling, constipation or diarrhea. These are more often seen in adults than in children. Most children however always have low-grade fever in addition to the abdominal pain. Younger children between the ages of 2 and 5 may, in addition to abdominal pain, experience vomiting with fever and loss of appetite also frequently occurring. Those less than 2 years old usually have accompanying vomiting, fever and, sometimes, diarrhea. It is however sometimes more challenging to make the diagnosis in the younger ones because of the difficulty they have articulating words to describe their symptoms.
At The Doctor's
While there are many more common causes of abdominal pain ranging from less serious conditions like constipation and gas to more serious ones like stomach ulcers and inflammatory bowel disease, if your child's abdominal pain worsens with movement, coughing, or sneezing, the chances that he or she has appendicitis becomes all the more likely and you should take him or her to the doctor's office immediately.
You Will Be Questioned
When we see these children, we try to characterize the abdominal pain so that we can narrow down the potential cause. Questions asked often include time of onset of symptoms as this can give the team an idea of how much time we have (or do not have) in the case. Intensity is another area that we ask about. The appendicitis pain is really intense and most kids and adults alike are usually in pain. If it is constant or intermittent, its specific location, if it radiates (moves to other parts or feels like it is beaming the pain across the abdomen). Also we want to know if anything makes the pain better or worse. As we know, it is "PAINFUL" to have to answer all these boring questions sometimes multiple times while the patient writhes in pain. However, these questions help us choose the best management strategy, tests and treatments. Some of these questions will be best answered by your child even though the child is in pain.
The doctor will do a physical examination looking through the whole body and more especially the abdomen. Some of the examination may involve eliciting more pain and may cause some discomfort however these are all needed to ensure that we do not make an erroneous diagnosis. The examination may also reveal signs which may suggest complications arising from the appendicitis like a rupture or an abscess.
Although a diagnosis may be made based on history of the abdominal pain and physical examination, the we may decide to carry out other imaging tests (CT scan or abdominal ultrasound if we have the personel) and some blood and urine tests. The blood test may reveal an elevated white cell count (sign of infection), the urine test may indicate a urinary tract infection (another cause of abdominal pain and fever). The imaging studies may help confirm the diagnosis or reveal another also.
There is a scoring tool that some clinicians use to help them narrow their diagnosis down. The tool can indeed help us drill down but it is only indicative of a higher likelihood and not a given.
Pediatric Appendix Score results: PAS ≤2 to 3 – 0 to 2 percent PAS 3 to 6 – 8 to 48 percent PAS ≥7 – 78 to 96 percent
The treatment of appendicitis in children is the same as in adults. The condition is cured by emergent removal of the appendix through surgery, a procedure known as appendectomy. Appendectomy is a relatively straightforward procedure andcomplications are somewhat rare. However, it is invasive and complications could still occur.
There are twobasic methods for removing the appendix depending on the approach into the abdomen.
Open appendectomy, involves making a large incision in the abdomen to remove the appendix or;
Laparoscopic appendectomy, involves making a much smaller incision to remove the appendix with a laparoscope.
If the diagnosis of appendicitis is not made early enough and a rupture of the appendix happens (as is the case in about 30% of children), the surgeon may decide to give antibiotics to resolve the infection and do an appendectomy 6 - 8 weeks later.
Omega Pediatrics is not a surgical center and as such we do not perform appendectomies here. However, we are across the street from North Fulton Hospital in Alpharetta and they do perform appendectomies on children there. We are also able to transfer our patiients to other hospitals such as Scottish Rite which has a large emergency room and does these surgeries on a daily basis.
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Omega Pediatrics Difference: At Omega Pediatrics in Roswell, Georgia we understand the challenges that parents face when their children develop symptoms late in the day or after hours. Many pediatric offices are closed after 4 pm however we are open every weekday up to 9 pm for walk-ins and we have telemedicine via evisits for our known patients. Our clinic is one of the easily accessible pediatric primary care clinics in Roswell and Alpharetta. We provide pediatric primary care to families in the North Fulton area and we have families that live in Sandy Springs, Johns Creek, Duluth and Cumming.
Immunizations after-hours: One advantage of switching to Omega Pediatrics for your child’s primary care is that you can bring your child in for immunization after regular business hours. We provide this service because we have the passion for what we do and we want to be a comfortable and convenient service, not the ordinary pediatric doctor’s office.