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Management of Appendicitis in Paediatrics

Introduction and Prevalence

Acute appendicitis is a condition in which the vermiform appendix is acutely inflamed. It is the primary cause of emergency abdominal surgery in children.1Alder AC. Pediatric Appendicitis Backgound. Available from http://emedicine.medscape. com-/article/926795-overview [Accessed on 3rd June 2016].   The most challenging group to manage in this condition are the infants and young children as almost half of them exhibit atypical symptoms.2Brennan GDG. Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging. Can J Emerg Med.2006; 8(6):425-32.   Appendicitis is a rare occurrence in infants (younger than 2 years of age) but the frequency increases in the teenage populace. The ratio of boys and girls affected until the onset of puberty is 1:1 as this group crosses the 15-year age limit, the ratio becomes 2:1.3Soud T. Gastrointestinal Emergencies. In: Thomas DO, Bernardo LM, Herman B (eds.) Core Curriculum for Pediatric Emergency Nursing. Sudbury, USA; 2003.p. 233-249.  

The prevalence of appendicitis worldwide is approximately 86 cases annually per 100,000 population. In the United States, almost seventy five per cent of appendicitis patients belong to paediatric population.2Brennan GDG. Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging. Can J Emerg Med.2006; 8(6):425-32.   A constant reduction has been observed in cases of acute appendicitis; its prevalence at present is 10 cases per 100,000 population. In the Asian and African continents, the incidence of acute appendicitis is less due to the type of diet that is consumed by the residents of these countries. A number of factors such as high faecal viscosity and increased time period of bowel movements expose persons to blockages detected in the lumen of the appendix. Dietary fibre acts as an aid in alleviating such factors.4Lohar HP, Calcuttawala MAA, Nirhale DS, et al. Epidemiological aspects of appendicitis in a rural setup. Medical Journal of Dr. D.Y. Patil University. 2014; 7(6): 753-757. DOI:10.4103/0975-2870.144867.  

Aetiology

The aetiology of paediatric appendicitis is as follows :5Alder AC. Pediatric Appendicitis Etiology. Available from http://emedicine.medscape.com/article/926795-overview#a6 [Accessed on 3rd June 2016].  

  • Lymphoid hyperplasia in the submucosal follicles: Its cause is controversial in the paediatric population; however dehydration and viral infection have been suggested.
  • Obstruction by a faecolith.
  • Foreign bodies, infestations caused by parasites and strictures resulting from inflammation are some of the unusual factors.
  • Host genetics plays its part in causing appendicitis, as the immediate family of the patient face a greater possibility of being afflicted by it.

Pathogenesis

Acute appendicitis is a disease that evolves in stages. Its entire 6 presentation is distributed over 5 stages as follows :6Friedman M. Evidence-Based Management of Suspected Appendicitis in the Emergency Department. Emergency Practice Medicine. 2011; 13 (10): 1-32.  

  • Obstruction of the appendix and the introductory distension.
  • Periumbilical pain is the result of triggering the visceral afferent nerves from T8 to T10, which persists for 4-6 hours.
  • Inside the appendiceal wall, when the local venous pressure rises and exceeds that of the intraluminal pressure, it leads to vascular congestion and subsequently ischemia within the tissues.
  • Inflammation and bacterial invasion occur due to tissue ischemia within the wall of the appendix.
  • The above process spreads beyond the appendiceal wall, into the neighbouring tissue, which gives rise to parietal peritoneal inflammation and localised pain in which the right lower quadrant (RLQ) is involved.

If this pathogenesis remains untreated, it will result in necrosis and perforation of the affected appendix. The time required for the manifestation of the entire pathogenic process is case-dependant (46 hours in case of gangrenous appendicitis and 71 hours in case of complications such as perforation).

Cases of “non-acute appendicitis” comprising of recurrent, subacute and chronic appendicitis exist along with the acute ones and its complications. The surgical fraternity agrees with the term recurrent appendicitis which is defined as a patient suffering from acute appendicitis who has endured at least a single episode of such symptoms previously.6Friedman M. Evidence-Based Management of Suspected Appendicitis in the Emergency Department. Emergency Practice Medicine. 2011; 13 (10): 1-32.  

Assessment

The assessment of acute appendicitis in paediatric population is done according to the set protocol. His/her clinical presentation at the beginning of the process varies according to the disease advancement. Diffuse abdominal pain is a factor present during the initial stages of the disease. On advancement of the illness, the child may exhibit symptoms such as walking with a forward bend while supporting the abdomen. The patient might even refuse to be examined or may be incapable of coming to the examination table without help. They might choose to lie still in bed with the head a little raised along with bent knees.3Soud T. Gastrointestinal Emergencies. In: Thomas DO, Bernardo LM, Herman B (eds.) Core Curriculum for Pediatric Emergency Nursing. Sudbury, USA; 2003.p. 233-249.   The following symptoms might be observed during the examination:

In case of a pelvic appendix, an obturator sign (pain on passive internal rotation of the flexed right thigh) is a marked feature (Figure 1).7Hardin DM Jr. Acute Appendicitis: Review and Update. Am Fam Physician.1999; 60(7):2027-2034.  

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Management

Operative (Laparoscopic or Open Appendectomy)

Either a laparotomy or an appendectomy is carried out purely on the findings during the clinical examination; the choice can be supplemented by imaging. The clinical prediction scores that are helpful in the diagnosis of appendicitis are numerous. The paediatric appendicitis score (PAS), was designed especially to be utilised in children. It encompasses various aspects like clinical manifestations, findings from the laboratory, and history of the patient on a ten-point scale resulting in a collective outcome. The PAS has a sensitivity of 100% and a specificity of 92% in the process of appendicitis detection.8Elofsson A, Gemryd E, Arnbjornsson E, et al. Laparoscopic or Open Appendectomy for Pediatric Patients? MOJ Surgery. 2016; 3(1): 00032. DOI:10.15406/mojs.2016.03.00032.  

An enduring cure for appendicitis is excision of the appendix which is the regular treatment procedure; open appendectomy (OA) or laparoscopic appendectomies (LA) are the probable methods. OA has been the established standard for treating appendicitis. In 1983, as endoscopic surgeries exhibited progression, LA was initially outlined as an alternative procedure for appendiceal excision.

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The introduction of LA has made it the first surgical choice in the treatment of paediatric appendicitis8Elofsson A, Gemryd E, Arnbjornsson E, et al. Laparoscopic or Open Appendectomy for Pediatric Patients? MOJ Surgery. 2016; 3(1): 00032. DOI:10.15406/mojs.2016.03.00032.  .

Non-operative

a) Antibiotics: The choice of antibiotics depends on the surgeon but is maintained for the prescribed time period (5, 7, or, 10 days) or until there is absence of fever in the patient. Cases of perforated appendix caused by aerobic and anaerobic organisms mandate the use of broad-spectrum antibiotics. Resistant Gram-negative bacteria, beta-lactam-producing staphylococci, and anaerobic organisms may require use of Piperacillin/Tazobactam. The length of stay and hospital costs are reduced while treating perforated appendicitis by using a single-agent antibiotic; antibiotics can be administered even at home by utilising a peripherally inserted central venous catheter.9GPelosi L. Appendicitis. In: Wise BV, McKenna C, Garvin G, Harmon BJ (eds.) Nursing Care of the General Pediatric Surgical Patient. Gaithersburg, USA; 2000.p. 333-337.  

b) Percutaneous drainage: The detection of an appendiceal abscess requiring percutaneous drainage in inhibiting its further progress can be done with the help of abdominal computed tomography (CT).

A combination of percutaneous drainage and broad-spectrum intravenous antibiotics is proven to be safe and effective in the introductory treatment of intra-abdominal abscesses nonoperatively. An interventional radiologist carries out this procedure either percutaneously or transrectally with the help of an ultrasound or a CT. This procedure has a number of benefits:

  • It helps to avoid extensive surgery which is quite frequent after intra-operative injuries.
  • It also reduces the risk of developing postoperative fistulae or frequent formation of abscesses.
  • It shortens the recovery period postoperatively which is encountered in emergency surgical procedures associated with intra-abdominal abscesses.

This method is beneficial for almost 80-90% of the patients. Subsequent operative procedures are required in patients who exhibit no progress within the 72 hours time-period. Successful nonsurgical introductory treatments reduce the span of hospitalisation, cost, as well as morbidity when compared with the surgical options.10RFabia R, Teich S. Interventions for Appendiceal Complications. In: Teich S, Caniano DA (eds.) Reoperative Pediatric Surgery. Totowa, USA; 2008.p. 241-254.  

c) Role of nutrition: After the operation, cases of non-perforated appendicitis are initiated on clear fluids. Diet is gradually increased depending on the patient’s tolerance.

Patients are discharged from hospital when they start consuming their normal diet. The normal bowel function in such patients starts with a minimum lag and this activity is not a necessity before discharge.

Patients who have undergone an urgent appendectomy due to a perforated appendix should not be given anything by mouth unless their normal bowel function resumes. Subsequently, they must be initiated on clear fluids and the diet is expedited depending on the tolerance exhibited by the patient. Children who have undergone an extended hospitalisation due to the rupture of the appendix require that nutrition is administered to them early via the parental route.11Alder AC. Pediatric Appendicitis Diet and Bowel Function. Available from http://emedicine.medscape.com/article/926795-treatment#d15 [Accessed on 6th June 2016].  

Benefits of Drotaverine Over the Others

Drotaverine is a highly potent and safe spasmolytic agent, suited for oral administration and is capable of relieving or preventing smooth muscle spasm of various organs. It does not interfere with the diagnosis of abdominal pain and is free of side effects, so can be used in children for the management of acute and recurrent abdominal pain, particularly long-term.12Blasko G. JAMA India; 4 (12).  

Drotaverine is a benzyl isoquinolone derivative and is an analogue of papaverine. Being a selective inhibitor of phosphodiesterase isoenzyme IV, it possesses a powerful spasmolytic action on smooth muscle cells and has been found useful in spastic and motility disorders of the smooth muscle. This inhibition of enzyme increases the intracellular level of cyclic adenosine monophosphate, which further causes relaxation of smooth muscle that suppress the pain associated with spasm caused by smooth muscle contraction.

This drug helps in prolonging the pain-relief and does not mask the symptoms of “acute abdomen”; a feature making it unique in the group, and may have relevant application in practice (Table 2).

Moreover, it does not have any morphine or dextropropoxyphene like effect, and thus, does not result in addiction. Drotaverine could be given in cases without finalised diagnosis.13Rathi P. Recurrent Abdominal Pain in Children: a review. Pedia Flash. 2015; 1(1): 6-10.  

  1. Amongst all antispasmodics used in practice, drotaverine has the fastest onset of action of 5 to 12 minutes whereas others take more than an hour.
  2. Drotaverine is free from anticholinergic side effects like dryness of mouth, and blurring of vision, confusion & constipation etc, which is commonly seen with anticholinergic drugs like hyoscine and dicyclomine.
  3. Drotaverine does not mask the symptoms of acute abdomen and does not interfere with diagnosis and further treatment modalities. Anticholinergics like dicyclomine and camylofin are not appropriate choices in emergency situations because they mask the physical symptoms of acute abdomen, thus hindering the diagnosis.

In the first of its kind paediatric study, Narang et al., evaluated the efficacy of Drotaverine in cases of recurrent abdominal pain. A statistically significant reduction in the number of episodes of abdominal pain [mean (SD) number of episodes 10.3 (14) vs. 21.6 (32.4); p=0.0] was observed in the Drotaverine group. Drotaverine also displayed statistically significant lesser school absence. There was no statistically significant difference of frequency of adverse events between children receiving Drotaverine or placebo (46.9% vs. 46.7%; p=0.98) during follow-up period.

Administration of Drotaverine Injection and Tablets

When drotaverine is given intravenously, the spasmodic pain is alleviated quickly and rapidly; its action is observed within 2 minutes. The intramuscular route exhibits results in under 5 minutes. When the drug is prescribed to be consumed orally, the quantity is 240 mg (80 mg 3 times daily). Drotaverine administered through the intravenous route must be given gradually (40-80 mg) and repeated 2-3 times daily. Usually, the loading dose is given intravenously which is succeeded by the drug being reinforced orally in the prescribed dosage.

Children: For the paediatric population within 1-6 years of age, the concentration dosage prescribed orally is 60 mg: 20 mg (1/2 tablet) 3 times daily; between 6-12 years, the drug is administered orally, 40 mg 3 times (120 mg) on a daily basis. When the adequate drug dosage is inferred on the basis of body weight, it is markedly higher in children when compared with the adult population.12Blasko G. JAMA India; 4 (12).  

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Conclusion

Modern physicians find the diagnosis of appendicitis a difficult task, as half of the paediatric patients present atypically. There are various causes of paediatric appendicitis such as lymphoid hyperplasia, faecolith, foreign bodies, parasitic infestations and even host genetics. It is a progressive 5-stage disease which finally culminates in necrosis and perforation of the appendix. Various guidelines are available for the diagnosis and management of appendicitis in the emergency department such as ACR Appropriateness Criteria, ACEP Clinical Policy etc. Management of paediatric appendicitis can be divided into operative and non-operative methods. Drotaverine (suspension, tablets and injection) is a safe and effective class of drug as it is free of side-effects and does not interfere with the diagnosis of abdominal pain, particularly long-term.

References

  1. Alder AC. Pediatric Appendicitis Backgound. Available from http://emedicine.medscape. com-/article/926795-overview [Accessed on 3rd June 2016].
  2. Brennan GDG. Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging. Can J Emerg Med.2006; 8(6):425-32.
  3. Soud T. Gastrointestinal Emergencies. In: Thomas DO, Bernardo LM, Herman B (eds.) Core Curriculum for Pediatric Emergency Nursing. Sudbury, USA; 2003.p. 233-249.
  4. Lohar HP, Calcuttawala MAA, Nirhale DS, et al. Epidemiological aspects of appendicitis in a rural setup. Medical Journal of Dr. D.Y. Patil University. 2014; 7(6): 753-757. DOI:10.4103/0975-2870.144867.
  5. Alder AC. Pediatric Appendicitis Etiology. Available from http://emedicine.medscape.com/article/926795-overview#a6 [Accessed on 3rd June 2016].
  6. Friedman M. Evidence-Based Management of Suspected Appendicitis in the Emergency Department. Emergency Practice Medicine. 2011; 13 (10): 1-32.
  7. Hardin DM Jr. Acute Appendicitis: Review and Update. Am Fam Physician.1999; 60(7):2027-2034.
  8. Elofsson A, Gemryd E, Arnbjornsson E, et al. Laparoscopic or Open Appendectomy for Pediatric Patients? MOJ Surgery. 2016; 3(1): 00032. DOI:10.15406/mojs.2016.03.00032.
  9. Pelosi L. Appendicitis. In: Wise BV, McKenna C, Garvin G, Harmon BJ (eds.) Nursing Care of the General Pediatric Surgical Patient. Gaithersburg, USA; 2000.p. 333-337.
  10. Fabia R, Teich S. Interventions for Appendiceal Complications. In: Teich S, Caniano DA (eds.) Reoperative Pediatric Surgery. Totowa, USA; 2008.p. 241-254.
  11. Alder AC. Pediatric Appendicitis Diet and Bowel Function. Available from http://emedicine.medscape.com/article/926795-treatment#d15 [Accessed on 6th June 2016].
  12. Blasko G. JAMA India; 4 (12).
  13. Rathi P. Recurrent Abdominal Pain in Children: a review. Pedia Flash. 2015; 1(1): 6-10.
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