Abdominal Emergencies, 'Surgical Abdomen'
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The appendicitis is the most common cause of 'surgical abdomen' in schoolchildren.
1. The diagnosis of appendicitis can be difficult in children.
Unknown. In some families there is a frequent occurrence.
|Pathology, anatomical types||Illustrations|
Depending on the stage of the disease, different pathoanatomical types are encountered: Acute focal, acute suppurative, gangrenous, and perforated appendicitis. A gangrenous appendicitis also leads to peritonitis as a perforated appendicitis. In case of perforated appendicitis there may be a communication with the abdominal cavity leading to a generalized peritonitis, or there is a localized peritonitis with a perityphlitic abscess due to adhesions of the adjacent intestinal loops.
The obstruction of the cavity of the appendix by stercoliths, foreign bodies, and hyperplasia of the lymphatic structures caused by germs seems to play an important role. Following an increase in pressure within the lumen situated distally of the obstruction, the venous and lymphatic outflow is hindered, and simultaneously, there is an increased germinal growth and invasion in the appendical wall.
|Clinical presentation (history, findings, clinical skills)||Illustrations|
History: Within 1 to 2 days, dull abdominal pain (not colics) followed by anorexia, nausea, vomiting, and constipation.
It is unknown why some episodes of appendicitis subside spontaneously, whereas probably most of them progress through all stages of the disease up to the perforation.
The differential diagnosis includes all diseases producing peritoneal irritation, of which gastroenteritis is the most frequent and most frequently suspected one. In addition, pathologies of the gonads must be considered, such as torsion of the testis in boys and of the ovary in girls, in the latter also disorders following puberty. Finally, all causes of abdominal and retroperitoneal emergencies such as obstructive ileus or complications of abdominal tumors, a pseudo-appendicitis in cystic fibrosis, or pneumonia.
A careful history and clinical examination is the most important factor for a prompt diagnosis because none of the available additional examinations has a 100-percent sensivity and specifity in the single case.
A prompt open or laparoscopic operation belongs to the golden standard of pediatric surgery. There are many publications about these two types of appendectomy without obvious advantages of one method over the other. Nevertheless, laparoscopic surgery is superior in girls with acute or obscure lower abdominal pain during puberty.
Depending on the stage of appendicitis at which surgery is performed: Abscesses in 1 % in acute appendicitis vs. 5 % in perforated appendicitis; and obstructive ileus due to adhesions in 1 % vs. more than 5 %.