… and needs to have their appendix removed. What we do is we give intravenous fluids, we give intravenous antibiotics which treats the infection and then surgically, we use laparoscopes now, so we do laparoscopic surgery. We go in and we remove the appendix and it usually requires a one or two-day hospitalization and afterwards, we expect the child to be completely normal.
Now, there are situations where the diagnosis is not so clear. One problem can be girls. A 13-year-old girl who is ovulating for the first time may have pain in their right lower quadrant because they rupture an ovarian cyst. They are ovulating and so, the pediatrician and a pediatric surgeon and emergency room doctors sometimes cannot be certain that it is appendicitis. Perhaps the story, epigastric pain migrating to the right lower quadrant is not there. Perhaps, the pain starts in the right lower quadrant. Perhaps there is no fever, perhaps there is no elevated while blood cell count. In those situations, where the story and symptoms do not quite fit with appendicitis, we can get an abdominal CAT scan and look at the appendix and see if there are signs of inflammation or signs of swelling in that area and that may help us make a decision. The CAT scan is not 100%, and also the CAT scan is not complelety benign, so we try to use common sense. If the predominance of the symptoms and the story and the history of the patient are consistent with appendicitis, we would just treat for appendicitis.
If there is a significant question, then we would get a scan or sometimes, we get a sonogram. The problem with the sonogram is it is much, much more difficult to interpret, and so it is only occasionally that we are able to tell for certain whether there is appendicitis with a sonogram.
Now, there are some situations where we do not operate on appendicitis. If there is somebody who has had a belly ache that has gone on for five or six days, what happens is the infection spreads outside of the appendix.
Now people use different words. It is interesting, they use different words to convey ideas and the ideas that they use about appendicitis are very dramatic. They use words that have propulsive sounds, Ps and Bs. We say the appendix perforated or we say it burst or we say it ruptured—well, the appendix does not explode inside the child’s belly. What happens is it gets infected and if it is not treated, if we do not give antibiotics, if we do not operate and take the appendix out, what happens is the infection spreads to the surrounding tissue and you may get what is called a phlegmon, which is just inflamed intestine and tissue around the appendix or may even get an abscess which is a collection of pus inside the belly around the appendix.
Now, if a child has been sick for five or six days and we know that the appendix is perforated, it is that the infection has spread. They are doing an operation can be quite difficult, there is a lot of inflammation. It can be difficult to actually identify the appendix and if you identify it, it may difficult to separate it from the tissues around it from the intestine around it because the inflammation makes things stick together.
So in patients who have been sick for a long time, we often give them IV fluids and antibiotics and hope that the antibiotics are strong enough to control the infection. That kind of treatment works with perforated appendicitis about 90% of a time. And what we do is we then plan to do what is called an interval appendectomy. In other words, we give antibiotics and an interval appendectomy. In other words, we plan an appendectomy as an elective operation six to eight weeks later, when the inflammation has gone down and we can do the operation quickly and safely.
There are some nice—I do want to point out, I said, it works 90% of the time. That means that there are some children who have signs and symptoms of appendicitis for various reasons, it is not treated for the first five or six days. They come to the hospital and we give them antibiotics. If they do not respond, if they are in that 10% that do not respond, we then go ahead and operate. Accepting the fact that there are some increased danger and increased difficulty for the surgeons, what we are trying to do is to control the infection and control the disease in a way that is safest to them. That is safest and easiest for the patient, and so, I would say that the vast majority of perforated appendices where the infection has spread get treated with antibiotics and then into the appendectomy, acute appendicitis—someone whose symptoms have started in the one or two days prior to coming to see us, we treat with antibiotics followed by an appendectomy.
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