Acute appendicitis in children

Introduction to acute appendicitis in children Acute appendicitis is the most common acute abdomen in children. The general condition is more serious than that of adults. Therefore, timely diagnosis and correct treatment of acute appendicitis in children is very important. The younger the appendicitis in children, the more abnormal the symptoms are, and the perforation occurs in a short time. Necrosis, diffuse peritonitis, if the diagnosis and treatment is not timely, it will bring serious complications, and even death, it should be taken seriously, so far reported the misdiagnosis rate of acute appendicitis in infants and young children 35% to 50%, newborns More than 90%. The resulting perforation rate is 33% to 52%, and the inflammation-free resection rate of the appendix is 10% to 30%. Postoperative complications are as high as 10% to 20%, and the mortality rate is still above 0.01%. basic knowledge Sickness ratio: 0.1% Susceptible people: children Mode of infection: non-infectious Complications: pelvic abscess, adhesive intestinal obstruction, fecal fistula

Causes of acute appendicitis in children

Obstruction factor (35%)

The secretions are retained, the pressure in the cavity is increased, and the blood supply of the appendix wall is impeded, which is beneficial to the invasion of bacteria. The most common causes of obstruction are fecal stone, foreign bodies (nucleus, aphids), twisted appendix, narrow scar of the lumen.

Bacterial infection (25%)

Bacterial infection is an acute systemic infection caused by pathogenic bacteria or conditional pathogens that invade the blood circulation and produce toxins and other metabolites. Bacteria can reach the appendix through the ulceration or damage of the mucous membrane and blood circulation, causing acute inflammation, such as angina, upper sense, tonsillitis and so on.

Neural reflex (15%)

Reflex is the most basic neural activity. When the gastrointestinal function is impaired, it is often accompanied by reflexes of the appendix muscles and blood vessels, and obstruction of the appendix cavity and inflammation of the blood vessels cause inflammation.

Pathogenesis

According to the different pathological development process, it can be divided into 3 types:

1. catarrhal (simple) appendicitis The main lesions are mucosal congestion and edema, neutral polymorphonuclear leukocyte infiltration.

2. Suppurative (cellulent inflammatory) appendicitis In addition to mucosal lesions, the musculocutaneous layer is also invaded, and purulent effusions are attached. In the early stage, peritoneal infection and exudation can occur, and the disease progresses.

3. gangrenous appendicitis appendix infection quickly vasospasm embolism, blood circulation disorder, rapid and extensive necrosis of the appendix wall, dark purple, less exudation, but infiltration of surrounding tissue faster, prone to adhesions, catarrhal appendicitis lesions are limited to The mucosa can be cured by conservative treatment, but it can also be converted into suppurative appendicitis due to poor drainage of the appendix cavity. Secondary diagnosis of suppurative and gangrenous appendicitis should be treated with early surgery. The younger the child is, the larger the child is. The shorter the omentum, the thinner the wall of the appendix, the perforation, and the limited ability, can lead to diffuse peritonitis, and because the cecal position of the child is relatively high, relatively free, and the activity is large, so the tender part has large variation.

Acute appendicitis prevention in children

Because the cause of acute appendicitis in children is still unclear, prevention of appendicitis can be noted from the following aspects:

1. Diet guides children to develop good eating habits, pay attention to food hygiene, wash hands before and after meals, do not overeating.

2. Do not eat while eating, avoid running, jumping, squatting and other strenuous exercises after meals.

3. Deworming to prevent intestinal parasites, promptly follow the doctor's advice for deworming treatment.

4. Exercise to enhance children's physique, strengthen exercise, prevent the occurrence of various diseases, such as active prevention of upper respiratory tract infections, measles, acute tonsillitis, etc. have positive significance.

Complications of acute appendicitis in children Complications, pelvic abscess, adhesive intestinal obstruction, fecal fistula

1. Residual abscess Peripheral perforation peritonitis, residual abscess is a serious complication, abscess is mostly confined to the pelvic cavity, intestinal space, underarm or liver, spleen, the most common pelvic abscess, 7 to 14 days after surgery Formation, the clinical manifestation is that the body temperature once decreased and then gradually increased, leukocytosis, anti-inflammatory and supportive therapy for such patients, so that the pus self-absorption, when the abscess range is large, the position is clear and there is tension, in the B-ultrasound Guide the puncture drainage or surgical incision drainage.

2. Adhesive intestinal obstruction occurs in periorbital perforation peritonitis or abscess. Inflammation of intestinal fistula and mesenteric adhesion may cause intestinal obstruction. Early postoperative (within 10 days) intestinal obstruction is associated with infection. Conservative therapy Gastrointestinal decompression, active control of post-infection obstruction can be alleviated, and late-stage (after 1 month) intestinal obstruction is not good after conservative treatment, it is necessary to open surgery.

3. Fecal sputum is caused by severe lesions around the appendix or appendix stump. Children are rare, and some are tuberculosis infections. If the dressing changes for several weeks, they should not undergo self-healing.

Acute appendicitis symptoms in children Common symptoms Abdominal bloating, abdominal pain, abdominal pain, lower abdominal pain, diarrhea, constipation, ailment, intussusception, peritonitis, fever

Clinical manifestations:

1, abdominal pain due to medical history and narrative difficulties, often do not get a typical history of metastatic abdominal pain, abdominal pain is more extensive, and sometimes abdominal pain is not the first symptom.

2, digestive tract symptoms are often prominent and prominent, vomiting is often the first symptom, vomiting is more serious, duration is also long, due to a large number of vomiting, can not eat and produce dehydration and acidosis, sometimes diarrhea, constipation is rare Diarrhea is caused by intestinal inflammation that stimulates excessive bowel movements.

3, systemic symptoms are more serious, fever occurs early, up to 39 ~ 40 ° C, and even there is a war, high fever, convulsions, convulsions, this is due to the instability of children's body temperature and inflammatory reactions.

4, tenderness and muscle tension tenderness points above the Mai's point, infants with high cecal position and activity, its tenderness point is above the upper part, the child's abdominal wall is thin, and it is not cooperative, it is not easy to judge whether there is muscle tension, should be patient, Check it gently and gently, and check it up and down, left and right.

5, abdominal distension and bowel sounds weakened due to early peritoneal exudation, gastrointestinal function is inhibited, so abdominal distension and bowel sounds are more prominent.

6, upper respiratory tract symptoms, the incidence of upper respiratory tract infection in children is higher, these diseases may be the cause of acute appendicitis in children, therefore, children often have upper respiratory tract disease, and then the clinical manifestations of acute appendicitis.

Pediatric emergency appendicitis has the following characteristics:

1, the child's body defense ability is weak

Due to the lack of humoral immune function, complement deficiency and neutrophil phagocytosis, coupled with unstable body temperature regulation, is prone to high fever, white blood cell elevation is more obvious than adults, and the symptoms of poisoning are more serious.

2, the clinical symptoms of larger children with acute appendicitis are similar to adults

Infants under the age of 6 often lack the symptoms of typical metastatic right lower quadrant pain, and the signs of abdominal pain and pain are often not fixed, so the rate of clinical misdiagnosis is high, with a report of 63%.

3, suppuration, perforation block children with appendix lymphoid tissue, the appendix wall is very thin, less muscle tissue, lymph edema after inflammation, can cause appendix obstruction, blood transport disorders, it is easy to perforate, the younger the age, the more perforation High, diffuse peritonitis is formed after perforation, and it is difficult to form a localized abscess due to adhesion, which is due to incomplete development of the omentum, perforation is too fast, and suppurative appendicitis can be perforated in the onset of 14 to 24 hours.

Examination of acute appendicitis in children

[Laboratory Inspection]

1. The total number of white blood cells and neutrophils in blood purulent appendicitis, the total number of white blood cells can be increased to (10 ~ 12) × 10 ⁹ / L; suppurative appendicitis can be as high as (12 ~ 14) × 10 ⁹ / L; When there is abscess formation or diffuse peritonitis, the white blood cells can reach 20×10 ⁹ /L or more, the neutrophils are 0.850.95, and the nucleus moves to the left. If the neutrophils increase to 0.85 or more, the reaction is heavier. Sometimes poisonous granules are also visible, but there is also a small increase in white blood cells in children with appendicitis.

2. Urine, there is no special change in routine, such as when the appendix is located near the ureter, there is a small amount of red blood cells in the urine. When the condition is heavier, there may be a small amount of pus.

3. Serum C-reactive protein and fibronectin protein values have been reported in children with acute appendicitis, serum C-reactive protein is significantly increased, plasma fibronectin protein value is reduced, these two determinations can be used as an auxiliary indicator to determine the extent of appendicitis before surgery.

4. Puncture fluid examination for suspected appendicitis and difficult to diagnose, especially those with peritonitis symptoms, can try abdominal puncture, generally with a subcutaneous needle puncture the right lower abdomen appendix point, the puncture liquid for microscopic examination, bacterial smear and biochemical examination, mirror Most patients with early pus-like appendicitis; such as thin puncture, mostly early localized peritonitis; puncture liquid pus and sticky, or bloody, with fecal odor, smear see a large number of bacteria, Mostly gangrenous appendicitis, diffuse peritonitis or abscess around the appendix.

Film degree exam

1. Anal finger examination has inflammatory infiltration and thickening in the right front of the rectum. There is tenderness in the pelvic abscess and inflammatory mass formation.

2. X-ray abdominal plain film with abdominal distension as the main X-ray examination, about 10% of cases can be seen in the appendix fecal stone shadow, when the appendix has inflammation, the flat film shows the right lower abdomen abnormal gas shadow, the right abdominal wall disappears, the psoas muscle The shadow is blurred, the lumbar vertebrae is curved to the right, and the X-ray image lacks specificity, but it helps to identify intestinal obstruction, gastrointestinal perforation, and necrotic enteritis.

3. CT examination can directly show the appendix and surrounding soft tissue and inflammation under CT. The detection rate is 13%-60%, which is characterized by thickening of the peripheral wall symmetry, complete occlusion of the lumen or pus filling with water-like density, and dilation around the cecum. The fat is blurred and the density is increased.

4. B-ultrasound B-normal normal appendix no image display, when appendicitis can be seen that the diameter of the appendix has increased to varying degrees, 6mm can determine the appendicitis diagnosis, the width of the appendix cavity increases, showing the size of the abscess around the appendix, Gangrenous appendicitis can also show the amount of exudate in the peritoneal cavity and the peristalsis of the intestine around the appendix, and can also make a correct diagnosis of the ectopic appendix.

Li Xinyuan's study of B-ultrasound diagnosis of children with appendicitis found that different types of appendicitis have their own imaging features: simple appendicitis, the appendix cavity presents a low echo zone, the intestinal peristalsis is active, the detection rate is 75%; suppuration Sexual appendicitis, the shape of the appendix changes, showing a "C" shape or "U" shape, the wall of the appendix is thick and uneven, some walls can be double-walled, the appendix cavity is increased in the low echo zone, and some are also spotted. Strong echo, intestines inactivated; gangrenous appendicitis, the curvature of the appendix is changed in a "C" shape, the wall of the appendix is dual, the cavity is in a low echo zone with varying strength, the intestine loses activity and becomes paralyzed; the perforator of the appendix is B-ultrasound See the formation of mass in the right lower abdomen, there is a diffuse hypoechoic area, and continue to the pelvic cavity, the image of the appendix is unclear, and the surrounding intestine is paralyzed. It is documented that the diagnostic rate of B-ultrasound is greater than 96%.

In addition, foreign data have been treated with B-ultrasound for conservative treatment of appendicitis. As the condition improves, the appendix image will gradually disappear. When the condition changes, the appendix image also changes accordingly. Therefore, the B-ultrasound image of the appendix The display is based on pathological changes, and its diagnostic specificity, accuracy, and sensitivity are high, which is a safer auxiliary examination method.

5. Abdominal wall electromyography examination Wang Wei according to the strength of the abdominal wall EMG amplitude, contrast examination to determine the abdominal signs of children with appendicitis, the presence or absence of muscle tension and degree, the results of simple appendicitis at rest of the myoelectric wave amplitude is not obvious The purulent appendicitis has a slight increase in the amplitude of the myoelectric wave at rest. When the right lower abdomen is pressed, the amplitude of the myoelectric wave is obviously increased. When the perforated peritonitis of the appendix is present, due to the persistent muscle tension, the amplitude of the left and right lower abdomen muscles is static. Both are significantly higher.

6. Electromyography examination Chen Xiao-gei through the study of intestinal electrogram examination of children with acute appendicitis found that the ileocecal voltage of children without peritonitis is significantly lower than the control group, the intestinal electrogram of each part of children with peritonitis is lower than In the normal control group, this change may be related to intraperitoneal inflammatory stimulation and decreased intestinal function. When the inflammation is confined to the appendix, the intestinal inflammation of the ileocecal area is directly stimulated, and the voltage of the part is abnormal. When the inflammation progresses, the appendix is aggravated. Suppuration, gangrene, perforation, abdominal inflammation inflammatory exudate increased, the entire intestinal tract has varying degrees of involvement, so the electrocardiogram showed that the voltage of all parts decreased significantly, lower than the normal control group, but the degree of peritonitis through the intestine The electric map has not seen any special changes.

Diagnosis and diagnosis of acute appendicitis in children

diagnosis

Children over 6 years old can complain about the location and nature of abdominal pain. It is easier to diagnose with the doctor's physical examination. The young age can't accurately express the nature of abdominal pain and cooperate with the physical examination. The diagnosis is difficult. Pay attention to the following points in the diagnosis:

1, children with fever, abdominal pain should consider the possibility of appendicitis, should do the necessary inspection and observation, fever, body temperature is more than 37.5 ~ 38.5 ° C, the baby's body temperature can reach more than 39 ° C when perforation of the appendix, can not exclude appendicitis Children should stay in the hospital for close observation. When the child falls asleep, pat the child's body while shaking. If you express resistance or cry, you should be vigilant and repeat the examination.

2, abdominal signs have greater value in the diagnosis, if repeated examinations can be found in the right lower abdomen with obvious tenderness, it is valuable for the diagnosis, and do not want to move, hi right knee knee position, waist flexion while walking.

3, anal finger test for the identification of enteritis, dysentery, intussusception has practical value, can not be simplified in the diagnosis.

4, white blood cells increased, generally around 15,000, the number of neutral nucleus increased.

Differential diagnosis

Part of appendicitis is atypical, with more changes, and is easily confused with other acute abdomen. The common diseases that are identified with it are listed below:

1. Diseases confused with early simple appendicitis

(1) pneumonia or pleurisy: the distribution of nerves around the diaphragm and the distribution of the nerves in the abdominal wall are from the 7 to 12 pairs of the spinal nerves. When the right lower lobe pneumonia or right pleurisy, the diaphragm is stimulated, and the right abdomen may have reactive pain and muscle tension. However, if you press the right rib to protect the chest and the other hand gradually presses the right lower abdomen, the abdominal muscle tension will gradually disappear. In addition, children with pneumonia may have a fast nasal flap, and the chest auscultation may have rubbing sound, voice and breath. The sound is reduced and the chest X-ray is helpful for diagnosis.

(2) acute mesenteric lymphadenitis: often have a history of acute upper respiratory tract infection or acute tonsillitis, abdominal pain is more extensive, because the mesenteric lymph nodes are more at the end of the ileum, so the right lower quadrant pain is also more obvious than other parts, but the tenderness is not limited, There was also no abdominal muscle tension, and after a few hours of observation (with antibiotics), the condition did not progress, or there was a reduction.

(3) acute gastroenteritis: some children with enteritis have abdominal pain, vomiting and fever before diarrhea does not appear, may be misdiagnosed as appendicitis, the abdominal pain of these children are mostly paroxysmal cramps, abdominal tenderness is not fixed, Abdominal muscle tension is not obvious, after a few hours of observation, diarrhea occurs, tenderness disappears, and more can be diagnosed.

(4) Intestinal ascariasis: Sometimes it causes intestinal cramps, which can cause irregular abdominal pain. Abdominal tenderness is not fixed during examination, and there is no muscle tension.

(5) allergic purpura: due to peritoneal and intestinal subserosal hemorrhage, it may have abdominal pain and tenderness, but no muscle tension, subcutaneous hemorrhage, joint swelling and pain help to identify.

2. Diseases confused with suppurative gangrene and advanced appendicitis

(1) Meckel's diverticulitis: the diverticulum is located within 20~100cm from the ileum of the terminal ileum. The tenderness and muscle tension are close to the midline when inflamed. The clinical manifestations are very similar to those of suppurative or gangrenous appendicitis. If there is a history of blood in the stool, the disease should be considered, both of which require early surgery. If the appendix is normal during surgery, the ileum should be explored.

(2) ovarian cyst torsion: girls suffering from right ovarian cyst torsion can cause paroxysmal severe cramps in the lower right abdomen, tumors can cause abdominal muscle tension and tenderness due to bleeding and necrosis of blood circulation disorders, rectal diagnosis and double diagnosis touch pelvic cavity An internal round tumor can be diagnosed.

(3) primary peritonitis: 4 to 7 years old children more common, rapid onset, high fever, bloating, vomiting, white blood cells up to (20 ~ 30) × 109 / L (20,000 ~ 30,000 / mm3) total abdominal tenderness, Muscle tension, with double lower abdomen, it is difficult to identify peritonitis caused by perforation of suppurative appendicitis. Abdominal pus is thin and odorless. Microscopic examination for coccidia is diagnosed as primary peritonitis, and it is appropriate to perform laparotomy. .

(4) tuberculosis in the ileocecal area: can be misdiagnosed as gangrenous appendicitis infiltration or abscess, tuberculosis patients generally have a history of chronic abdominal pain, body weight loss, often low fever, often can touch the mass, other parts of the body may also have tuberculosis lesions, should Further examination and observation of tuberculosis.

(5) acute necrotizing enterocolitis: history of diarrhea and blood, often high fever during hospitalization, severe poisoning or shock state, right lower abdomen or total abdominal tenderness, whether it is necrotic enteritis or appendicitis caused by peritonitis, must open Exploring to confirm the diagnosis of surgical treatment.

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