A 6-7 year old boy walks through the door while holding his mother’s hand.  His face is somewhat pale and has an expression of pain.  Leaning slightly forward, he takes his steps carefully because of possible pain.  They are sitting across from me.  While he had no complaints until the day before, he first started to have a widespread pain in her abdomen.  He didn’t want to eat anything.  Evening nausea is also added.  He hasn’t pooped in two days.  When he felt a slight warmth on his forehead, his mother gave him a pain reliever syrup at home.  He slept early.  When he got up in the morning, he had pain even when walking to the toilet.  Especially when he had very serious pain in the lower right side of his abdomen, they quickly made an appointment and came.  As a result of my examination and the tests I requested, I say that I think it is appendicitis and make a detailed explanation about the surgery.  Since he does not have breakfast in the morning, the fasting period is appropriate, I take him to the operating room and perform a laparoscopic appendectomy.  Everything is running smoothly.  He starts feeding slowly, I send him home after 1 day.
 
This is a typical case of appendicitis that we see very often.  But it may not always be this easy.  In the Pediatric Surgeon’s journal, I will talk about acute appendicitis in children today.
 
First, let me tell you what this appendix is.
 
At the junction of the small intestine and the large intestine, there is a finger-like extension coming out of the large intestine.  We call this worm-like piece of intestine the “appendix”.  Some say that “it’s just a remnant from the embryological period, it has no role”.  However, the increase in the amount of lymphatic tissue it contains from infancy until the age of 30 makes us think that the intestines have a serious role in the fight against the enemies they encounter.  It also shows that in recent years, the intestine acts as a warehouse for healthy bacteria.  As you know, the importance of healthy bacteria for the immune system of our body is a very popular topic these years.  Anyway, back to our appendix.
 
As I said, this appendix is ​​a finger-like bowel extension, that is, intestinal tissue.  It contains the normal intestinal wall, there are normal intestinal secretions from its wall, and these secretions are poured into the large intestine and turned into poop and thrown out.
 
When the mouth of our appendix is ​​blocked, these secretions cannot be poured into the large intestine.  It begins to accumulate in the appendix.  So our worm is starting to get fat.  Bacteria also begin to multiply in the puddle.  The appendix begins to inflame.  Here, the infection and inflammation of the appendix is ​​called “appendicitis”.  When viewed with ultrasonography, we say that the worm’s abdominal circumference, that is the diameter of the appendix, exceeds 6 mm, radiologically, “acute appendicitis” is developed.
 
Not finished yet.  In the acute stage of appendicitis, if left untreated, the worm’s abdomen continues to swell.  The pressure is increasing.  Inflammation in the appendix wall increases and the wall begins to thicken.  Then the pressure increases even more.  The blood is no longer able to flow from the vessels feeding the wall.  And there is a puncture from one part of the appendix wall, that abundant bacterial and filthy intestinal contents accumulated in the appendix are emptied into the abdomen.  
Now people say ruptured appendicitis however, we call this “perforated appendicitis”.  If it is not treated at this stage, the body is now trying to protect itself.  It is trying to wrap the hole with the organs in the abdomen and abscess by forming a wall around the spilled liquid.  In other words, an appendix with plastron and abscess is formed.
 
Still not cured?  Now the infection spreads to the whole body, the picture of sepsis begins.  Even if it cannot be intervened, the patient is lost.  Fortunately, although this rate is quite low, especially nowadays, the mortality rate in children can still vary between 0.1-1%.
 
In order not to make the subject too long, I will quickly proceed with the answers to the questions I received.
 
How long does it take for appendicitis to perforate?
 
For every person it’s different.  In some, after 48-72 hours, in some the progress is much faster, in others it’s progress more slowly.  It changes according to the person’s body and more importantly, the obstruction of the tip of the appendix.  If it is completely blocked with a hard poop stone, that is, “appendicolith”, the process can progress faster.
 
We said that the tip of the appendix is ​​blocked, why, how is it blocked?
 
I witness it mostly clogged with hardened, petrified poop.  Therefore, it is more common in people suffering from constipation. It is less common in Asian countries.  You know, Asian countries are less constipated due to their eating habits.  And for the same reason, the rate of appendicitis started to decrease in western countries because the importance of high-fiber foods is now understood.
 
Another cause of congestion is swelling of the lymph nodes.  It can be triggered after diarrhea or any infection, especially at the ages when the lymphatic function of the appendix is ​​high.
 
It also might be clogged with foreign objects.  You know, they say “Eating watermelon seeds causes appendicitis”.  I’ve never seen.  Once a swallowed pin got stuck in the appendix, I had it removed by an appendectomy, but it wasn’t appendicitis.  But I have encountered cases of appendicitis by clogged the tip with parasites such as pinworms and and other worms like ascaris.
 
After all, somehow children get appendicitis.  According to US data, there are 70,000 children with appendicitis every year.  Although the rate varies according to age groups, it is between 1-25 per 10 thousand.  And not every patient is like I just described.  For example, it can be very difficult to diagnose because young children cannot express themselves properly.  As a matter of fact, while the rate of ruptured appendicitis is 20% in children over 10 years old, it can be 80-100% in children under 3 years old.  So just think about it, almost all of the young children come across as ruptured appendicitis.  Of course, the complication and mortality rate also increases.
 
The first complaint in children with appendicitis is usually abdominal pain.  It is followed by nausea and fever.  In other words, it is generally necessary to seek another diagnosis in a child who first has a fever of 39 degrees and then starts to have a stomachache.  Of course, nothing is 100 percent.  Children’s throats get red, their stomachs hurt, they have diarrhea, they get stomachache, they get constipated. 
 
Our most important weapon in diagnosis is physical examination.  Our inspection is very important.  Of course, we support our examination with ultrasonography, if necessary, with computerized tomography and laboratory tests.  But we also encounter situations where the ultrasound is normal, the leukocyte count is normal, and we diagnose appendicitis, or vice versa.  Depending on where the worm, which we call this appendix, lies, different examination findings may occur.  Sometimes, when it is hidden behind the intestine, the examination can be misleading and it can be impossible to see with diagnostic methods such as ultrasound.
 
Let’s not take too long.  You should definitely go to the hospital if your child has stomach ache, generalized abdominal pain has started to turn into right lower abdominal pain, does not want to move, wants to pull his feet to his stomach and lie still, if nausea begins to add to the loss of appetite, if he has a tendency to have a fever.  If the diagnosis of acute appendicitis is made as a result of the examinations and tests, the currently accepted treatment option is surgical removal of the appendix.  First, he is admitted to the ward and antibiotic treatment is started.  Today, these surgeries are performed not in the middle of the night, but at an hour when the surgeon and the operating team are more fit and comfortable after antibiotic treatment is started.  We can solve the problem early with the “laparoscopic appendectomy” surgery, which we perform very often, with an umbilical camera and accompanying instruments.
 
In recent years, the treatment of appendicitis with antibiotics has been discussed.  In very selected cases, in very early cases, in cases where there is no poop stone or abscess, it can definitely be under the supervision of a pediatric surgeon.  But again, the risk of appendicitis should be considered.  In children with a single abscess and plastron, the abscess can be drained first, antibiotic treatment is given and surgery can be performed 3-6 months later.  But these decisions must be made by your surgeon.
 
Yes, we have come to the end of a beautiful course where I informed you about a very important subject.  Please click if you like to watch the video. Please subscribe and follow us on instagram.
 
And stay happy.
 
November 2021
Prof.  Dr.  Egemen Eroglu