An Illness Even M.D.s Can Miss: Appendicitis in Children

The (Rough) Road to a Diagnosis

The appendix is often referred to by doctors as "vestigial," which means that it has no known function. We rarely think about it until it misbehaves. The problems begin when something in the intestines -- typically a hard piece of stool -- obstructs the opening to the appendix. Bacteria get trapped inside, and the irritated appendix swells. The intestine's natural function is to squeeze, moving food and waste through the digestive tract. The obstruction prevents it from squeezing. That leads to nausea and, in some patients, vomiting and/or diarrhea. The pain usually moves from around the belly to the lower right side of the abdomen during the first 12 to 24 hours after the obstruction begins. During that time, the pain will worsen, but it'll be easier for a doctor to recognize the problem.

Between 25 and 50 percent of children who develop appendicitis will have a rupture, which occurs when the appendix gets so inflamed its wall breaks down. The hole lets intestinal bacteria, stool, and mucus leak into the otherwise sterile abdominal cavity and cause a serious infection. Sometimes the rupture happens within the first 18 hours after the obstruction, but it can take several days -- or not happen at all.

The most accurate way to diagnose appendicitis is with a CT scan, but because it involves radiation, not all doctors will use it on a child. Ultrasound is slightly less accurate -- there is a 5 percent error rate compared with the CT scan's 2 to 3 percent -- but it's also safer, says Kevin P. Lally, M.D., surgeon- in-chief of the Children's Memorial Hermann Hospital, in Houston.

However, because only about 7 to 10 percent of children who come to the emergency room complaining of stomach pain actually have appendicitis, a stomachache alone doesn't guarantee a visit to the imaging department. A doctor's first step is to take a medical history and perform a physical exam. She may order blood work to determine whether there is an infection. Which tests are ordered depends largely on hospital protocol, the child's age, and the extent of the illness.

After a diagnosis, though, the surgery is straightforward, and the long-term prognosis for most children is excellent. If the child's appendix did not rupture, she'll generally leave the hospital within two days. But if it did, she'll usually stay between four and eight days because the infection caused by the rupture requires powerful intravenous (IV) antibiotics.

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