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

When Catherine Holecko's 6-year-old daughter, Josie, complained of a stomachache the day before the family was to fly to California, Catherine and her husband, Jeff, briefly considered postponing. But Josie had eaten a large cinnamon roll and Jeff had also just had a stomachache. They figured Josie's symptoms would pass.

During the two-hour ride to the airport the next afternoon, Josie's stomach still hurt. Catherine treated her with acetaminophen and antacids. After arriving at their rented apartment in San Francisco, Josie threw up. At 3 a.m. she awoke, still in pain.

That's when Catherine called their family practitioner back home in Neenah, Wisconsin, for advice. Once the doctor heard Josie's symptoms, he told Catherine it was possible that it was her daughter's appendix and she should be seen by a doctor within the next four hours. "I wasn't thinking she had anything serious," she says. "It never occurred to me that a 6-year-old could get appendicitis."

The truth is, anyone with an appendix can get appendicitis, a painful inflammation of the hollow finger-shaped organ attached to the end of the large intestine. Untreated, an inflamed appendix can rupture, leading to a lengthy hospital stay for complications including abdominal infection and bowel obstruction.

When surgeons removed Josie's appendix 12 hours after her mother brought her to a San Francisco emergency room, it had already ruptured, probably days earlier. Catherine was overwhelmed with guilt. "We dragged her 2,000 miles from home when she felt so awful, and we kept giving her Tylenol and Tums. We were so clueless."

A Confusing Condition
Child with stomach pain

Jenny Risher

Appendicitis eludes doctors too. Approximately 80,000 children in the United States suffer from it every year. Although it's most common in kids over age 10, more than 80 percent of children younger than 3 who have the illness already have a rupture by the time they reach the operating room. Many of them had been seen and sent home at least once by a health-care professional. That's because in the very early stages, the condition can be hard to diagnose, especially when patients are too young to accurately describe their symptoms.

"We'll have kids come in and say, 'My stomach hurts,' when they may have pneumonia or strep throat," says Geeta Singhal, M.D., head of pediatric hospital medicine at Baylor College of Medicine, in Houston. She coauthored a recent study in Pediatrics that addressed the confusion surrounding appendicitis. Pediatricians had to rank ten common ailments based on how commonly they were misdiagnosed; appendicitis came in fourth. "Children can't always point to their right lower quadrant and say, 'It hurts here,'" she says. "It can be challenging, depending on a child's developmental level and how verbal he is." Part of the problem is that the symptoms -- abdominal pain, loss of appetite, nausea, vomiting, diarrhea, fever -- are common to so many conditions. And not every child will have every symptom.

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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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Surgeons have two methods for removing an appendix, both of which are performed under general anesthesia and take from 30 to 60 minutes. The technique used depends on the doctor, the hospital, and the child. In a traditional open surgery, the doctor makes an incision between a half inch and 2 inches on the right side of the abdomen. Josie had a laparoscopy, a newer procedure where the surgeon makes tiny incisions on the abdomen and uses a telescope and a camera to locate the appendix.

Unfortunately, complications after surgery are common, says Dr. Lally. About 5 percent of children develop a bowel obstruction. The treatment can consist of inserting a tube to drain what's causing the obstruction, or it may require further surgery. And 15 to 20 percent of children with a rupture will develop an abscess, an infection caused when pus collects in the abdomen. It's usually drained and treated with IV antibiotics for up to two weeks.

Like many patients recovering from a ruptured appendix, Josie wasn't allowed to eat anything other than ice pops and ice chips until her bowel began working again. After that, she was given solid food. She spent another two days in the hospital while doctors made sure her digestive system was functioning properly. She was on IV antibiotics during her entire hospital stay.

The appendectomy took a lot out of Josie -- and her family. "She wasn't eating and wasn't getting out of her hospital bed," Catherine recalls. "It became harder for me to imagine her feeling better. I thought, 'How can she bounce back from the state she's in?'" Before the doctors released Josie, they warned her parents that she could develop a fever or more pain.

Back home in Neenah three days later, that's exactly what happened, and she had to be admitted to the Children's Hospital of Wisconsin in Milwaukee. Hooked up again to IV antibiotics, Josie underwent several CT scans that eventually showed she had developed an abscess.

Josie needed to be sedated with a general anesthetic so that the surgeon could insert a plastic tube into her lower abdomen to drain the infected pus. The tube remained in place for three days. If the drain didn't work, or if she had had multiple abscesses, she probably would have required further surgery.

A Full Recovery
Happy child with fixed health problem

Jenny Risher

For all the trauma surrounding her experience, Josie doesn't seem to have bad memories of it. When passing the hospital a few months after being discharged, she announced what she would do if her friends wound up there: "I'll visit them and bring cards to help them feel better."

Catherine has a different take on the situation. "The whole incident really shook my faith in my children's robust good health as well as my own ability to recognize a serious problem when I'm faced with it," she says. "Thank goodness this one had a happy ending."

Dr. Lally's advice is simple: Use common sense. If your child is acting unusual or has severe pain, go to your doctor or to the emergency room. Try to write down the symptoms and share that information with the doctor. "You are partners," Dr. Singhal says. "Everyone wants the best outcome: a healthy, happy, pain-free child."

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If your child has these symptoms, ask your doctor whether an ultrasound or a CT scan is in order:

  • Loss of appetite, with or without vomiting or diarrhea
  • Persistent, unexplained belly pain in the lower right side that lasts more than 24 hours
  • Inability to cough, jump, or go over bumps in the car without pain
  • Difficulty walking and/or staying upright
  • "Rebound pain," so called because when you push gently on your child's belly it hurts more when you let go than when you pressed down

Originally published in the September 2011 issue of Parents magazine.

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