Summary

Acute appendicitis in children is inflammation of the appendix, a small pouch attached to the large intestine. Think of the appendix as a small, dead-end tube—when it gets blocked (usually by stool or lymphoid tissue), bacteria multiply inside, causing inflammation, swelling, and eventually rupture if not treated. Appendicitis is the most common surgical emergency in children, with a peak incidence in older children and adolescents (10-15 years), though it can occur at any age. The presentation in children can be different from adults—younger children may have less specific symptoms (vomiting, fever, irritability) and may present later, making diagnosis more challenging. The key to management is recognizing the condition (abdominal pain, especially migrating to right lower quadrant, fever, vomiting), confirming the diagnosis (clinical assessment, sometimes imaging), and urgent surgical removal (appendicectomy) before rupture. Most children recover well with prompt surgery, but delayed diagnosis can lead to perforation, peritonitis, and more serious complications.

Key Facts

• Definition: Acute inflammation of the appendix
• Incidence: Very common (most common surgical emergency in children)
• Mortality: Very low (<0.1%) unless complications
• Peak age: Older children and adolescents (10-15 years), but can occur at any age
• Critical feature: Abdominal pain (often migrating to right lower quadrant), fever, vomiting
• Key investigation: Clinical diagnosis (usually), ultrasound/CT if uncertain
• First-line treatment: Urgent surgical removal (appendicectomy)

Clinical Pearls

"Presentation varies by age" — Younger children (<5 years) often have less specific symptoms (vomiting, fever, irritability) and may present later, making diagnosis more challenging. Always consider appendicitis in children with abdominal pain.

"Migration of pain is classic" — The pain often starts around the umbilicus (belly button) and then migrates to the right lower quadrant. This is a classic feature, though not always present, especially in younger children.

"Don't delay surgery" — Once appendicitis is diagnosed, surgery should be done promptly to prevent rupture. Delayed surgery increases the risk of perforation and complications.

"Younger children are at higher risk of perforation" — Younger children (<5 years) have a higher risk of perforation because they present later and have less specific symptoms. Have a lower threshold for investigation in younger children.

Why This Matters Clinically

Appendicitis is the most common surgical emergency in children and can be life-threatening if not treated promptly. Early recognition (especially in younger children where symptoms may be less specific), prompt diagnosis, and urgent surgery are essential to prevent complications (perforation, peritonitis). This is a condition that pediatricians, emergency clinicians, and surgeons manage frequently, and prompt treatment leads to excellent outcomes.

Structured Approach: ABCDE

A - Airway

• Assessment: Usually patent
• Action: Secure if compromised

B - Breathing

• Look: Usually normal (may have shallow breathing if pain)
• Listen: Usually normal
• Measure: SpO2 (usually normal)
• Action: Support if needed

C - Circulation

• Look: May have signs of dehydration, sepsis
• Feel: Pulse (may be high), BP (usually normal, may be low if sepsis)
• Listen: Heart sounds (usually normal)
• Measure: BP (usually normal), HR (may be high)
• Action: IV fluids if dehydrated, monitor if sepsis

D - Disability

• Assessment: Usually normal (may be altered if sepsis)
• Action: Assess if severe

E - Exposure

• Look: Abdominal examination
• Feel: Tenderness, guarding, rebound
• Action: Complete examination

Specific Examination Findings

Abdominal Examination:

• Inspection: May have distension (if perforated)
• Palpation:
  • Right lower quadrant tenderness: Classic
  • Rebound tenderness: Peritonitis
  • Guarding: Peritonitis
• Special tests:
  • Rovsing's sign: Pain in right lower quadrant when pressing left lower quadrant
  • Psoas sign: Pain when extending right hip (retrocecal)
  • Obturator sign: Pain when flexing and rotating right hip (pelvic)

Special Tests

Natural History (Without Treatment)

Untreated Appendicitis:

• High risk of perforation: Almost certain if not treated
• Peritonitis: High risk
• Sepsis: High risk
• Mortality: High if not treated

Outcomes with Treatment

Factors Affecting Outcomes:

Good Prognosis:

• Early surgery: Better outcomes
• Simple appendicitis: Usually quick recovery
• No perforation: Better outcomes
• Older children: Usually better outcomes

Poor Prognosis:

• Delayed surgery: Higher risk of perforation
• Perforation: Longer recovery, more complications
• Younger children: Higher risk of perforation
• Sepsis: More serious

Prognostic Factors

Key Guidelines

1. NICE Guidelines (2020) — Appendicitis: diagnosis and management. National Institute for Health and Care Excellence

Key Recommendations:

• Clinical diagnosis
• Ultrasound first-line in children
• Urgent surgery
• Evidence Level: 1A

Landmark Trials

Multiple studies on laparoscopic vs open, timing of surgery.

Evidence Strength

What is Appendicitis?

Appendicitis is inflammation of the appendix, a small pouch attached to the large intestine. Think of the appendix as a small, dead-end tube—when it gets blocked, bacteria multiply inside, causing inflammation, swelling, and eventually rupture if not treated. Appendicitis is the most common reason children need emergency surgery.

In simple terms: Your child's appendix (a small pouch in the tummy) has become inflamed and infected. It needs to be removed with surgery to prevent it from bursting and causing serious infection.

Why does it matter?

Appendicitis can be serious if not treated promptly. If the appendix bursts (perforates), it can cause a serious infection in the tummy (peritonitis). The good news? With prompt surgery, most children recover completely and quickly.

Think of it like this: It's like a small pouch in the tummy getting infected—it needs to be removed before it bursts and causes more serious problems.

How is it treated?

1. Diagnosis:

• Examination: Your doctor will examine your child's tummy
• Tests: Blood tests and sometimes an ultrasound to confirm
• Why: To make sure it's appendicitis

2. Preparation for Surgery:

• IV fluids: Your child will get fluids through a drip (if needed)
• Antibiotics: Your child will get antibiotics to prevent infection
• Pain relief: Your child will get medicine for pain
• Nothing to eat/drink: Your child won't be able to eat or drink before surgery

3. Surgery:

• What: The surgeon will remove the appendix (usually through small cuts using a camera - laparoscopic)
• When: Usually within a few hours of diagnosis
• Why: To remove the infected appendix before it bursts
• Duration: Usually 30-60 minutes

4. After Surgery:

• Recovery: Your child will recover in hospital
• Antibiotics: May continue antibiotics if the appendix had burst
• Going home: Usually within 1-2 days (longer if it had burst)

The goal: Remove the infected appendix quickly to prevent it from bursting and causing more serious problems.

What to expect

Recovery:

• Surgery: Usually within a few hours of diagnosis
• Hospital stay: Usually 1-2 days (longer if the appendix had burst)
• Pain: Should improve quickly after surgery
• Full recovery: Most children are back to normal within 1-2 weeks

After Treatment:

• Wound: Small cuts that heal quickly
• Activity: Can return to normal activities within 1-2 weeks
• Follow-up: Usually not needed unless complications

Recovery Time:

• Simple appendicitis: Usually 1-2 days in hospital, back to normal within 1-2 weeks
• If it had burst: Usually 3-5 days in hospital, may take longer to recover

When to seek help

Call 999 (or your emergency number) immediately if:

• Your child has severe tummy pain
• Your child has a high fever and is very unwell
• Your child's tummy is very tender or hard
• Your child is very unwell

See your doctor if:

• Your child has tummy pain that's getting worse
• Your child has a fever and tummy pain
• Your child is vomiting and has tummy pain
• You're concerned about your child

Remember: If your child has tummy pain, especially if it's getting worse, has a fever, or they're vomiting, see your doctor. Appendicitis is common and usually easy to treat if caught early, but it can be serious if the appendix bursts.