Professor at Rīga Stradiņš University and paediatric surgeon Aigars Pētersons tells about acute appendicitis, the most common symptoms of acute abdominal disease in children and the stereotypes about acute appendicitis in children that are still widespread in the society. Pētersons urges to refrain from treatment of children without physicians' consultation, and emphasises that surgical treatment is only required in some situations when the child suffers from acute appendicitis.
“Acute appendicitis is one of the most common acute abdominal diseases in children. It should be noted that this is the most common surgical disease. Children of all ages suffer from acute inflammation of the vermiform appendix of the caecum, but it most commonly affects children aged 7 to 14, when nearly one child in seven undergoes a surgery to remove the vermiform appendix," says Professor Aigars Pētersons.
The symptoms of acute appendicitis vary in young children, i.e., under the age of 3 and teenagers. The most common symptoms in young children include abdominal pain, high body temperature that ranges between 39°C and 39.5°C, vomiting and diarrhoea. Older children suffer from abdominal pain, their body temperature is usually between 37.2°C and 37.5°C; they rarely have vomiting, nausea is more common, they refuse food, and they have constipation as the most common bowel disorder. Diarrhoea is not typical for older children.
“Acute appendicitis is certainly an issue requiring an urgent physician's consultation,” emphasises the paediatric surgeon.
“Diagnostics and therapeutic approach in case of acute appendicitis in children of different ages have evolved significantly over the last years. It was believed that immediate surgical treatment is required in all cases during the first hours after the patient's admission to hospital. However, today, the surgeon first establishes if a patient suffers from a complicated or uncomplicated inflammation of vermiform appendix.
In case of complicated appendicitis, i.e. the appendix bursts (perforates) resulting in intra-abdominal infection, the patient undergoes a surgery. The surgery is performed immediately after the patient is prepared for the surgery. It is not appropriate to say that the surgery must be performed within one, two or four hours. It depends on the patient's health condition at the moment of admission to hospital and on the time required to restore the patient's vital body functions,” says Aigars Pētersons.
“In case of uncomplicated appendicitis, we start antibacterial or antimicrobial treatment, i.e., the child is treated with antibiotics. This experience comes from the Scandinavian countries, where children have received antibacterial treatment for over 10 years, and this treatment is successful in 75 % of cases of uncomplicated appendicitis. Parents often ask if 100% of acute appendicitis cases can be treated using antibiotics. Relapse may occur in up to 15% of cases, when we recommend urgent operative treatment for the child," the professor continues.
"We conducted a survey of parents whose children underwent treatment in the Department of Emergency Medicine of the Children's Clinical University Hospital. They turned to us when their children had abdominal pain or traumatic injuries. We asked them four to five questions related to the children's abdominal pain and acute appendicitis treatment.
The first question was the following: "What factors contribute to acute appendicitis in children?" They were given three possible answers: 1) cherry pits, sunflower seeds or other foreign bodies; 2) flu or other viral diseases; 3) constipation. The third answer is correct – "constipation", but unfortunately 57 % of parents gave an incorrect answer stating that a child may develop acute appendicitis after swallowing cherry pits.
The second question: "Is self-treatment always acceptable in case of acute abdominal pain?" This question had three possible answers: 1) I don't know if self-treatment is acceptable; 2) I deny self-treatment; 3) self-treatment is acceptable. Unfortunately, 18 % of parents believe that self-treatment is acceptable in case of acute abdominal pain. 24% claimed that they do not know how to act. Thus, almost half of our society does not know what to do when a child has acute abdominal pain. The correct answer: you should immediately call the ambulance and turn to the nearest hospital. It is even not right to call the family physician which may only come on the following day.
The third question: "Should we always call an ambulance case of acute abdominal pain?" The possible answers: 1) yes; 2) no; 3) I don't know. 61 % of parents answered correctly that it is necessary to call the ambulance in case of acute abdominal pain. 39 % of respondents – approximately one third of the respondents – failed to give a correct answer.
The fourth question was the following: "Is operative treatment performed in all cases of acute appendicitis?" Parents were given three possible answers: 1) yes; 2) no; 3) I don't know. 85 % of parents failed to answer this correctly. The society still believes that in all cases acute appendicitis is treated only surgically, which is not correct, as the European and international experience of the last five to ten years shows that acute appendicitis in children can be successfully treated without surgery, by administering intravenous saline solution and antibacterial drugs.
The parents who considered that operative treatment was the only option in case of acute appendicitis in children were asked the fifth question: "When should operative treatment be provided after admission to hospital?" with the possible answers: 1) within two hours; 2) within six hours; 3) within 24 hours. 81 % of parents were of the opinion that operative treatment should be provided within two hours after admission to hospital. It should be noted that acute appendicitis is not operated at night in many European countries. It has been proven that the surgery performed on the following morning does not affect the recovery.
What conclusions can be drawn from the results of the questionnaire? The professor concludes that “parents are not ready for the modern therapeutic approach applied by paediatric surgeons and paediatricians in case of acute abdominal pain. Therefore they fail to call the ambulance in time, a child is often treated at home without a diagnosis and physician's consultation. This may explain the increase of the number of cases of delayed admission of children to the Children's Clinical University Hospital who are often diagnosed with abdominal complications of acute appendicitis over the two last years."