Could it be appendicitis?

You son or daughter comes to you complaining of belly pain and you wonder — is my child just trying to get out of another day at school (again!) or is this something serious?

The first point is this: you probably won’t be sure of the diagnosis, so call your health care provider.

There are, however, some clues that can help you recognize whether this is an urgent problem, the most common of which in children is an inflamed appendix, i.e. appendicitis. In its classic presentation, the pain of appendicitis starts around the belly button and over a few hours — usually less than 24 — migrates to the the region of the appendix, located in the lower right portion of the belly. The pain is usually accompanied by fever, vomiting and a loss of appetite.

However, whereas most of these symptoms are almost always present in adults, adolescents and school-age children with appendicitis, they may not be evident in very young children. For pre-school age children, a careful examination by a health care provider is therefore particularly essential, so call and have your child seen as soon as possible (at One Medical, we’ll make sure that as soon as possible means right away!)

My colleague Penelope Hsu, our pediatrician at the Park Slope office in Brooklyn, says determining the origins of a tummy ache can be mysterious for parents.

“It’s hard for a parent to know what it is. It could be gas, constipation, indigestion, too much McDonald’s — it could be a whole bunch of things,” she says. But with appendicitis, “when I get them on the exam table they are tender on the right lower side or they’re shrieking when I touch the abdomen.” 

She shares some typical symptoms of appendicitis:

• Intense pain that becomes constant.
• Pain that starts in the belly then moves to the right side.
• Fever and vomiting.
• They refuse to eat or drink anything.
• They bend over to the right while walking.

When she sees a child with these telltale signs, Hsu sends the patient to the emergency room for an evaluation that may include an ultrasound or CT scan.

Once the diagnosis is confirmed, the treatment is surgery, right? Well, not so fast. Previous work in adults had found that approximately 7 out of 10 patients who are diagnosed with appendicitis can get better initially with antibiotics alone. Some of these patients will eventually require surgery within days or a few to months (10 to 37 percent), but delaying surgery for a trial of antibiotics doesn’t lead to poorer outcomes — everyone gets better! One important consideration is that this antibiotics-first strategy is only appropriate in patients with uncomplicated appendicitis, i.e. they have not perforated their appendix and any infection in the appendix has not spread to their bloodstream.

Can an antibiotic-first approach work for children? A new study in JAMA Surgery says that the answer is “yes.” In this investigation, the parents of more than 100 children (average age 12) with uncomplicated appendicitis were given the option of choosing either immediate surgery or a 24-hour course of inpatient observation while receiving intravenous antibiotics followed by 10 days of oral antibiotics if they demonstrated improvement. Out of the 100 families, 65 chose surgery while 37 chose antibiotics first. The results were impressive — although the children treated with just antibiotics had a slightly longer hospital stay (37 versus 20 hours), 35 were able to leave the hospital without surgery, and approximately 75 percent had not required an operation after 21 months of follow-up.

The 25 percent of children who eventually went to surgery had excellent outcomes; in other words, the delay in surgery was not harmful. And it’s certainly worth noting that the children who avoided surgery also avoided the potential for surgical complications, which although uncommon (7.7 percent) and usually minor, did result in one readmission and one re-operation.

The bottom line is that an antibiotics-first approach can lead  to outcomes comparable to those from immediate surgery and in many cases allows children with the diagnosis of appendicitis to avoid surgery altogether.

Remember, however, that the first step in managing appendicitis is to make the right diagnosis, and for that you need the rapid assessment of a health care provider you can trust.