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Sorting out your child's bellyaches

Pediatrician and “Today” show contributor Dr. Mark Widome  on when parents should worry about appendicitis.
/ Source: TODAY

Bellyaches are among the most common complaints of childhood, and among the most worrisome for parents. The causes range from simple stomach upset to urgent conditions such as appendicitis. Pediatrician and “Today” show contributor Dr. Mark Widome discusses the importance of suspecting serious causes early, and when to consult your child's physician.

Except for injuries, appendicitis is the most common cause for emergency surgery in children and adolescents. About 70,000 appendectomies are performed on U.S. children each year, and among children under 14 years old, as many as one child in 250 will require the operation each year. Over a lifetime, one in seven people can expect to have appendicitis.

Yet, although appendicitis is common, it is often difficult to diagnose in children; it is frequently misdiagnosed, and the diagnosis is often delayed. This is particularly true in young children where the signs and symptoms can be vague and the child may not be good at communicating the complaint to parents or physicians. However, early diagnosis of appendicitis is important. With delay, the appendix will rupture, leading to a longer hospitalization and increased likelihood of complications.

Recent studiesIdeally, physicians would wish to see everyone with appendicitis get a prompt diagnosis and operation. It would also be good not to do too many unnecessary operations on normal appendices. However, it is better to occasionally operate on a child with a normal appendix than to fail to operate in a timely fashion on a child with an inflamed appendix. In the January issue of the journal Pediatrics, there appear several articles examining ways to better diagnose appendicitis in children.

In one study, researchers looked at data on over 37,000 child appendectomies performed at 2200 hospitals across the United States. They found, not surprisingly, that about 3000 of the operations were done on apparently normal appendices, giving a "misdiagnosis" rate of about 8 percent. What was interesting was that when they compared children treated at hospitals that did few child appendectomies (less than one per week) with those that did many (3 or more per week), the children treated at "low volume" hospitals had a 50% higher chance of misdiagnosis. The authors conclude that hospitals that treat lots of children with appendicitis have better diagnostic accuracy.

Two other January studies looked at the role of diagnostic imaging—ultrasound and CT scans—in helping physicians and surgeons make (or exclude) the diagnosis of appendicitis in children. An ultrasound or CT scan is frequently performed in a child where appendicitis is suspected, but uncertain. While imaging for diagnosing appendicitis has become very popular in recent years, and while they can be helpful in equivocal cases, scans have their downside. Ultrasound accuracy is very dependent on having a radiologist skilled in this procedure, and CT scans involve a significant dose of radiation. One study concluded that the numbers of diagnostic scans could be reduced if hospitals had protocols to use scans "selectively" depending on how high the risk of appendicitis is judged to be in a given child. A third study reported that early referral of children with suspected appendicitis from the primary care doctor to a pediatric surgeon can result in highly accurate diagnosis as well as judicious use of diagnostic imaging.

What are the signs of appendicitis?
The appendix is a blind-ending hollow finger-shaped (and sized) projection from the beginning of the large intestine. Appendicitis occurs when the appendix gets blocked with intestinal contents and then becomes irritated and inflamed. Infection sets in within the blocked appendix causing it to stretch like a small balloon. This stretching is responsible for the first sign of appendicitis: pain that appears to the child to be coming from the area around the umbilicus. The pain is, at first, colicky and intermittent, but soon becomes continuous as it gradually worsens. The pain is usually different from anything that the child has experienced or the parent has witnessed before. The child may prefer to remain curled up in bed and may either refuse to walk or walk with difficulty. The child may complain of loss of appetite and nausea, and then may begin to vomit. There may or may not be bowel movements, but if there are, the volume of stool is not great, in contrast to the larger watery bowel movements typical of intestinal virus infections (gastroenteritis.) As the tissues between the intestine and the abdominal wall also become irritated and inflamed, the pain will usually (but not always) move to the right lower corner of the abdomen.

Why is early diagnosis important?
It is important to seek the advice of your child's physician as early as possible when you suspect appendicitis. This is because it is best to have the appendix removed before it ruptures and spills its bacteria and infected fluid outside of the confines of the intestines and into the abdominal cavity. This spread of infection to the abdominal cavity is called peritonitis.  Peritonitis is much more serious, and it greatly prolongs the length of hospitalization. A ruptured appendix with peritonitis may even necessitate that your child have more than one operation before he is fully recovered.

It is estimated that only 10 percent of appendices rupture in the first 24 hours of the illness but that the majority have ruptured by the end of the second day. The older the child, the more likely that the appendicitis will be diagnosed—and the appendix removed—before it has ruptured. In the younger child, despite the best efforts of parents and skilled physicians, it is often not possible to suspect and diagnose appendicitis before rupture.

When should parents become concerned?
Parents should suspect appendicitis if their child experiences worsening abdominal pain over three or more hours, with or without vomiting. Pay particular attention to pain that is different from anything you have witnessed before. Two important signs that parents should not ignore are that the belly pain is continuously getting worse, and that if there is vomiting, the vomiting begins after the belly pain, rather than before. Another important point is that, unlike in gastroenteritis, if diarrhea is part of the picture at all, it is not the main part. The worsening belly pain is the most important feature.

How to get the best care for your child
Although appendicitis is common and appendectomies have been performed for over a 100 years, the diagnosis difficult to make in young children and imperfect even in older children. Early and accurate diagnosis is most likely when parents take serious belly pain seriously, making sure their child gets a prompt medical evaluation whenever belly pain is building in intensity over a number of hours.  Children with appendicitis do best when there is good communication between parents and physicians, and where physicians have access to experienced surgeons.

An important note to parents
The health information in this article is meant to complement, not replace the advice and care from your child's physician. Every child is different, and parents know their own children best. Seek medical advice when you are concerned about your child's health. Your child's physician is usually in the best position to offer advice that is right for your child.

Mark Widome is professor of pediatrics at The Penn State Children's Hospital in Hershey, Pennsylvania. He is a regular contributor to "Today."