Acute Appendicitis In Children

Acute appendicitis is inflammation of the vermiform appendix, usually following luminal obstruction with subsequent bacterial proliferation, inflammation and progressive ischaemia. Perforation occurs more rapidly and is more common in younger children because diagnosis is frequently delayed.

Typical progression is:

• Poor appetite and vague periumbilical pain
• Migration of pain to the right lower quadrant
• Nausea or vomiting
• Low grade fever
• Localized tenderness and guarding

Other findings include percussion tenderness, pain with movement and reduced willingness to walk.

Young children frequently present atypically with generalized pain, diarrhoea, irritability or advanced perforation.

Diagnosis is primarily clinical supported by imaging where required.

• FBC and CRP may support inflammation but neither excludes appendicitis when normal.

• Urinalysis helps exclude UTI but mild pyuria can occur from adjacent appendiceal inflammation.

• Ultrasound is first line imaging in children.

• MRI is an excellent radiation free second line option where available.

• CT is reserved for unresolved diagnostic uncertainty when the result will alter management.

• Keep the child fasting, obtain IV access, correct dehydration and give adequate analgesia.

• Give preoperative antibiotics covering Gram negative enteric organisms and anaerobes.

A common regimen is:

Ceftriaxone 50 mg/kg IV once daily, maximum 2 g/day

plus

Metronidazole 10 mg/kg IV every 8 hours, maximum 500 mg per dose.

• Uncomplicated appendicitis is usually treated with laparoscopic appendicectomy, although carefully selected nonoperative antibiotic pathways are increasingly used in some centres.

• Perforation, abscess or generalized peritonitis requires surgical management plus broader and longer antimicrobial therapy individualized to source control and clinical response.

Tracheoesophageal Fistula

Also known as: TOF, TEF

A tracheoesophageal fistula is an abnormal communication between the tracheobronchial tree and oesophagus.

Most congenital fistulas occur with oesophageal atresia, particularly a distal fistula associated with type C atresia.

An isolated fistula with intact oesophageal continuity is termed an H type tracheoesophageal fistula.

The physiological consequences depend on the pressure gradient between airway and oesophagus.

Air can enter the gastrointestinal tract during ventilation, while gastric or oesophageal contents can enter the airway during swallowing.

A fistula associated with oesophageal atresia usually presents in the neonatal period as described above.

An isolated H type fistula can be considerably more difficult to diagnose.

Typical features include:

Coughing during feeds
Choking
Cyanotic episodes with feeding
Recurrent lower respiratory infection
Persistent wheeze
Recurrent aspiration pneumonia
Abdominal distension during positive pressure ventilation

Symptoms may be intermittent, and some children are diagnosed months or years later.

For suspected H type fistula, a routine contrast swallow can miss the lesion.

A carefully performed prone or oblique pullback contrast oesophagram can improve detection.

Bronchoscopy is particularly useful because it can:

Identify the tracheal opening
Determine its relationship to the vocal cords and carina
Exclude additional airway pathology
Permit catheterisation of the fistula before surgery

Oesophagoscopy can provide complementary localisation.

Repeated normal routine contrast studies do not reliably exclude an H type fistula when clinical suspicion remains high.

Initial management

Prevent aspiration.

Use:

Appropriate feed modification or temporary cessation of oral feeds when severe
Enteral access distal to the fistula when necessary
Treatment of aspiration pneumonia

A significant symptomatic congenital fistula requires definitive closure.

H type fistula repair

The operative approach depends on fistula level.

Most H type fistulas lie in the lower cervical or upper thoracic region.

A cervical fistula can be approached through a neck incision.

Identify and protect:

Recurrent laryngeal nerve
Trachea
Oesophagus

Divide the fistula.

Close both defects separately.

Interpose vascularised tissue, such as strap muscle, between the tracheal and oesophageal suture lines where feasible to reduce recurrence.

Lower fistulas can require thoracic or thoracoscopic exposure.

Recurrent fistula

Recurrent fistulation after neonatal EA repair is challenging because the mediastinum is scarred.

Initial stabilisation includes control of aspiration and respiratory infection.

Definitive repair can require:

Open or thoracoscopic fistula division
Tracheal repair
Oesophageal repair
Interposition of pleura, pericardium, muscle or other vascularised tissue

Endoscopic obliteration techniques using cautery, adhesive or other methods can be used in selected small recurrent fistulas, but persistent disease often requires formal surgical division.

Complications

Important postoperative problems are:

Recurrent laryngeal nerve injury
Fistula recurrence
Oesophageal leak
Stricture
Tracheomalacia
Continued aspiration from dysmotility or reflux despite successful fistula closure

Acute Appendicitis In Children

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management