Appendicitis: Treatment and Care
Guest: Dr. Chris Streck – Department of Surgery, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Chris Streck. Dr. Streck is Assistant Professor of Pediatric Surgery at the Medical University of South Carolina, and a specialist in a very exciting new area, which is the minimally invasive surgical treatment of our smallest patients, our pediatric patients. Dr. Streck, in this podcast, let’s talk about the laparoscopic, or minimally invasive approach to treating children with appendicitis. First of all, symptoms of appendicitis, lots of kids get stomach aches, and aches and pains of various sorts, when should you begin to suspect that this might be appendicitis?
Dr. Chris Streck: Sure. Appendicitis is a very common surgical problem. However, as you mentioned, children often have abdominal pain, fevers. Surprisingly, it can be very difficult to make the diagnosis. And often, in children, appendicitis is missed until the appendix has already ruptured. So, as pediatric surgeons, dealing with both early cases of appendicitis and ruptured cases of appendicitis is a pretty significant portion of the work we do. The most common way that children will present would be to have abdominal pain. The classic description is that within 12 to 24 hours that pain around the belly button, the umbilicus, begins to migrate into the right lower quadrant of the abdomen and it becomes more sharp and focal. Often those children, in addition to pain, can have nausea or vomiting, and a fever, associated with that. But the hallmark, really, is that focal pain in the right lower quadrant of the abdomen.
Dr. Linda Austin: The lower right area?
Dr. Chris Streck: Yeah.
Dr. Linda Austin: Appendicitis is something that’s so familiar to you, but for a lot of folks, they may not even know exactly what the appendix is, and what appendicitis really is. What’s going on there?
Dr. Chris Streck: Sure. The appendix is actually an organ that you don’t need; it’s not something that’s required. It’s a vestigial organ. It hangs off of the colon and serves, really, no functional purpose. The appendix does have a lumen, which is an opening, so there’s a connection between the colon and the appendix. And often, that lumen, or hole, can be blocked, or obstructed. The common things that cause blockage are a piece of food, or stool. Or, sometimes children can suffer from a viral illness which will cause swelling of the lymph nodes, and that can cause blockage of the appendix as well.
Dr. Linda Austin: You mentioned rupture, explain that. Why is that such a particular problem? .
Dr. Chris Streck: As that opening between the colon and appendix becomes closed, fluid that builds up in the appendix doesn’t have anywhere to go, and the appendix swells and becomes larger, progressively causing more pain to the child. And eventually, as it gets big enough, it’s forced to rupture; a hole in the appendix breaks open.
Dr. Linda Austin: And that’s pretty dangerous, potentially, isn’t it?
Dr. Chris Streck: It can be. Fortunately, with the techniques that we employ with fluid management and antibiotics, we’re able to save most children with perforated appendicitis. Years ago, surgeons worried about patients actually dying from this process. However, even with all of our best techniques, the children become very sick after the appendix ruptures. It can cause significant abdominal pain, fever. They can develop infections within the abdomen, called abscesses, and all this can make for a very rocky course for the child.
Dr. Linda Austin: The child has to be hospitalized if their appendix has ruptured.
Dr. Chris Streck: Certainly.
Dr. Linda Austin: And you really want to get a child to an emergency room before that happens, or call your pediatrician.
Dr. Chris Streck: Exactly.
Dr. Linda Austin: Now, walk us through the difference between a laparoscopic or minimally invasive approach, versus the traditional approach.
Dr. Chris Streck: The traditional approach is with an incision in the right lower part of the abdomen, over the appendix, cutting through the skin and all the different layers of the abdominal wall, and trying to bring a part of the colon and appendix up out of the wound to remove the appendix. Potentially, this type of incision can lead to pain you might imagine from cutting through the different layers of the abdominal wall. We think that, especially in the appendixes that have ruptured, there may be a higher rate of infection.
What’s nice about a laparoscopic surgery is that we make three small incisions. Each of these is probably the size of the tip of your fingernail. These small incisions allow us to put a camera, or scope, into the abdomen, inflate the abdomen with air and use small instruments, that we place through the incisions, to remove the appendix. We have staplers now that can be placed in the abdomen and divide the appendix, and safely allow us to put the appendix in a bag and remove it through the tiny incision without as much pain to the child, and with much better cosmetic results.
Dr. Linda Austin: Now, into a bag, I’m envisioning a little baggie going in that you kind of scoop it up in.
Dr. Chris Streck: Believe it or not, there’s a very small bag that looks like a rolled up ziplock bag that goes into the belly. We can unroll it, looking through the camera, and place the appendix in that bag, close it up with a draw string and bring the appendix out.
Dr. Linda Austin: That’s amazing. And then sew up the child?
Dr. Chris Streck: Yes.
Dr. Linda Austin: And how long does that procedure take?
Dr. Chris Streck: The nice thing is, particularly if the appendix hasn’t ruptured, it usually takes between 30 minutes and an hour.
Dr. Linda Austin: So you can do it during your lunch hour and hardly break your stride, it sounds like.
Dr. Chris Streck: Yeah.
Dr. Linda Austin: And, of course, that’s great for the child because there’s less anesthesia. How long does a child have to stay in the hospital then?
Dr. Chris Streck: For acute appendicitis, children can usually go home later that evening or the next morning, once they’re able to tolerate a diet and their pain is well-controlled. Typically, there’s not as much pain, we’re finding, with the laparoscopic approach.
Dr. Linda Austin: That’s amazing. You make it sound kind of quick and easy.
Dr. Chris Streck: It is. You know, as you mentioned, often, now, we’re seeing children after the appendix has ruptured, and that’s a much more difficult situation, both for the surgeon and for the patient and family. And what’s interesting about the management of ruptured appendicitis is that we’re actually finding that removing the appendix once it’s perforated is less important than was thought in the past. Often, these children can be managed with antibiotics, through their vein, and rest of the bowels, and can get over pretty significant illness due to ruptured appendicitis. Most of the children are able to go home from the hospital within a few days, and come back in six or eight weeks to have their appendix taken out at a time that’s convenient to the parents and child.
Dr. Linda Austin: You don’t have to go in though and close up the little rupture site?
Dr. Chris Streck: We don’t. Amazingly, that hole seems to heal on its own. Once the appendix has ruptured, the cat’s out of the bag, if you will. The infection has set in, the kids are feeling sick, and we feel that, often, that’s not the best time to put a child through an operation. Often, the kids can get better with the medical treatment of appendicitis and go home, then come back to have it removed.
Dr. Linda Austin: Is it conceivable then that this could happen in a community hospital, and a parent might wish to have the child come to a specialty hospital taking care of children, such as our Children’s Hospital, to have the laparoscopic procedure done?
Dr. Chris Streck: Yeah. I think the great thing that Children’s Hospital has to offer is, when the patients are admitted with ruptured appendicitis, 'with fever and pain, and feeling very ill, we have nursing staff and physicians that manage children all the time. There are children’s services. There’s a playroom. There are nurses that are used to dealing with patients that, sometimes, can’t even communicate their needs. And, as I stated, often, with ruptured appendicitis, we’re treating with antibiotics. There may be, sometimes, a prolonged hospitalization, and it’s very nice for the family to be in a center that specializes in children’s care.
Although there are differences in the management of acute and ruptured appendicitis, if a parent is concerned that their child has appendicitis, the best thing to do is call their pediatrician, be seen early on, so that we can try to catch the cases as early as possible, get the appendix out before it ruptures.
Dr. Linda Austin: Dr. Streck, thank you so much.
Dr. Chris Streck: Thank you.
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