The Appendix: 5 Common Questions

More than 700 kids are treated for appendicitis at CHOC Children’s every year. The appendectomy is one of the most commonly performed surgeries in the world. But just what is the appendix, and why does it send so many people to the emergency room with stomach pain?

Dr. Peter Yu, CHOC Children’s pediatric general and thoracic surgeon, explains everything you’ve ever wondered about the appendix, and more.

dr-peter-yu-choc-childrens
Dr. Peter Yu, pediatric general and thoracic surgeon at CHOC Children’s

 

  1. What does the appendix do?

The appendix is a small, finger-like projection that sticks out of the large intestine, located in the right side of the abdomen. It weighs about as much as an earthworm. In fact, its old-fashioned name is vermiform appendix, which means worm-like, Dr. Yu explains.

Everyone’s appendix is different. Some are long, some are short and stubby. But one thing they all have in common is that they are not necessary for a happy, healthy life.

“We are not sure if the appendix has a purpose. Some doctors don’t believe it does anything,” Dr. Yu says. “Some think it plays a role in the development of the immune system, and some believe it harbors ‘good bacteria’ that helps intestinal health. The bottom line, though, is that appendicitis is common, and patients do extremely well after removal of their appendix.”

  1. What causes appendicitis?

Bacteria naturally live in the large intestine and flow in and out of the appendix. Sometimes, the opening to the appendix gets blocked. Either constipation, a hard piece of stool called a “fecalith,” or enlarged lymph nodes cause these blockages.

The blockage traps the bacteria inside where it festers and multiplies. This leads to inflammation of the organ. If left untreated, the appendix can burst, releasing the infectious bacteria into the body.

Symptoms of a Burst or Inflamed Appendix

What are signs of appendicitis?

  • sudden severe pain
  • pain that starts near the belly button and moves to the lower abdomen on the right side
  • fever, nausea or vomiting

To diagnose appendicitis, the Julia and George Argyros Emergency Department at CHOC Children’s Hospital will check your child’s blood for signs of an infection and will do an ultrasound of the abdomen. While many hospitals use a CT scan to diagnose appendicitis, CHOC radiologists and sonographers have the training and experience to make a diagnosis using ultrasound, in order to minimize your child’s exposure to radiation. If the ultrasound is inconclusive, the radiologist may conduct a CT scan.

  1. How does the surgeon remove the appendix?

The surgeon will perform a procedure called a laparoscopic appendectomy to remove the appendix. A pediatric anesthesiologist will put your child to sleep using general anesthesia. The procedure takes about 30 minutes, though CHOC’s pediatric general surgeons can remove the organ in less than 10 minutes if needed.

During surgery, three tiny incisions are made on the abdomen. Carbon dioxide is blown into the belly to create a dome, giving the surgeon room to work. Small surgical tools are inserted in two of the incisions and a laparoscopic camera is inserted in the third. The appendix is identified, stapled or tied off, and removed.

The surgeon closes the incisions with surgical glue and dissolvable strips. In most cases, children will stay in the hospital for one day before the doctor discharges them. They should have no heavy activity or sports for two weeks after surgery and can usually return to school quickly, often even the next day.

  1. What do you do with the appendix after you take it out?

Pathologists then inspect the removed appendix in the pathology department under a microscope. This inspection is important because it will confirm the diagnosis of appendicitis and rule out other conditions such as ulcerative colitis, Crohn’s disease and carcinoid. Your surgeon will update you with the results during your follow-up appointment.

  1. What if my appendix bursts?

“Fortunately, perforated appendicitis is less common than non-perforated appendicitis, but it can happen,” Dr. Yu says. “For some, the appendix can burst quickly, and for others it does not burst at all. There are many factors that a surgeon will consider before deciding whether to operate immediately, or to wait.”

If your surgeon decides to wait, then treatment can include antibiotics, placement of a drain in the abdomen, and nutrition through an IV if needed. Most patients improve in several days, after which the doctor discharges them. Your surgeon will then schedule your child for an interval appendectomy, which is removal of the appendix 8-12 weeks later. This gives the body time to recover from the infection and inflammation, making surgery safer and less complicated.

The CHOC Emergency Department, equipped to treat appendicitis 24 hours a day, with pediatric surgeons ready for all situations is mainly for kids and teens.

Learn more about appendicitis in kids and teens

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Do’s and Don’ts for Parents of Picky Eaters

Why won’t you eat the apple? You love applesauce!

 Try the roasted chicken! It’s the same thing as the chicken nuggets you love.

 Taste the tomato! It’s what spaghetti sauce is made of and you like that. 

When it comes to children and picky eating, logic can go right down the garbage disposal. A quarter of all children experience minor feeding problems, and many parents fret about their kids’ eating habits.

The good news is that most children outgrow fussy eating habits. In the meantime though, Dr. Mitchell Katz, a pediatric gastroenterologist and medical director of CHOC Children’s Multidisciplinary Feeding Program, has some Do’s and Don’ts for parents of picky eaters.

  • Don’t try to trick children into putting food in their mouths. This tactic doesn’t help them learn about the new food. Exploring foods by touching, licking, smelling, poking and rolling are important ways that children can learn about food before they put it in their mouths and eat it.
  • Do consider how food looks. Like on cooking shows, plating and presentation matter for picky eaters. Try making food look like fun shapes, play up colors, or create scenes to help capture kids’ interest in new or unappealing foods.
  • Don’t worry about fluctuating eating habits. Just like adults eat more on some days than others, it’s normal for children to be inconsistent with how much and what foods they eat.
  • Do focus more on variety than quantity. It’s more important for children to eat a small amount of food from a broader number of food groups than to eat a large quantity at one meal.

While many children will outgrow the habit, some kids’ picky eating can be a sign of a more serious problem. Dr. Katz offers some warning signs that parents should look for when evaluating their children’s eating habits:

  • A child is delayed in meeting feeding milestones but not in other milestones. Children’s eating skills should mirror their other physical and cognitive developmental skills, like sitting, walking, talking and paying attention.
  • The child cannot transition or advance to the next level of eating. Are children progressing from bottle to sippy cup, from smooth purees to lumpy foods, or from familiar to new foods?
  • The child eats only a certain brand or type of preparation for all or most of their food.
  • The child has minimal intake or outright refuses to eat for several days, unrelated to an illness.
  • Extreme measures are taken to nourish a child. Force feeding, feeding when children are asleep or distracted, or abiding by intense routines are cause for concern.

Parents who recognize these signs in their children should seek medical attention, Dr. Katz says.

A severe feeding issue – like what Dr. Katz and his team treat at CHOC – involves physical, psychological, behavioral, nutritional, and familial obstacles to eating.

Addressing all a child’s medical problems is important to start to make positive associations with food and eating, which may require the help of multiple specialists.

Learn more about CHOC's feeding program

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3 Surprising Causes of Stomach Pain in Kids

Children complaining of stomach pain is common, and some sources – like constipation, food allergies or even appendicitis – are obvious.

But a few illnesses might not come to mind first when considering the source of a child’s stomachache. Here is information from the American Academy of Pediatrics (AAP) about some causes of stomach aches that might surprise parents.

Strep throat
Even though this diagnosis is tied to another relatively distant body part, strep throat can also cause stomach pain.

An infection caused by a bacterium called streptococci, strep throat’s more obvious symptoms are a sore throat and fever, and sometimes vomiting or headaches.

Parents who suspect their child has strep throat should visit the pediatrician, who will swab the child’s throat to test for bacteria. If positive, the physician will prescribe antibiotics.


Urinary tract infection (UTI)
Though the tell-tale sign of a UTI is pain and burning during urination, these infections can also cause discomfort in the abdomen.

UTIs are a common ailment in children, with more than 1.3 million children treated annually for the condition. Girls ages 1 to 5 are more likely than other children to experience a UTI.

Parents who suspect their child has such an infection should visit the pediatrician, who will prescribe an antibiotic following a positive diagnosis.

Learn how to prevent UTIs in children.

Emotional upset
Stomach pain can also be the result of sadness, stress or anxiety. Though this type of pain is more common in school-age children, children younger than 5 under unusual stress may also experience it.

Parents should carefully assess the child for other symptoms that might indicate an illness such as fever, vomiting, weakness, pain while urinating, sore throat or diarrhea. If none of those are present, consider other aspects, like timing: Does it wax and wane over a period of more than a week, and surface around activities that are unpleasant or stressful?

A lack of other physical symptoms and pain with curious timing could point to emotional upset. In this case, talk to the child about what’s bothering them. A pediatrician can also suggest ways to help, and, if necessary, refer the child to a therapist, psychologist or psychiatrist.

When to call the doctor

No matter the source, stomachaches should be taken seriously. Not all aches require a doctor’s appointment, but here are some signs from the AAP that medical attention is necessary:

  • Abdominal pain that comes on suddenly or persists
  • The child has other symptoms, such as a change in his bowel pattern, vomiting, fever (temperature of 100.4°F or higher), sore throat or headache
  • A baby younger than 1 year shows signs of stomach pain such as legs pulled up toward the abdomen or unusual crying
  • A child aged 4 or younger has recurrent stomachache
  • If abdominal pain awakes a child or stops him from sleeping
Looking for a pediatrician? Find one near you.

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Remedies for Constipation in Children

Constipation in children is an all-too-common ailment, accounting for nearly five percent of all pediatric visits each year and one out of every four pediatric gastroenterology visits. More than 90 percent of constipated children have “functional” constipation, meaning constipation without any underlying disease.

Although symptoms may vary for each patient, common signs to look for include:

  • Infrequent bowel movements (less than three per week)
  • Stool leakage
  • Withholding behavior
  • Difficult, painful or hard bowel movements
  • Abdominal pain
  • Urine accidents
  • Blood-coated stools

The most common cause of constipation in  children is withholding due to past experience with painful passage of stools, says Dr. Ashish Chogle, pediatric gastroenterologist at CHOC Children’s. Other leading factors relate to water and food intake.

constipation in children
Dr. Ashish Chogle, pediatric gastroenterologist at CHOC

Stool leakages in the underwear are often encountered in children with long standing constipation. Most children will not feel the stools passing accidently, as feeling in the rectum decreases as a result of the stretching that takes place from being constipated for a long time.

There are several things parents can try at home to alleviate the problem of constipation, he says. First, if your child is not usually a keen water drinker, increase their water intake to normal levels. CHOC recommends one full eight ounce glass of fluids per year in age every day. Increasing their fiber intake can also help relieve mild cases of constipation in children. Good sources of fiber include whole grains, whole wheat items, beans, green leafy vegetables and fruit. The minimum amount of fiber for children is equal to your child’s age plus five grams. For example, a child who is 5 years old should eat 10 grams of fiber each day (5 years + 5 = 10 grams). If the child isn’t better after trying these methods at home, consult your pediatrician. Your pediatrician may recommend a treatment plan or refer you to a pediatric gastroenterologist.

Treatment plans may include a stool softener regimen such as laxative therapy, or lifestyle changes, depending on the severity and underlying causes of the constipation. If your child has significant stool back up in the colon, the doctor might recommend a bowel clean out with Miralax.

Parents may worry that their child will become dependent on a stool softener if given for an extended duration, and thus may stop the laxatives sooner than advised by their physician.

“By stopping a laxative therapy plan too soon, the child can bounce back to being constipated,” says Dr. Chogle. “The treatment needs to last long enough that the colon fully recovers from the stretching that has occurred due to constipation. Parents don’t need to worry about their children becoming dependent, as long as they follow their physician’s treatment plan and have an understanding that it can take months for the colon to recover and function properly.”

The length of the regimen will vary depending how long the child has been constipated. There are some patients with an inherently slow colon (those with slow transit constipation). These patients will likely require laxatives long term, says Dr. Chogle.

Older children or teens with chronic constipation issues may actually be suffering from pelvic floor dysfunction, especially if they spend a long time straining on the toilet or pass only small amounts of stools each time. This could be due to an incoordination in pelvic floor muscles, also known as anal dyssynergia. Muscles tighten instead of opening up while attempting to pass a bowel movement- similar to trying to squeeze out toothpaste from a tube with the cap half open. Your child’s doctor may order a test called an anorectal manometry to determine anal pressures and pelvic floor coordination if they do not respond to other treatment options. Physical therapy, specifically anal biofeedback therapy, may be recommended for some patients.

Learn more about constipation from the gastroenterology experts at CHOC.

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    U.S. News Names CHOC One of the Nation’s Best Children’s Hospitals

    From treating the most complicated cases of epilepsy and repairing complex urological conditions, to curing cancer and saving premature lives, CHOC Children’s physicians and staff are committed to delivering the highest levels of safe, quality care. That commitment has earned CHOC its most recent accolade:  inclusion on the coveted U.S. News & World Report’s Best Children’s Hospitals rankings.   CHOC ranked in eight specialties: cancer, neonatology, neurology/neurosurgery, pulmonology, orthopedics, gastroenterology and GI surgery, diabetes and endocrinology, and urology, which earned a “top 25” spot.

    U.S. news

    According to U.S. News, the Best Children’s Hospitals rankings are intended to help parents determine where to get the best medical care for their children. The rankings highlight the top 50 U.S. pediatric facilities in 10 specialties, from cancer to urology. Of the 183 participating medical centers, only 78 hospitals ranked in at least one specialty. For its list, U.S. News relies on extensive clinical and operational data, including survival rates, clinic and procedure volume, infection control measures and outcomes, which can be viewed at http://health.usnews.com/best-hospitals/pediatric-rankings. An annual survey of pediatric specialists accounts for 15 percent of participants’ final scores.

    “The Best Children’s Hospitals highlight the pediatric centers that offer exceptional care for the kids who need the most help,” says U.S. News Health Rankings Editor Avery Comarow. “Day in and day out, they offer state-of-the-art medical care.”

    Dr. James Cappon, chief quality and patient safety officer at CHOC, points to the survey as an invaluable tool for him and his colleagues to evaluate programs and services, determining best practices, and making plans for the immediate and long-term future.

    “CHOC is certainly honored to be recognized once again by U.S. News. But our dedication to serving the best interests of the children and families in our community is what truly drives us to pursue excellence in everything we do. Our scores, especially in the areas of patient-and-family-centered care, commitment to best practices, infection prevention, breadth and scope of specialists and services, and health information technology, for example, reflect our culture of providing the very best care to our patients,” explains Dr. Cappon. To hear more about CHOC’s commitment to patient safety and quality care—and what parents need to know— listen to this podcast.

    CHOC’s culture of excellence has it earned it numerous accolades, including being named, multiple times, a Leapfrog Top Hospital. Additional recent honors include the gold-level CAPE Award from the California Council of Excellence; Magnet designation for nursing; gold-level Beacon Award for Excellence, a distinction earned twice by CHOC’s pediatric intensive care unit team; “Most Wired Hospital”; and The Advisory Board Company’s 2016 Workplace Transformation Award and Workplace of the Year Award. Inspiring the best in her team, CHOC’s President and CEO Kimberly Chavalas Cripe was recently named a winner of the EY Entrepreneur of the Year Award in the “Community Contributions” category.