When a belly ache or stomach pain might mean appendicitis

February 28, 2013 Robert L. Weinsheimer, MD

As a pediatric surgeon, I am often asked when to “worry” about abdominal pain. Children often report aches or pains near the belly button (umbilicus), and the question arises around when this might mean something significant such as appendicitis.

Appendicitis is a common occurrence affecting about 7% of people over their lifetime, and it begins with vague abdominal pain of the central abdomen. Once the appendix becomes obstructed and begins to suffer from lack of circulation (ischemia), the body can detect more accurately the exact source of the pain. After this localization occurs, children older than 6 or so can identify that the pain is most severe in the right lower part of the abdomen. The localization usually occurs within 24 hours of feeling unwell. The pain is typically worse with movement of the appendix during activities such as walking, coughing, and change in position. I often ask children to jump up and down (on their bed is something kids are excited to do!) and watch their face to see if they wince. Typically with appendicitis, a child will either refuse to jump or may try it once but will not continue due to the pain.

Distraction is also frequently used in children that seem to be particularly “focused” on their pain. In gently feeling the abdomen of a child with early appendicitis that is distracted, the abdomen is soft until palpating the area of the appendix. This right lower part of the abdomen is firm as the muscles in this area are contracting to protect the appendix (guarding). As the appendix is part of the intestinal tract, once it becomes swollen children typically lose their appetite, which can be the biggest clue to suggest appendicitis in a child that otherwise has a voracious appetite.

A major goal of appendicitis management is to intervene before the appendix ruptures or perforates which is typically 24-48 hours from the onset of pain. In that regard, if a child has 12 hours or more of pain that is constant, localizes to the right lower abdomen, worsens with movement, and possibly associated with fever, loss of appetite, nausea/vomiting; then this would be concerning for appendicitis. But if pain is coming and going, less than 12 hours in duration, not localized, and your child is able to move easily without wincing or complaining of pain; this is most likely not appendicitis.

Evaluation for appendicitis typically involves a thorough history, an examination of the abdomen, some lab tests, and possibly imaging if indicated. Once the diagnosis of appendicitis is made, treatment consists of surgical removal of the appendix in most cases. In the setting of a ruptured appendix with widespread infection and abscess formation, sometimes initial treatment is with antibiotics, and surgery in a delayed fashion is considered to prevent recurrence.

The diagnosis of appendicitis can be tricky, so if in doubt do not hesitate to seek medical attention.

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