Appendicitis

Author: Michael S Katz, MD, Research Fellow, Department of Pediatric Surgery, St Christopher's Hospital for
Children
Coauthor(s): Michael Stephen Freitas, MS, State University of New York at Buffalo School of Medicine and
Biomedical Sciences; Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency
Medicine, University of Connecticut and Connecticut Children's Medical Center; Philip Glick, MD, MBA, Professor,
Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Finance and
Development, Department of Surgery, State University of New York at Buffalo
Contributor Information and Disclosures
Updated: Jan 7, 2009

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• Overview
• Differential Diagnoses & Workup
• Treatment & Medication
• Follow-up
• References
• Keywords
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Introduction

Background
Appendicitis is acute inflammation and infection of the vermiform appendix, which is most commonly
referred to simply as the appendix. The appendix is a blind ending structure arising from the cecum.
Acute appendicitis is one of the most common causes of abdominal pain and the most frequent condition
leading to emergent abdominal surgery in children.

Pathophysiology
Appendicitis is due to a closed-loop obstruction of the appendix. Most commonly, the obstruction is due
to either lymphoid hyperplasia within the appendix or impacted fecal matter, referred to as a
fecalith. Obstruction of the appendix leads to bacterial overgrowth and an increase in intraluminal
pressure. The increased intraluminal pressure obstructs the venous blood flow in the appendix and leads
to congestion in the appendix. Over time, this congestion leads to ischemia in the appendix, allowing for
bacterial translocation and infection. The ischemia and the bacterial infection cause the inflammation of
the appendix. As the disease progresses, the inflammation progresses from a mild inflammation to a
gangrenous appendix. When the appendix becomes gangrenous, it may perforate. This process usually
takes place over 72 hours. This is an important point when considering the patient’s history.

When the appendix perforates, inflammatory fluid and bacterial contents are released into the abdominal
cavity. This fluid may infect the peritoneum, and the patient may develop generalized
peritonitis. Concomitantly, the patient develops more intense and generalized abdominal pain. However,
the omentum and loops of small bowel may wall off the fluid and form an abscess. In this case, the
patient may continue to have localized abdominal pain in the area of the abscess.

Frequency
United States

Appendicitis occurs in all age groups but is rare in infants. If an infant has appendicitis, the diagnosis of
Hirschsprung disease should also be considered. The incidence in the United States is 4 cases per 1000
children. Overall, 7% of people in the United States have their appendix removed during their life.

Mortality/Morbidity
At the time of diagnosis, the rate of perforation is 20-35%. Younger children have a higher rate of
perforation, with reported rates of 50-85%. The mortality rate for children with appendicitis is 0.1-
1%. This is most commonly seen in neonates and infants. This is due to 2 factors. First, appendicitis is
rare in this age group; thus, unless the physician’s index of suspicion is high, appendicitis is often low on
the list of suspected differential diagnoses. Second, very young patients are unable to communicate the
location and nature of their pain. Some neonates may not even become febrile. Often, the patient’s only
symptom is irritability or inconsolability.

Sex
The male-to-female ratio is approximately 2:1.

Age
Appendicitis occurs in all age groups. The mean age in the pediatric population is 6-10 years.
Appendicitis is rare in the neonate, and the diagnosis is typically made after perforation for the reasons
discussed above (see Mortality/Morbidity). Younger children have a higher rate of perforation (50-85%
reported).

Clinical

History
As with almost any clinical entity, the best place to start is with the patient’s history. The classic
description of appendicitis is a patient who develops vague periumbilical pain, followed by nausea,
vomiting, and anorexia. Over time, the pain migrates to the right lower quadrant. If the appendix
perforates, an interval of pain relief is followed by development of generalized abdominal pain and
peritonitis. Although some patients progress in the classical fashion, some patients deviate from the
classic model. Fifteen percent of patients have a retrocecal appendix, and their signs and symptoms may
not localize to the right lower quadrant, localizing instead to the psoas muscle. Other patients may have
the tip of their appendix deep in the pelvis, and their signs and symptoms localize to the rectum or
bladder.

• Pain: The initial symptom is poorly defined periumbilical pain. Acute onset of severe pain is not
typically present in acute appendicitis but is seen with acute ischemic conditions such as
volvulus, testicular torsion, ovarian torsion, or intussusception. If the pain is initially located
in the right lower quadrant, severe constipation should be considered.
• Nausea and vomiting: Generally, vomiting that occurs prior to pain is unusual. However, in
retrocecal appendices, particularly those that extend cephalad along the posterior surface of the
 right colon, inflammation of the appendix irritates the nearby duodenum, resulting in nausea and
vomiting prior to the onset of right lower quadrant pain.
• Diarrhea: Likewise, significant diarrhea is atypical in appendicitis, and the physician should
consider other diagnoses, while not ruling out appendicitis. In patients with an appendix in a
pelvic location, inflammation of the appendix occasionally results in an irritative stimulation of the
rectum. These patients often report diarrhea. However, upon closer questioning, such patients
relate symptoms of frequent, small-volume, soft stools and usually not true diarrhea.
• Shift to right lower quadrant pain: After a few hours, pain shifts to the right lower quadrant
because of inflammation of the parietal peritoneum. This pain is more intense, continuous, and
localized.
• Fever: Most children with appendicitis are afebrile or have a low-grade fever and characteristic
flushness of their cheeks. Severe fever is not a common presenting feature unless perforation
has occurred and may still be a rare finding. According to one study, vomiting and fever are
more frequent findings in children with appendicitis than in children with other causes of
abdominal pain.
Physical
The physical examination findings in children may vary depending on age. Irritability may be the only sign
of appendicitis in a neonate. Older children often seem uncomfortable or withdrawn. They may prefer to
lie still because of peritoneal irritation. Teenaged patients often present in a classic or near-classic
fashion.

• General examination: Patient’s general state should be observed before interacting with
them. The patient’s state of activity or withdrawal may lend information into their state. A patient
in obvious distress with abdominal pain gives the impression of an infectious process; however,
other causes must be ruled out.
• Cardiac and pulmonary examination: The evaluation of the heart and lungs of the patient reflects
the overall state more than suggests the appendix as a cause. Patients are often dehydrated or
in pain and may be tachycardic or tachypneic. Pediatric patients have great physiological
reserve and may not show any general symptoms until they are very ill.
• Abdominal examination
○ The child's abdomen should be examined in the same way an adult's abdomen is
examined. Full exposure of the abdomen is key. Localization of the pain is also key but
may depend on the position of the appendix.
○ Observing the patient cough and asking them to localize their pain with one finger often
localizes their discomfort to the right lower quadrant. Typically, maximal tenderness can
be found at the McBurney point in the right lower quadrant. However, the appendix may
lie in many positions.
 A medially positioned appendix may present as suprapubic tenderness.
 Patients with a laterally positioned appendix often have flank tenderness.
 Patients with a retrocecal appendix may not have any tenderness until it is
advanced or perforated.
 ○ Palpation of the abdomen should be performed with a gentle and light touch, searching
for involuntary guarding of the rectus or oblique muscles. Eliciting rebound tenderness
is an unnecessary part of the abdominal examination.
○ The Rovsing sign is pain in the right lower quadrant in response to left-sided palpation
or percussion and strongly suggests peritoneal irritation.
○ To perform the psoas sign, place the child on the left side and hyperextend the right leg
at the hip. A positive response suggests an inflammatory mass overlying the psoas
muscle (retrocecal appendicitis).
○ Perform the obturator sign by internally rotating the flexed right thigh. A positive
response suggests an inflammatory mass overlying the obturator space (pelvic
appendicitis).
• Rectal examination
○ A rectal examination is important and should be performed in all patients who are
evaluated for appendicitis.
○ The caliber of the patient's anus should be taken into consideration, and smaller digits
should be used for examining younger patients.
○ The rectal examination in a young child may be completely objective because they may
not be able to communicate variations in tenderness or may have general discomfort
from the examination.
○ Objective information to ascertain includes impacted stool or an inflammatory mass.
○ A patient able to communicate should be asked if they have tenderness in different
areas of the rectum.
○ Right-sided tenderness of the rectum is the classic finding in pelvic appendicitis or in
pus that pools in the pelvis from an inflamed appendix elsewhere in the abdomen.
Causes
Appendicitis is caused by a closed-loop obstruction of the appendix. Most cases are caused either by
impacted fecal material, called a fecalith or appendicolith, or by hyperplasia of submucosal lymphoid
follicles. Rarely, foreign objects or nematodes may cause luminal obstruction.

• Obstruction leads to increasing intraluminal pressure from bacterial overgrowth. This increase in
pressure leads to vascular compression initially on the venous side. This causes congestion and
decreased wall perfusion. This decreased perfusion leads to necrosis and inflammation of the
appendix.
• During this initial stage the patient feels only periumbilical pain due to the T10 innervation of the
appendix. As the inflammation continues, an exudate forms on the appendiceal serosal surface.
When the exudate touches the parietal peritoneum, a more intense and localized pain develops.
The location of this pain has been described above (see History).
• As the obstruction continues, bacteria within the appendix proliferate and increase intraluminal
pressure. The bacteria then infiltrate the wall of the appendix. If the diagnosis is not made early,
the obstruction progresses, and the wall of the appendix stretches.
• Over time, the intraluminal pressure in the appendix increases and the strength of the
appendiceal wall decreases due to the necrosis, and perforation occurs. At this point,
 inflammatory fluid and bacterial contents release into the abdominal cavity. This further inflames
the peritoneal surface, and peritonitis develops. At this point, the location and extent of
peritonitis (diffuse or localized) depends on the degree to which the omentum and adjacent
bowel loops can contain the spillage of luminal contents.
• If the contents become walled off and form an abscess, the pain and tenderness may be very
localized to the abscess. If the contents are not walled off and the fluid is able to travel
throughout the peritoneum, a general peritonitic state is observed.

Differential Diagnoses
Constipation Pneumonia
Ectopic Pregnancy Pregnancy Diagnosis
Hemolytic-Uremic Pyelonephritis
Syndrome
Henoch-Schoenlein Purpura Urinary Tract Infection
Meckel Diverticulum
Ovarian Cysts
Pelvic Inflammatory Disease
Other Problems to Be Considered
Ovarian cyst
Ovarian torsion
Pelvic inflammatory disease (PID)
Pregnancy
Ectopic pregnancy
Renal calculi
Mesenteric lymphadenitis
Mittelschmerz
Pneumonia (right lower lobe)
Neutropenic typhilitis

Workup

Laboratory Studies
Laboratory findings may increase suspicion of appendicitis but are not diagnostic. The minimum
laboratory workup for a patient with possible appendicitis includes a WBC count with differential and
urinalysis.

• CBC count
○ The WBC count is elevated in approximately 70-90% of patients with acute appendicitis.
However, remember that this is elevated in many other abdominal conditions.
Furthermore, the elevation is usually only mild and the increase of the WBC count
occurs only as the disease process progresses.
○ The WBC count is often within the reference range within the first 24 hours of
symptoms. Therefore, its predictive value is limited.
 ○ If the WBC count exceeds 15,000 cells/μL, the patient is more likely to have a
perforation. However, one study found no difference in the WBC counts of children with
simple appendicitis and those with perforated appendicitis.
○ A WBC count within the reference range does not exclude appendicitis because this is
typical in at least 10% of patients with appendicitis.
○ In the immunocompromised patient, a neutrophil count of less than 800 may suggest
typhilitis.
• Urinalysis
○ Urinalysis is useful for detecting urinary tract disease, including infection and renal
stones. However, irritation of the bladder or ureter by an inflamed appendix may result
in a few urinary WBCs. The presence of 20 WBCs suggests a urinary tract infection.
○ Hematuria may be caused by renal stones, urinary tract infection, Henoch-Schönlein
purpura, or hemolytic uremic syndrome. However, small numbers of RBCs can also
occur in appendicitis in as many as 20% of patients when an overlying phlegmon or
abscess lies adjacent to the ureter. Typically, RBCs are less than 20 per high power
field.
○ Normal urinalysis results do not provide any diagnostic value for appendicitis, although
a grossly abnormal result may be suggestive of an alternative cause of abdominal pain
• Electrolytes: Electrolyte assessments and renal function tests are more helpful for management
than diagnosis. Indications include a significant history of vomiting or clinical suspicion of
significant dehydration.
• Additional studies
○ Liver function tests and amylase and lipase assessments are helpful when the etiology
is unclear.
○ A beta-human chorionic gonadotropin (beta-HCG) test should be performed to rule out
pregnancy or ectopic pregnancy in female patients.
Imaging Studies
Abdominal radiography

• Abdominal radiography findings are normal in many individuals with appendicitis. However, plain
films may be helpful in the setting of severe constipation.
• A calcified appendiceal fecalith is present in less than 10% of persons with inflammation, but its
presence confirms the diagnosis.
• Radiographic signs suggestive of appendicitis include convex lumbar scoliosis, obliteration of
right psoas margin, right lower quadrant air-fluid levels, air in the appendix, or localized ileus. In
rare incidents, a perforated appendix may produce pneumoperitoneum.
• If no other imaging studies are to be performed, an abdominal series is strongly suggested.
Ultrasonography

• Prior to the advent of CT scans, graded compression ultrasonography was the preferred imaging
modality in the evaluation of pediatric acute appendicitis. This technique involves locating the
appendix using ultrasonography and then attempting to compress the lumen of the appendix.
 • The advantages of ultrasonography include its noninvasiveness, lack of radiation, no contrast
medium, and minimal pain.
• The downside of ultrasonography is that the examination is operator dependent. In experienced
hands, ultrasonography has an overall sensitivity of 85% and a specificity of 94% in pediatric
patients.
• For ultrasonography to be diagnostic of appendicitis, it must locate and visualize the appendix.
Ultrasonography that does not visualize the appendix does little to rule in or out appendicitis.
• Specific ultrasonography findings can support the diagnosis of appendicitis.
• The finding of a noncompressible dilated appendix is a strong indicator of nonperforated
appendicitis.
• After perforation, ultrasonography can reveal a periappendiceal phlegmon or abscess formation.
• Additional supportive findings include an appendicolith, fluid in the appendiceal lumen, focal
tenderness over the inflamed appendix (sonographic McBurney point), and a transverse
diameter of 6 mm or larger.
• Ultrasonography is also useful in diagnosing alternate pathology (eg, tubo-ovarian abscess,
ovarian torsion, ovarian cyst, mesenteric adenitis).
CT scanning

• CT scans have become the modality of choice for diagnosing appendicitis in children.
• Although radiation exposure is a concern, CT scans have been shown to have an accuracy of
97% in diagnosing appendicitis.
• Other advantages include the ability to evaluate the entire abdomen and locate abscesses and
phlegmon, lack of dependence on operator skill, and physician familiarity with reading CT scans.
• Disadvantages include the aforementioned radiation exposure, the need for oral and intravenous
contrast and its related disadvantages, and the need for the patient to be still, which is often
difficult for small children.
• Because of the advantages of CT scans, 62% of surveyed North American pediatric surgeons
preferred it for evaluation of appendicitis. Of note, less than 1% of pediatric surgeons favored CT
scanning for every case of suspected appendicitis. Most preferred CT scanning on a selected
basis, with 51-58% of patients with suspected appendicitis undergoing CT scanning.
• However, despite now widespread use of CT scanning for evaluation of appendicitis with its
superior sensitivity and specificity, the negative appendectomy rate in children has not shown a
statistically significant reduction.
Chest radiography: If the history, physical examination, laboratory tests, and imaging studies have failed
to produce a satisfactory differential diagnosis, anteroposterior (AP) and lateral chest radiography should
be performed to look for right lower lobe pneumonias.

Histologic Findings
Typically, histologic findings range from acute inflammatory infiltrate most apparent in the submucosal
level in early appendicitis to transmural infarction in perforated appendicitis.

• The finding of an apparently normal appendix at surgery requires careful follow-up of the
histologic findings. Occasionally, early appendicitis is histologically identified and clinically
 correlates with the resolution of preoperative symptoms. Additionally, unsuspected findings of
luminal nematodes should indicate further anthelmintic therapy (eg, mebendazole [Vermox]).
• The authors have recently seen a small group of patients with “early appendicitis” based on
history, physical examination findings, and/or CT scans with minimal changes found in the
appendix in the operating room or based on only intraluminal inflammatory cells on
histology; these patients have complete resolution of their signs and symptoms after
appendectomy. Whether this is because the appendectomy is performed at an earlier stage in
the pathophysiologic sequence of appendicitis or whether the patients' signs and symptoms
resolve due to the placebo effect of the appendectomy is unknown.
Staging
The clinical staging of appendicitis has important implications in the postoperative treatment of the child.
Although somewhat subjective at the time of surgery, appendicitis may be divided into 3 broad
categories: acute (nongangrenous) appendicitis, suppurative or gangrenous (nonperforated)
appendicitis, and perforated appendicitis. Perforated appendicitis can be divided further into cases with
diffuse peritonitis and those with localized peritonitis.

• Acute (nongangrenous): This stage of appendicitis is referred to as early appendicitis. No mural

gangrene or infarction is present. This type requires no further antibiotic therapy in most
settings. The child may be discharged home as soon as diet and oral pain medications can be
tolerated.
• Suppurative or gangrenous (nonperforated): Persons with exudative appendicitis, particularly in
individuals with mural gangrene, have an increased rate of postoperative intraabdominal and
wound infections, even in the absence of demonstrable perforations. Often, microperforations
are present, as evident on routine cultures findings. However, if the gram stain and culture
findings are negative, the antibiotics can be stopped in approximately 24 hours, and the child
may be discharged home as soon as diet and oral pain medications can be tolerated.
• Perforated: Perforated appendicitis (either diagnosed by intraoperative findings or positive
intraoperative cultures) is associated with a postoperative infection rate in as many as 30% of
patients. Children with perforated appendicitis require antibiotic therapy for a minimum of 10
days. Often, the patient may develop intra-abdominal abscesses that require drainage. A high
index of suspicion for a postoperative abscess is required in the patient with
perforated appendicitis who has fevers of ileus that last more than 5 days

Treatment

Medical Care
Making a timely diagnosis of appendicitis is a difficult challenge when evaluating children with abdominal
pain. Classifying patients with abdominal pain into the following 3 major categories may be helpful:

• Diagnosis not consistent with appendicitis

○ This group includes patients whose history and physical examination findings are not
consistent with appendicitis or any significant abdominal process.
○ Performing a complete physical examination, including rectal palpation and urinalysis,
before discharge is important.
 ○ Few patients require sophisticated radiological evaluation. However, as discussed
above, radiographic evaluation of the kidney, ureters, bladder, and chest may assist in
diagnosis (constipation or pneumonia) and treatment.
• Classic history for appendicitis
○ Patients with a classic history require prompt surgical consultation.
○ Maintain nothing-by-mouth status in patients with suspected appendicitis and start
intravenous fluids to restore intravascular volume.
○ Ensure adequate hydration for patients who present with suspected appendicitis.
○ Even in early acute appendicitis, children frequently have not had sufficient oral intake
and present with some degree of intravascular dehydration.
○ Antibiotic therapy is an important aspect of the preoperative treatment of appendicitis
but should not be administered until consulting with a surgeon.
○ Direct antibiotic therapy against gram-negative and anaerobic organisms (eg,
Escherichia coli, Bacteroides species).
○ Most of these patients do not require radiological evaluation if their history, physical,
and laboratory evaluations are convincing. However, some surgeons still prefer
ultrasonography in female patients because of the possibility of a gynecological
etiology.
• Unclear diagnosis
○ In these children, the history may be consistent with appendicitis; however, the
examination is not supportive. In other children, the inverse may be true.
○ This is the main group who benefit from double-contrast abdominal CT scanning. Serial
examinations and test results may also help to clarify the diagnosis.
○ Reevaluate the patient over a few hours to determine the need for surgical consultation.
If uncertainty persists after a period of observation, obtain surgical consultation.
Surgical Care
Appendectomy

• The definitive treatment for appendicitis is appendectomy.

• Historically, appendectomy had a 10-20% false-positive rate, but the frequent use of radiologic
imaging has reduced this rate.
Open versus laparoscopic appendectomy

• The classic operation for removing the appendix is an open appendectomy. This involves
making a McBurney, Rocke-Davis, or Fowler-Weir incision. Dissection then proceeds through
the external oblique, internal oblique, and transversalis in a muscle-spreading or muscle-splitting
fashion. The peritoneum is entered. The appendix is then brought out into the field, clamped,
ligated, and divided. The exposed mucosa is then cauterized. Inversion of the stump may be
performed. The cecum is then returned to the abdomen, and the incision is closed.
• The use of laparoscopic appendectomy has now come into favor. In this procedure, port
placement consists of first putting the camera port in the umbilicus. Then, under direct
visualization, two 5 mm ports are placed. According to surgeon preference, one is placed in the
 right lower quadrant and one is placed in the left lower quadrant or both are placed in the left
lower quadrant. The cecum and appendix are laterally to medially mobilized. Various methods
(ie, electrocautery, endo-loops, stapling devices) are used to remove the appendix and should
be left to the discretion of the surgeon. The appendix is then removed from the abdomen using
an endobag.
• After an appropriate learning curve, the difference in operative time of open versus laparoscopic
appendectomy has shown no statistical significance.
• Potential advantages of laparoscopic appendectomy include reduced postoperative pain, lower
wound infection rate, and quicker return to normal activities.
• Length of stay has shown to be 0.6 days shorter with laparoscopic versus open appendectomy.
Patients also have a faster return to daily activities, including school and gym.
• The other advantage of laparoscopic appendectomy is the ability to evaluate the entire
abdomen, which can be useful or diagnostic in the adolescent female, in whom gynecological
etiologies can often imitate appendicitis.
Surgical treatment of perforated appendicitis

• Because of the short time from obstruction of the appendix to perforation, 20-35% of patients
who present with acute appendicitis have already perforated. In fact, estimates suggest that
most patients perforate within 72 hours of symptom onset. If a patient presents beyond 72 hours
from symptom onset, perforation is highly suggested. However, if a patient presents with
symptoms of appendicitis beyond 72 hours and has not perforated, diagnoses other than
appendicitis must be entertained.
• Controversy surrounds the ideal management of patients with perforated appendicitis, including
laparoscopic versus open appendectomy performed emergently or initial conservative
management with appendectomy at a later date when the acute inflammation has subsided.
This delayed surgical treatment is referred to as interval appendectomy and is generally
performed 8-12 weeks after the initial episode.
○ Interval appendectomy has gained popularity because of the perceived challenges in
operating on potentially distorted anatomy and difficulties in closing the inflamed
appendiceal stump. These challenges can result in ileocecal resection, right
hemicolectomy, and/or temporary ileostomy.
○ Recently, the need for interval appendectomy has been questioned because of the
relatively small recurrence rate of appendicitis after the initial episode.
○ This area is a popular topic of current research; however, no large scale prospective
randomized trials have compared continued conservative management with interval
laparoscopic appendectomy for perforated appendicitis.
• Patients with perforated appendicitis can be divided into 2 cohorts; those who are discovered to
be perforated in the operating room during appendectomy and those with radiographic evidence
of perforation, most commonly seen on CT scan findings. The management of these two cohorts
is different and the latter group has been the focus of much research.
• Patients discovered to have perforated appendicitis in the operating room during appendectomy
should be treated in the same fashion as those with nonperforated appendicitis. The surgeon
should complete the appendectomy in a normal fashion. If a laparoscopic appendectomy is
being performed, perforation alone is not a reason for conversion to open appendectomy.
 However, if an abscess is encountered and drained, placement of a drain in the abscess cavity
should be considered. Also, when an open appendectomy is being performed on a patient with a
perforated appendix, the high incidence of wound infection should be considered in terms of skin
closure.
• Because CT scans are commonly used in the diagnosis of appendicitis, many patients are
diagnosed with perforated appendicitis prior to undergoing operative management. CT scan
findings that suggest perforated appendicitis include periappendiceal or pericecal air, abscess,
phlegmon, and extensive free fluid. Because the etiology of the disease is due to obstruction of
the appendix and the inflammation occurs distal to the obstruction, extravasation of contrast or
extensive free air is rarely seen. If a patient is found to have free air throughout the abdomen or
under the diaphragm, other diagnoses should be entertained.
• Historically, a patient with perforated appendicitis was rushed to the operating room for
appendectomy; however this is no longer the case.
○ Conservative management with interval appendectomy is now recommended. A patient
found to have perforated appendicitis on imaging study findings should be admitted to
the hospital, be placed on a nothing-by-mouth (NPO) diet, and given intravenous (IV)
fluid resuscitation.
○ If the patient is hemodynamically unstable or is unable to have their urine output
measured, a Foley catheter should be placed.
○ The patient should be started on IV antibiotics. Generally, antibiotics for this condition
are targeted at enteric flora (eg, second-generation cephalosporin, gentamicin,
metronidazole), and discharge from the hospital is based on demonstration of lack of
fever, tolerance of pain on oral medications, and adequate oral intake.
○ If the patient has an abscess that is accessible, percutaneous drainage is performed.
○ Despite the use of conservative management, as many as 38% of children with
perforated appendicitis fail medical therapy. If the patient does not improve after
admission and use of IV antibiotics, they should undergo immediate appendectomy.
Factors that suggest failure of conservative management include bandemia on
admission CBC count, fever of more than 38.3 º C after 24 hours of medical therapy,
and multisector involvement on CT scan findings. Medical therapy is deemed to have
failed at a median of 3 days.
○ Most patients do well with this conservative approach alone, and recurrence rates range
from 0-20%, with a pooled rate of 8.9% found by one large meta-analysis.1 A much
higher recurrence rate (72%) is seen in pediatric patients with an appendicolith present
during the initial acute episode. This overall low recurrence rate in patients without
appendicolith has caused many to advocate that interval appendectomy is not needed.
Recurrence is noted in most patients within the first 6 months; the longest follow-up to
date is 13 years. However, the status of future recurrence as adults in pediatric patients
with appendicitis is unknown. Because of this uncertainty, many pediatric surgeons
prefer to perform interval appendectomy.
• When a patient undergoes interval appendectomy, the laparoscopic approach is preferred
because of the ability to visualize a wider area of the abdomen, to lyse any postinflammatory
adhesions that may be present, and to avoid the need for extending an open incision in case of
abnormal anatomy. However, the complication rate is reported to be 12-23%, which is less than
 the 26% complication rate for emergent appendectomy in perforated appendicitis. These
numbers are based on relatively small studies with different protocols, which limits their
usefulness for direct comparison. However, a large meta-analysis did show a significantly
greater morbidity with immediate surgery versus conservative treatment with interval
appendectomy (35.6% vs 13.5%).
• A recent study by Whyte et al suggested that interval laparoscopic appendectomy may be
performed as an outpatient procedure; 12 of 24 patients were discharged the evening of the
procedure.2 Of the patients who stayed, 9 stayed only one night. Although this report is
encouraging, well-known complications of laparoscopic appendectomy should not be forgotten,
including wound infection, abscess, sepsis, and ileus.
• Delaying definitive surgery is associated with significant resource use, with increased imaging,
drainage procedures, and additional admissions. A potential drawback of conservative
management with laparoscopic appendectomy performed at a later date is the risk of
misdiagnosis. The major differential diagnoses for acute appendiceal abscess or mass include
Crohn disease and malignancy. The increased use of CT scanning or ultrasonography in the
emergent setting has decreased this risk of misdiagnosis. This has helped to confirm the
diagnosis of appendiceal mass and also guides drainage interventions. The increased use of
technology, combined with improvements in antibiotics, makes conservative management a
more attractive and less risky choice from a misdiagnosis or treatment failure perspective.
Consultations
The following consultations may be appropriate:

• Pediatrician
• General surgeon

Medication

Administer one dose preoperative antibiotics to children with suspected appendicitis and stop
administration after surgery if no perforation is noted. Patients who present with perforated appendicitis
may be volume depleted and in need of aggressive fluid resuscitation. Administer a combination of
ampicillin, clindamycin (or metronidazole), and gentamicin to prevent infection from aerobic and
anaerobic organisms. Alternative regimens include ampicillin/sulbactam, cefoxitin, cefotetan,
piperacillin/tazobactam, ticarcillin/clavulanate, and imipenem/cilastatin. Fifteen percent of patients with a
ruptured appendix may develop resistant organisms and require a change in the antibiotics initially
chosen.

Antibiotics
Antibiotic regimens should cover most commonly encountered organisms, including Escherichia coli and
Bacteroides, Klebsiella, Enterococcus, and Pseudomonas species