Journal of Pediatric Surgery (2007) 42, 1439 1442

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Nonoperative treatment of acute appendicitis in children

Musa AbeS *, Bulent Petik, Selcuk Kazil s
Department of Pediatric Surgery, AdV yaman State Hospital, AdV yaman 02100, Turkey Department of Radiology, AdV yaman State Hospital, AdV yaman 02100, Turkey Index words:
Children; Acute appendicitis; Ultrasound; Nonoperative treatment

Abstract Background/Purpose: Appendicitis is considered by many surgeons to be a surgical emergency for which necessary to avoid perforation of the appendix. Although it has also been treated nonoperatively using antibiotic therapy, experience in such treatment in children with acute appendicitis (AA) is extremely limited. In addition, previous studies on nonoperative treatment (NT) showed it to be a cause of morbidity and mortality. The authors hold that not all appendicitis cases respond to NT because only some of the cases recover. In the present study, 16 of 95 cases with AA were selected for NT according to physical and ultrasound examinations. The clinical and ultrasonographic findings of the cases are presented. Methods: The medical records of all children with appendicitis treated between August 2003 and March 2006 were retrospectively reviewed . Patients who had history of abdominal pain for less than 24 hours with localized abdominal tenderness and hemodynamic stability underwent NT. Children were treated with parenteral antibiotics (ampicillin with sulbactam, 100 mg d kg1 d 24 h1, divided into 3 doses daily, and ornidasole, 20 mg d kg1 d 24 h1, divided intro 2 doses daily), intravenous fluid, and nothing by mouth for at least 48 hours. Results: A total of 136 patients with appendicitis were treated. Of the cases, 95 (70%) were AA, and 41 (30%) had perforated appendicitis. Sixteen (16.8%) cases of AA were selected for NT (12 boys and 4 girls; age range, 5-13 years; mean age, 9 years). The mean anteroposterior diameter of the appendix at the presentation was 7.11 F 1.01 mm (range, 6-9.5 mm). Ultrasound examination was repeated after 48 hours of treatment. The mean diameter of the appendix was 4.64 F 0.82 mm (range, 3.6-6.8 mm). The difference was statistically significant (t = 9.63, P b .0001). Nonoperative treatment was successful in 15 (93.7%) of the 16 patients. Conclusion: Hyperplasia of the appendiceal lymphoid follicle frequently causes luminal obstruction. Antibiotic therapy probably causes regression of lymphoid hyperplasia because of suppression of bacterial infection and prevents ischemia and bacterial invasion in the early stage of appendicitis. We found that some of the patients who had a history of abdominal pain for less than 24 hours with localized abdominal tenderness and hemodynamic stability could be treated nonoperatively. D 2007 Elsevier Inc. All rights reserved.

* Corresponding author. AdVyaman Devlet Hastanesi, Cocuk cerrahisi servisi, AdVyaman 02100, Turkey. E-mail address: musaabes@hotmail.com (M. Abes). S 0022-3468/$ see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.03.049

Acute appendicitis (AA) is the most common surgical emergency in children [1]. It results from luminal obstruction with fecaliths, hyperplasia of the appendiceal lymphoid follicle, carcinoid tumors, and foreign bodies. Hyperplasia of the appendiceal lymphoid follicle frequently causes

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M. AbeY et al. Y

Fig. 1

Ultrasound images, which show transverse diameters of the appendix before (A) and after (B, C) treatment.

luminal obstruction. Obstruction of the lumen is followed by distension and vascular changes. When the mucosal barrier is broken, bacteria invade the muscular wall and, finally, perforation develops [2-6]. Appendicitis is therefore considered to be a surgical emergency. However, it has been also treated nonoperatively with antibiotic therapy [5,7-12]. In most cases, antibiotics are used in the early stage of appendicitis, in an effort to cause regression of lymphoid

hyperplasia caused by bacterial infection and ultimately to prevent ischemia and bacterial invasion. The experience with nonoperative treatment (NT) of AA in children is extremely limited. Nonoperative treatment was observed to cause morbidity and mortality in previous studies [8,10-12]. We believe that not all appendicitis cases respond to NT and that only some of these cases are able to recover. In this study, 16 cases with AA were selected of a

Fig. 2

Algorithm for NT of AA.

Nonoperative treatment of acute appendicitis in children total of 95, according to physical and ultrasound (US) examinations signs. They were then treated nonoperatively. Clinical and ultrasonographic findings of the cases are presented in the forthcoming sections.

1441 398C). The mean WBC count before treatment was 15,156 (range, 9750-24,100) and after treatment 7989 (range, 580013,200). Ultrasound examination at the time of admission revealed an enlarged noncompressible appendix without appendicolith or free fluid. The mean anteroposterior diameter was 7.11 F 1.01 mm (range, 6-9.5 mm). Ultrasound examination was repeated, and the median diameter of the appendix was measured after 48 hours of treatment in all of the patients. The mean diameter of the appendix was 4.64 F 0.82 mm (range, 3.6-6.8 mm). The statistical analysis was performed using the Student t test. The difference between appendiceal diameter before and after treatment was found to be statistically significant (t = 9.63, P b .0001). The patients received antibiotics until abdominal tenderness resolved (range, 4-7 days; mean, 5 days). The NT regimen was successful in 15 (93.7%) of 16 patients. There were no complications except recurrence. Of the 15 patients, 2 (13.3%) had recurring appendicitis within 1 year of discharge. One of these patients was treated nonoperatively for a second time, but appendicitis recurred again 6 months later, and the patient underwent surgery. Recurrent infection had not caused any adhesions. Open appendectomy was performed on both patients.

1. Materials and methods

The medical records of all children with appendicitis who were treated in AdVyaman State Hospital, AdVyaman, Turkey, between August 2003 and March 2006 were retrospectively reviewed. Diagnosis was made according to history, physical examination, fever, increased white blood cell (WBC) count, and US examination [2,9,13]. Ultrasound examinations were performed on all patients by 2 radiologists using a GE Logiq 400 CL (GE Yokogawa Medical Systems, Tokyo, Japan) with a 7- to 9-MHz linear array transducer. The maximum diameter of each appendix was measured before and 48 hours after treatment (Fig. 1). Anteroposterior diameter of 6 mm or greater and a noncompressible tubular structure were evaluated as appendicitis [2,7,13]. Patients who had history of abdominal pain for less than 24 hours, localized abdominal tenderness, and hemodynamic stability underwent NT (Fig. 2). Patients who had generalized peritoneal irritation signs, appendicolith, and free fluid underwent surgery. The children received parenteral antibiotics (ampicillin with sulbactam, 100 mg d kg1 d 24 h1, divided into 3 doses daily, and ornidasole 20 mg d kg1 d 24 h1, divided into 2 doses daily), intravenous fluid, and nothing by mouth for at least 48 hours. The antibiotics were administered until abdominal tenderness was resolved. During the first 48 to 72 hours of the treatment, patients were physically examined every 4 hours, temperature and pulse were measured every 2 hours, a WBC count was made every 24 hours, and a US examination was made every 48 hours. Patients whose abdominal pain and tenderness persisted, whose diameter of appendix had not decreased, and whose WBC count and temperature had increased underwent open appendectomy. Patients were followed up for 1 year. The statistical analysis was performed using the Student t test.

3. Discussion
Acute appendicitis proceeds to perforation, phlegmon, or abscess formation without treatment. Urgent appendectomy has therefore been generally considered the only treatment for appendicitis [10,11,14]. On the other hand, various studies have shown that certain cases of both AA and PA can be treated nonoperatively [2,7-12,15]. Appendicitis results from luminal obstruction, which is caused by fecalith, hyperplasia of the appendiceal lymphoid follicle, carcinoid tumors, and foreign bodies. Bacterial infection such as Escherichia coli, Yersinia, Salmonella, and Shigella; parasitic infestation such as Entamoeba histolitica and Enterobius vermicularis; and enteric and systemic viral infection such as measles, chicken pox, and cytomegalovirus cause reaction of the lymphoid follicle. Obstruction of the lumen is followed by distension and vascular changes. When the mucosal barrier is broken, bacteria invade the muscular wall. Effective antibiotic treatment during the early stage of appendicitis causes the regression of lymphoid hyperplasia because of bacterial infection and most probably prevents ischemia and further bacterial invasion [2-6]. Nonoperative treatment has been successfully used for patients in the United States Navy and in the Antarctic [8]. Harrison [16] reported the successful medical treatment of 42 of a total of 47 cases of appendicitis. Coldrey [17] reported 471 cases of appendicitis treated conservatively, with 1 death, 9 cases of abscess formation, and 48 failures requiring appendectomy. Cobben et al [9] reported on 60 cases treated medically, with a 38% recurrence rate. Kaneko and Tsuda [7] reported 22 cases treated non-

2. Results
One hundred thirty-six patients with appendicitis were admitted. Ninety-five (70%) of them had AA, and 41 (30%) had perforated appendicitis (PA). Sixteen (16.8%) patients with AA were suitable for NT. Twelve of the patients were boys, and 4 were girls. The mean age of the patients was 9 years (range, 5-13 years). All of the patients had a history of right lower quadrant abdominal pain and tenderness at palpation. The mean duration of the pain at the time of presentation was 18 hours (range, 3-24 hours). The mean body temperature at admission was 37.88C (range, 36.88C-

1442 operatively. Oliak et al [11] reported 77 cases of PA treated nonoperatively, with a success rate of 95%, recurrence of 6.5%, and complications arising in 12%. Dixon et al [12] reported 237 cases of PA treated nonoperatively, with 3% failure, 57% abscess formation (of which 27% underwent drainage), and a 14% recurrence rate. Ein et al [10] reported 96 cases of PA treated nonoperatively with 6% failure, 66% abscess formation (drained by interventional radiology and surgically), and a 43% recurrence rate. Despite evidence that NT has achieved a high cure rate, it has also resulted in death; complications such as peritonitis, abscess formation, fistula, and intestinal obstruction; and a high recurrence rate, especially in the perforated cases [10-12,17]. In this study, NT was administered only for selected cases of AA. Of 95 cases of AA, 15 (10.7%) were successfully treated nonoperatively, without any complication except for recurrence of appendicitis in 2 (13.3%) of the 15 cases. Nonoperative treatment was chosen after careful assessment of each patients history, general condition, and physical and US examination signs. Because most perforations occur within 24 to 48 hours of initial symptoms [5], NT was administered to those patients who had experienced abdominal pain for less than 24 hours without generalized peritoneal irritation signs and appendicolith. Ultrasound is useful because it can be used to identify an inflamed appendix with 90% to 100% accuracy [6,18]. Therefore, US examination was used in the study, both in the diagnosis and in the evaluation of the effectiveness of the treatment. Ultrasound examination enables the detection of an enlarged noncompressible appendix with a diameter of 6 mm or greater, appendicolith, periappendiceal inflamed fat, and free fluid in the appendix [2,7,9,10,13,17,18]. Typically, patients with an appendicolith are likely to experience a 72% rate of recurrence [10]. Free fluid with appendicitis may be because of perforation. In this study, because of the high rate of recurrence in patients with appendicolith and the high risk of complications in patients with perforations, it was decided that patients with these conditions would undergo surgery. Nonoperative treatment failed in 1 of the 15 patients selected. Despite treatment, the complaint of the patient and abdominal tenderness did not regress. The patient underwent surgery 1 day later without any complication. All patients were followed up according to Fig. 2. Many factors affect the success of NT, but the severity and causes of appendicitis are the most important. Appendiceal luminal obstruction caused by appendicolith, carcinoid tumors, foreign bodies, and hyperplasia of the lymphoid follicle related to viral infection do not regress with antibiotic treatment. Luminal obstruction caused by hyperplasia of the lymphoid follicle because of bacterial infection and parasitic infestation can be reversed with medical treatment.

M. AbeY et al. Y It has thus been concluded that some of the patients who had a history of abdominal pain for less than 24 hours with hemodynamic stability without generalized peritoneal irritation signs, necrosis, and appendicolith can be treated nonoperatively with success.

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