Acute Appendicitis in Children Management UpToDate 04 03 2019

4/3/2019 Acute appendicitis in children: Management - UpToDate
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Acute appendicitis in children: Management
Author: David E Wesson, MD
Section Editor: Jonathan I Singer, MD
Deputy Editor: James F Wiley, II, MD, MPH
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2019. | This topic last updated: Jan 20, 2019.
INTRODUCTION
This topic will review the management of appendicitis in children. The evaluation, diagnosis, and
diagnostic imaging of acute appendicitis in children and management of appendicitis in adults are
discussed separately:
● (See "Acute appendicitis in children: Clinical manifestations and diagnosis".)
● (See "Acute appendicitis in children: Diagnostic imaging".)
● (See "Management of acute appendicitis in adults".)
DIAGNOSIS
The diagnostic approach to children with suspected appendicitis is provided in the algorithm
(algorithm 1) and is discussed separately. (See "Acute appendicitis in children: Clinical manifestations
and diagnosis" and "Acute appendicitis in children: Diagnostic imaging".)
APPROACH
Once appendicitis is diagnosed, further management is determined by whether the appendix is intact,
has undergone perforation (advanced appendicitis), or has developed into an appendiceal mass
(phlegmon) or abscess. All children with appendicitis warrant fluid resuscitation as determined by their
degree of dehydration, intravenous (IV) antibiotics targeting gut flora, and analgesia. Once stabilized
as needed, patients with early or advanced appendicitis warrant urgent appendectomy as do ill
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appearing patients with an appendiceal mass or abscess. Wellappearing patients with an
appendiceal mass or phlegmon may initially be managed nonoperatively or undergo appendectomy.
(See 'Early appendicitis' below and 'Advanced appendicitis' below and 'Appendiceal mass or abscess'
below.)
The status of the appendix (intact, perforated, localized mass [phlegmon], or abscess) is determined
by clinical findings as follows:
● Patients with early appendicitis typically have a recent onset (one to two days) of abdominal pain
that over time has migrated from the periumbilical region to the right lower quadrant (RLQ)
followed by lowgrade fever, vomiting, and anorexia and associated with RLQ tenderness on
physical examination. White blood cell (WBC) count, absolute neutrophil count, and/or Creactive
protein are typically elevated. In addition, some patients with early appendicitis may have
equivocal findings of appendicitis by history and physical examination but have diagnostic
imaging that confirms the diagnosis. (See "Acute appendicitis in children: Clinical manifestations
and diagnosis", section on 'Clinical suspicion' and "Acute appendicitis in children: Diagnostic
imaging", section on 'Imaging approach'.)
● The combination of clinical findings of appendicitis as described above for early appendicitis with
additional findings of peritonitis (eg, fever, rebound, guarding, or rigid abdomen) and evidence of
perforation on diagnostic imaging (eg, ultrasound, computed tomography [CT], or magnetic
resonance imaging [MRI]) can frequently establish the presence of advanced appendicitis prior to
surgical removal [1]. However, in some patients, perforation is only discovered intraoperatively.
● Children with an appendiceal mass (phlegmon) or abscess have a delayed presentation (at least
five to seven days), and evidence of a periappendiceal mass or abscess on physical examination
and diagnostic imaging [2].
EARLY APPENDICITIS
Early appendicitis is defined as appendicitis without evidence of perforation.
Appendectomy — We suggest that patients with early appendicitis have the appendix removed.
Timely removal of an inflamed appendix prevents progression to rupture with peritonitis in some
children and is curative [35]. Timely appendectomy has been the standard approach since the 1890s
[6]. Appendectomy also permits direct pathologic examination of the appendix and diagnosis of rare
but important coexisting conditions such as a carcinoid tumor or alternative diagnoses such as
terminal ileitis or ovarian torsion that change subsequent management [7].
It is a safe procedure with children experiencing less morbidity than adults [8]. Wound infection and
paralytic ileus are the primary early complications of appendectomy and occur in up to 9 percent and
2 percent of patients, respectively [3]. Since the advent of antibiotics for preoperative treatment and
an emphasis on early removal, mortality following appendectomy is very rare [6]. The major life
threatening complication consists of late small bowel obstruction due to adhesions and occurs in <1
percent of patients. (See 'Complications' below.)
However, preliminary evidence suggests that nonoperative management in selected patients can be
successful. (See 'Nonoperative management' below.)
Preoperative care — Key aspects of preoperative care for children with early appendicitis include
antibiotic prophylaxis, fluid therapy, and analgesia as follows:
Antibiotic prophylaxis – We recommend that children with nonperforated appendicitis receive a
single prophylactic dose of a broad spectrum antibiotic before operation rather than no treatment.
Acceptable antibiotic choices include:
● Cefoxitin
● Ceftriaxone and metronidazole
● Cefotetan
● Gentamicin and either clindamycin or metronidazole in patients allergic to penicillins and
cephalosporins
● Piperacillin and tazobactam
Antibiotics should be administered as soon as the diagnosis of appendicitis is established and at least
30 to 60 minutes before the incision is made [9].
The inclusion of piperacillin and tazobactam for prophylaxis of uncomplicated appendicitis in children
differs from joint guidelines for prophylaxis for simple appendectomy proposed by the Infectious
Diseases Society of America, the Surgical Infection Society, The American Society of HealthSystem
Pharmacists, and the Society for Healthcare Epidemiology of America [10] but is consistent with
guidelines proposed by the American Pediatric Surgical Association [11]. The use of piperacillin and
tazobactam for such patients is based upon the frequent difficulty in identifying whether the appendix
is perforated in children prior to operation. However, in an observational study of almost 18,000
children with uncomplicated appendicitis of whom onethird received extended spectrum antibiotics
(primarily piperacillin and tazobactam), treatment failure, defined as readmission within 30 days
related to a complication of appendicitis, occurred in approximately 1 percent of all patients and was
not reduced in the patients receiving extended spectrum antibiotics (adjusted odds ratio [aOR] 1.32;
95% CI 0.92.0) [12].
Patients with simple appendicitis do not require further doses of antibiotics after appendectomy. By
contrast, antibiotics should be continued postoperatively in children with perforated appendicitis. (See
'Antibiotics' below.)
The effectiveness of prophylactic antibiotics in patients with early appendicitis is supported by a meta
analysis of 45 trials that noted a significant reduction in wound infections (5 versus 11 percent, odds
ratio [OR] 0.37) and intraabdominal abscesses (0.6 versus 1.4 percent, OR 0.46) among adults and
children undergoing appendectomy who received antibiotic prophylaxis [13]. Whether any additional
doses of antibiotics are beneficial in these patients was not addressed by this metaanalysis.
However, a systematic review by the American Pediatric Surgical Association concluded that
evidence is lacking to support postoperative antibiotics in children with nonperforated appendicitis and
most experts agree that additional doses of antibiotics in these patients are unnecessary [11].
Fluid therapy and analgesia – Intravenous (IV) hydration and analgesia should be provided. Any
identified electrolyte abnormalities should be corrected before surgery. Rehydration can be
accomplished by giving 20 mL/kg boluses of isotonic crystalloid until the signs of dehydration have
resolved and the patient has voided. Once euvolemia has been established the child should receive
half normal saline with 10 to 20 mEq/L of potassium chloride at 1 to 1.5 maintenance and additional
fluid losses (eg, vomiting) should be replaced. (See "Treatment of hypovolemia (dehydration) in
children".)
Pain control is also an important component of preoperative care of children with acute appendicitis,
both before and after the diagnosis is made. Pain management should be guided by the patient's self
assessment of pain severity whenever possible. IV opioids (eg, morphine) are typically the best
choice. Ketorolac is an excellent choice for postoperative pain medication, and does not significantly
increase the patient's bleeding risk. (See "Evaluation and management of pain in children", section on
'Assessment of pain severity' and "Evaluation and management of pain in children", section on
'Opioids'.)
Timing of operation — In the past, appendicitis has been considered a surgical emergency that
requires prompt appendectomy to avoid perforation and other complications. However, evidence from
observational studies suggests that adverse outcomes (eg, perforation, complications, or operating
time) are not increased for children who receive timely administration of antibiotics and undergo
appendectomy less than 24 hours after diagnosis [1417].
Of note, limiting the total time of symptoms prior to appendectomy rather than the time from
diagnosis to surgery appears to be of greatest importance in preventing adverse outcomes. As an
example, in a prospective, observational study (not included in the above systematic review) that
evaluated 230 children who underwent appendectomy, patients with symptoms greater than 48 hours
had a significantly higher rate of perforation when compared with patients with symptoms ≤48 hours
(46 versus 12 to 18 percent) [18]. When evaluated according to time from diagnosis, the perforation
rate, length of stay, and operating time were not significantly different.
Furthermore, nonoperative management with antibiotics alone is feasible in selected patients with
early, uncomplicated appendicitis. (See 'Nonoperative management' below.)
Examples of findings from specific studies include:
● A systematic review of observational data and subsequent metaanalysis of 2510 patients with
acute appendicitis (539 children younger than 16 years of age) found no increase in the
frequency of complex appendicitis in patients who had a delay of 12 to 24 hours after admission
[14]. However, an increased risk of surgical site infection and 30 day complications occurred in
patients for whom appendectomy was delayed beyond 48 hours after admission.
● In a multicenter, prospective observational study of 955 children 3 to 18 years of age with
appendicitis, duration of time ≤24 hours between emergency department evaluation and
operation was not associated with a significant increase in appendiceal perforation on adjusted
analysis, including children without perforation on computed tomography of the abdomen during
initial evaluation [15]. A retrospective observational study of over 2400 children undergoing
appendectomy at 23 children’s hospitals also found no association between time to
appendectomy ≤24 hours and complicated appendicitis or postoperative complications [16].
Laparoscopic or open approach — We recommend that children with early appendicitis undergo
appendectomy with a laparoscopic approach rather than an open approach.
Evidence supporting this recommendation for laparoscopic appendectomy includes the following:
● Two metaanalyses that compared laparoscopic to open surgery for acute appendicitis in children
noted that laparoscopic procedures were associated with a significantly decreased hospital
length of stay (mean difference 0.5 to 0.6 days) and risk of wound infection (1 to 2 versus 5 to 6
percent, odds ratio [OR] 0.20 to 0.45) [19,20]. The mean difference in operative time was 7 to 11
minutes longer for laparoscopy, which is of marginal clinical significance. Intraabdominal abscess
was more common after laparoscopy in one metaanalysis that included observational studies
and randomized trials [19] but was of low frequency and could not be analyzed in the other meta
analysis of seven trials [20].
Good evidence to support decreased postoperative pain and earlier return to normal activities
after laparoscopic appendectomy in children is lacking. However, the decrease in hospital length
of stay provides indirect evidence for these benefits of the laparoscopic approach and is
consistent with our experience.
● In a systematic review of almost 75,000 children undergoing appendectomy for uncomplicated
appendicitis, laparoscopic appendectomy was associated with a reduced length of hospital stay
and no significant difference in postoperative complications such as wound infections or
intraabdominal abscess when compare to open appendectomy [21].
Laparoscopic appendectomy may be performed using a three port (three incisions) or single incision
technique [22,23]. In a prospective observational study of 186 children with early appendicitis, 96
percent successfully completed the procedure using single incision laparoscopic surgery.
Intraoperative considerations — Important intraoperative considerations arise based upon the
appearance of the appendix or discovery of a carcinoid tumor as follows:
● Abnormal but intact appendix – The following surgical principles should be followed [24]:
• A segment of omentum that is firmly attached to the appendix should be divided a few
centimeters away and removed with the appendix.
• The base of the appendix should be ligated close to the cecum. There is no proven benefit to
inversion of the stump.
• All purulent fluid should be aspirated.
• All incisions and trocar sites that are larger than 5 mm should be closed primarily.
● Perforated appendix – In some patients thought to have early appendicitis based upon
preoperative clinical findings, a perforated appendix will be encountered. Intraoperative
considerations for patients with advanced (perforated) appendicitis are discussed separately.
(See 'Intraoperative considerations' below.)
● Normal appendix – When an apparently normal appendix is found, it should be removed.
Removal of an appendix that appears grossly normal is generally recommended because
microscopic inflammation may be noted on pathologic examination [25]. Removal of the appendix
will also significantly diminish concern for the diagnosis of appendicitis if the patient develops
another episode of abdominal pain, although stump appendicitis remains possible. (See 'Late'
below.)
Evidence for other possible causes of abdominal pain, including Meckel's diverticulitis, terminal
ileitis, mesenteric adenitis, omental torsion, renal mass or obstruction, cholecystitis, or tubal or
ovarian pathology should be sought if the appendix appears to be normal.
● Carcinoid tumor – Rarely, a carcinoid tumor will be seen or palpated in the appendix at the time
of appendectomy [26]. Simple appendectomy is sufficient treatment for most cases of
appendiceal carcinoid. On the other hand, a right hemicolectomy is indicated if the tumor is
greater than 2 cm in diameter, if the tumor invades through the wall of the appendix, or if the
adjacent mesenteric nodes are involved. (See "Staging, treatment, and posttreatment
surveillance of nonmetastatic, welldifferentiated gastrointestinal tract neuroendocrine (carcinoid)
tumors", section on 'Appendix'.)
Postoperative care — The principle management issues after appendectomy in children with
early appendicitis include adequate pain control and resumption of oral intake as follows:
● Analgesia – Postoperative pain is initially managed with parenteral opioids (eg, morphine with
repeated doses every four to six hours based upon additional pain assessment) supplemented by
parenteral ketorolac or acetaminophen with conversion to oral agents (eg, ibuprofen,
acetaminophen, or hydrocodone) once the child is drinking well. To avoid side effects such as
drowsiness and constipation some surgeons avoid all opioids for postoperative management of
early appendicitis. Instead, they rely on wound blocks at the time of surgery and nonsteroidal
antiinflammatory medications after surgery. This approach is especially appropriate for sameday
discharge. Close attention to pain assessment and resolution of pain is essential, regardless of
the regimen chosen. (See "Evaluation and management of pain in children", section on
'Assessment of pain severity'.)
Little evidence provides a comparison of pain regimens for postoperative appendectomy care in
children. In the past, use of nonsteroidal antiinflammatory drugs (NSAIDs) was discouraged
because of the theoretical risk of bleeding. However, in studies of their use after other operations
where hemorrhage is more likely to occur (eg, tonsillectomy), NSAIDs have not been associated
with increased bleeding [27]. In one observational study of 186 children undergoing
appendectomy for early appendicitis using a single incisional laparoscopic technique, pain control
with oral NSAIDs was adequate for most patients [22].
● Oral intake and diet – Oral fluids can be introduced as soon as the child is awake. Diet may be
advanced to solid food as tolerated. If admitted, most children are able to go home within 24 to
48 hours. Longer lengths of stay to permit continued treatment with antibiotics is necessary if the
appendix was gangrenous or perforated. (See 'Antibiotics' below.)
Sameday discharge — Evidence suggests that selected children with early appendicitis may
be discharged on the same day of surgery with high caregiver satisfaction and without an increase in
complications, urgent revisits, or readmissions when compared to overnight hospitalization [22,28,29].
Nonoperative management — Although appendectomy for early appendicitis remains the treatment
of choice, nonoperative treatment (NOT) of early appendicitis has been proposed and may be an
option in selected children with early, uncomplicated appendicitis depending upon caregiver
preference. Specifically, it may be safe and effective for older children who can better describe their
symptoms (over six years of age) and have features of early appendicitis as follows [30]:
● Abdominal pain for <48 hours
● White blood cell (WBC) count ≤18,000/microL
● Normal Creactive protein
● No appendicolith present on imaging
● Appendix diameter ≤1.1 cm on imaging
● No preoperative concern for rupture based upon clinical findings
NOT may be especially appropriate in children who meet the above criteria and who have
comorbidities that raise the risk of appendectomy. NOT should only be performed by a surgeon with
pediatric expertise.
Antibiotic protocols vary widely but typically include 1 to 2 days of inpatient broadspectrum IV therapy
(eg, piperacillintazobactam, ceftriaxone and metronidazole, or ciprofloxacin and metronidazole) until
resolution of symptoms and normalization of WBC count occur followed by oral antibiotics (eg,
amoxicillinclavulanic acid or ciprofloxacin and metronidazole) as an outpatient [31].
Initial findings from small prospective observational studies, nonrandomized trials, and one
randomized trial indicate potential benefits for selected children who undergo NOT of acute,
uncomplicated appendicitis. However, more evidence, preferably from large randomized trials, is
needed to provide guidance as to which patients should undergo NOT or appendectomy [32]:
● In a systematic review of 10 studies that provided outcomes for 413 children undergoing NOT,
initial treatment was effective in 88 to 99 percent of patients and was associated with no
appendectomy at reported followup (ranging from 8 weeks to 4 years) in 62 to 92 percent of
patients and recurrent appendicitis documented in 2 to 29 percent of patients [31]. There was a
suggestion that longer periods of followup from initial presentation were associated with a
greater risk of recurrence. Complications (described in five studies) and total length of hospital
stay (reported in two studies) appeared similar during followup regardless of initial treatment. In
one study that was included in this review, perforation occurred during the initial hospitalization
for NOT [33]. Pooled estimates were performed by the investigators but, given the underlying
variation in methodology of the included studies, may be misleading.
● In a metaanalysis that was confined to five prospective trials: one randomized trial included in
the first metaanalysis and four prospective controlled trials where NOT was performed based
upon parent preference (one trial not included in the first metaanalysis); successful initial
management without appendectomy in the first month after presentation (168 patients) was 91
percent [34]. By one year, 73 percent of patients had not undergone appendectomy (including
patients who failed NOT within the first month of presentation) and recurrent appendicitis was
documented in 22 percent of all patients undergoing NOT. Subgroup analysis identified a
significantly higher risk for failure of NOT in children with an appendicolith.
More recent observational studies suggest that patient selection strongly influences outcomes and
that NOT using more rigorous initial criteria for inclusion is associated with the best balance of risks
and benefits. For example, in a prospective observational study of 197 children with a Pediatric
Appendicitis Score ≥7, acute symptoms (average duration 20 to 24 hours), and a pelvic ultrasound
demonstrating signs of acute appendicitis without perforation and no appendicolith, NOT was
successful in 87 percent of patients at up to 18 months of followup [35]. Intraluminal fluid on
ultrasonography was significantly associated with failure of NOT. In another prospective,
observational study in which only children with evidence of complicated appendicitis (signs of
perforation or sepsis at presentation) had surgery within 12 hours, of the 197 children with
uncomplicated appendicitis who first received IV antibiotics and observation for 24 to 48 hours, 58
percent improved and avoided appendectomy during initial hospitalization [36]. Subsequently, 2
percent of those managed without appendectomy required operation after discharge. In a
retrospective study of an insurance database that documented initial NOT in over 4,000 children, 46
percent subsequently underwent appendectomy and 14 percent had perforated appendicitis. During
one year of followup, NOT was associated with significantly more advanced imaging and
hospitalizations [37].
The nonoperative management of early appendicitis in adults is discussed separately. (See
"Management of acute appendicitis in adults", section on 'Evidence for nonoperative management'.)
ADVANCED APPENDICITIS
Appendicitis is considered advanced when perforation or gangrene has developed. When possible,
advanced appendicitis in infants and young children should be managed by a pediatric surgeon [38].
Appendectomy — We recommend that children with advanced appendicitis and without an
appendiceal mass or abscess, undergo urgent appendectomy rather than delayed appendectomy.
Timely appendectomy for patients with advanced appendicitis has been the standard approach since
the 1890s [6]. Appendectomy may prevent progression to sepsis and septic shock and also permits
aspiration of pus and irrigation of the abdominal cavity. It is a safe procedure with children
experiencing less morbidity than adults [8]. Wound infection, intraabdominal abscess, and paralytic
ileus are the primary early complications of appendectomy and occur in up to 9 percent, 5 percent,
and 2 percent of patients, respectively [3]. Since the advent of antibiotics for preoperative treatment
and an emphasis on early removal, mortality following appendectomy for advanced appendicitis is
very rare [6]. The major lifethreatening complication consists of late small bowel obstruction due to
adhesions and occurs in <1 percent of patients. (See 'Complications' below.)
Initial nonoperative management followed by interval appendectomy may result in better outcomes
than early appendectomy for children with a delayed presentation of appendicitis associated with an
appendiceal mass (phlegmon) or abscess. However, the presence of an appendicolith at initial
evaluation is associated with failure of nonoperative management [39]. (See 'Appendiceal mass or
abscess' below.)
Preoperative care — Adequate preoperative preparation is of paramount importance in patients
with complicated appendicitis and includes the following measures:
● Replacement and maintenance fluid therapy should be provided and adjusted for serum sodium
and potassium. (See "Treatment of hypovolemia (dehydration) in children" and "Maintenance fluid
therapy in children".)
● A nasogastric tube should be inserted if the child has persistent vomiting. All measured gastric
drainage should be replaced with 10 to 20 mEq/L of potassium chloride in isotonic or half normal
saline. Routine use of nasogastric tube drainage does not appear to improve the postoperative
course [40].
● A urethral catheter should be inserted to monitor urine production when the child is severely
dehydrated. An hourly urine output of 1 to 2 mL/kg is a sign that the intravascular volume has
been restored and the patient is fit for surgery.
● All patients should receive preoperative antibiotics. We generally use piperacillin and tazobactam
when gangrene or perforation is suspected preoperatively as recommended by the American
Pediatric Surgical Association guidelines [11].
The optimal prophylactic regimen is not clear and acceptable alternatives to piperacillin and
tazobactam include:
• Cefoxitin
• Ceftriaxone and metronidazole
• Cefotetan
• Gentamicin and either clindamycin or metronidazole in patients allergic to penicillins and
cephalosporins
The initial dose or doses of antibiotics should be completed as soon as possible and ideally at
least 30 to 60 minutes before the operation. (See 'Preoperative care' above.)
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In an observational study of over 7000 children with complicated appendicitis of whom twothirds
received extended spectrum antibiotics (primarily piperacillin and tazobactam), treatment failure,
defined as readmission within 30 days related to a complication of appendicitis, occurred in
approximately 6 percent of all patients with complicated appendicitis and was increased in
patients who received extended spectrum antibiotics (adjusted odds ratio [aOR] 1.4; 95% CI 1.1
1.9) [12].
Clinical trials are needed to determine the best empiric antibiotic regimen for these patients.
Laparoscopic or open approach — We suggest that children with appendiceal perforation
undergo appendectomy by a laparoscopic approach when surgeons who are well trained in this
technique are available. Open laparotomy for neonatal appendicitis is suggested for newborn infants
with abdominal distension and sepsis who show no signs of necrotizing enterocolitis on imaging or
who display perforation or obstruction on plain abdominal radiographs [41]. (See "Acute appendicitis
in children: Clinical manifestations and diagnosis", section on 'Neonates (0 to 30 days)' and "Neonatal
necrotizing enterocolitis: Clinical features and diagnosis".)
Evidence supporting laparoscopic appendectomy in patients with advanced appendicitis includes the
following:
● In a metaanalysis of 16 comparative studies and 3 trials published since 2000 (34,474 children
with complicated appendicitis of whom 10,965 underwent laparoscopic appendectomy),
laparoscopic appendectomy when compared with open appendectomy was associated with
significantly reduced hospital length of stay (mean reduction 0.7 days), lower risk of wound
infection (3.3 versus 4.1 percent), lower risk of bowel obstruction (1.2 versus 1.5 percent), longer
operative time (range of mean excess time 2 to 50 minutes), and a higher risk for intraabdominal
abscess (3.7 versus 2.6 percent) [21]. However, there was significant heterogeneity for most
pooled results.
● In an unblinded randomized trial not included in the above metaanalysis, of 131 children younger
than 18 years of age with a clinical diagnosis of perforated appendicitis and no mass or
phlegmon, early appendectomy was associated with a significantly shorter time to return to
normal activities (mean number of days: 14 versus 19) and reduced adverse events (eg,
abscess, small bowel obstruction, or unplanned readmission, 30 versus 55 percent) than interval
appendectomy six to eight weeks later [42]. In addition, hospital charges and costs were
significantly lower for children who had an early appendectomy [43].
● In an observational study not included in the above metaanalysis and that utilized a national
database, 660 children undergoing laparoscopic appendectomy had an overall complication rate
of 12 percent [44]. This rate was not significantly different for the 169 obese children undergoing
the procedure.
Taken together, these studies suggest that laparoscopic appendectomy in children with advanced
appendicitis is associated with overall lower postoperative morbidity than open appendectomy with a
slight increase in the risk of intraabdominal abscess but a shorter length of hospital stay.
Intraoperative considerations — Variation exists among pediatric surgeons regarding the
intraoperative management of advanced appendicitis in children [45]. We, along with most others,
follow these general principles [24]:
● A search should be made for an appendicolith in the pelvis or periappendiceal area when the
appendix is grossly perforated, especially if one was noted on the preoperative imaging.
● We do not routinely culture the stump, free pus, or peritoneal fluid because the results almost
never alter treatment.
● As in simple appendicitis, the base of the appendix should be ligated close to the cecum.
● A drain should be inserted if there is a wellformed abscess cavity or if the stump closure is
tenuous.
● Although one observational study found no increase in adverse outcomes (wound infection or
dehiscence, intraabdominal abscess, prolonged ileus, or small bowel obstruction) when irrigation
and drainage was not performed [46], we and the majority of surgeons irrigate the peritoneal
cavity, including the pelvis, with an isotonic crystalloid solution until the returns are clear.
● The wound(s) should be irrigated generously and closed primarily.
● A peripherally placed central venous line (PICC) may be inserted at the time of surgery to
facilitate outpatient management of intravenous (IV) antibiotics, obtaining blood for laboratory
studies, and, if required, parenteral nutrition.
Postoperative care
Antibiotics — We recommend that children receive IV antibiotics after appendectomy for
advanced appendicitis until they are tolerating a regular diet and are afebrile. Children who are still
febrile, have a white blood cell (WBC) count ≥12,000/mm3, and/or are unable to tolerate a regular diet
five to seven days after surgery warrant diagnostic imaging studies to search for an abdominal or
pelvic abscess [47].
● Immediate postoperative period – Based upon a metaanalysis of 45 studies, initial treatment
with IV antibiotics significantly reduces wound infection and intraabdominal abscess formation for
patients with gangrenous or perforated appendicitis compared to no treatment although data in
children are limited [13]. We use piperacillin/tazobactam as recommended for perforated
appendicitis by the American Pediatric Surgical Association guidelines [11]. In retrospective
series, therapy with a single antibiotic (such as piperacillin/tazobactam, cefoxitin, or ceftriaxone)
appears to be as effective as multiple antibiotic therapy (such as ampicillin, gentamicin, and
metronidazole) for preventing complications of perforated appendicitis, as measured by length of
hospital stay and readmission rates and is more cost effective [11,48,49].
In a prospective randomized controlled trial of 98 children with perforated appendicitis,
metronidazole (30 mg/kg as a single daily dose) and ceftriaxone (50 mg/kg as a single daily
dose) was as effective as standard multiple daily doses of ampicillin, gentamicin, and clindamycin
in preventing abscess or wound infection and is a reasonable alternative to
piperacillin/tazobactam [50]. In a separate retrospective observational study, metronidazole and
ceftriaxone once daily was equivalent to ertapenem alone or combined with cefoxitin in terms of
abscess or other postoperative complications but was markedly less costly [51]. Length of
hospitalization was similar between groups. However, patients who received the simplified
regimen incurred significantly lower antibiotic charges.
In a separate observational study of over 7000 children with complicated appendicitis, treatment
failure, defined as readmission within 30 days related to a complication of appendicitis, occurred
in approximately 6 percent of all patients with complicated appendicitis and was increased in
patients who received extended spectrum antibiotics [12].
Thus, the benefits of extendedspectrum antibiotics are not clear. Clinical trials are needed to
determine the optimal antibiotic regimen.
● Duration of antibiotics and use of oral antibiotics – Our approach is to continue IV antibiotics
in children with advanced appendicitis until they are afebrile, well controlled on oral analgesics
and tolerating a regular diet. When they meet these criteria, we check their WBC count, and, if it
is normal, we discharge them on no antibiotic. If the WBC count is still elevated, we keep them in
hospital on IV antibiotics.
This approach is supported by the following observational studies:
• In a retrospective observational study of 304 children with ruptured appendicitis that
compared IV antibiotic duration determined by clinical response and oral antibiotic therapy at
discharge determined by WBC to antibiotic duration of at least four days (152 patients) with
no oral antibiotics at discharge, patients whose duration of antibiotics was determined by
clinical response went home, on average 39 hours sooner than patients who received at
least four days of IV antibiotics regardless of clinical findings (mean length of stay 95 versus
134 hours, respectively) with significant cost savings [52]. There was no difference in
abdominal abscesses, reoperations, interventional radiology drainage of abscess, or
inpatient readmission between the groups.
• In a prospective observational study of 540 children before and after antibiotic regimen
change in a single institution, the 270 patients who met discharge criteria prior to completion
of five days of IV antibiotics and who were discharged without oral antibiotics had similar
rates of postoperative abscess after discharge when compared with patients who received
oral antibiotics to complete a seven day course (8 versus 6 percent, respectively) [53].
• In a prospective trial of 100 children with perforated appendicitis, 42 percent underwent
discharge on oral antibiotics (amoxicillin and clavulanate potassium, Augmentin) to complete
a seven day course of antibiotics prior to postoperative day five without an increased risk of
postoperative abscesses [54].
Many pediatric surgeons use resolution of pain, return of bowel function, normalization of WBC,
and absence of fever as indications to discontinue IV antibiotics, and this approach is endorsed
by the American Pediatric Surgical Association [11,55]. In some of these patients, fever on the
third postoperative day may be a poor predictor of intraperitoneal infection [56]. A systematic
review of postoperative antibiotic duration for children with advanced appendicitis noted that
children treated with IV antibiotics for three days did not have an increased number of infectious
complications compared with those treated for longer periods [57].
We discharge patients with advanced appendicitis when they meet our discharge criteria even if
they have been treated for fewer than five days. Although a minimum of five days of IV antibiotics
is recommended by the American Pediatric Surgical Association (APSA), [11,55], as noted
above, several studies have reported good outcomes with durations of IV antibiotics less than
five days in these patients since the publication of the APSA guidelines.
Pain control — Postoperative pain should be initially controlled with parenteral opioid
analgesics (eg, morphine). Patientcontrolled analgesia is preferable, when possible. Opioid analgesia
may be supplemented with parenteral ketorolac or acetaminophen. Dosing for these agents is
discussed in more detail separately. (See "Evaluation and management of pain in children", section
on 'Opioids' and "Evaluation and management of pain in children", section on 'Nonopioid analgesics'.)
Administration of IV acetaminophen has been associated with tenfold dosing errors and toxicity that
occur when the dose in mg is administered as the volume in mL. When ordering IV acetaminophen in
children, both the dose in mg and volume in mL should be specified along with the other
recommended parameters for drug order safety (ie, mg/kg, the child’s weight in kg, and the maximum
accumulated amount for 24 hours). (See "Evaluation and management of pain in children", section on
'Acetaminophen' and "Clinical manifestations and diagnosis of acetaminophen (paracetamol)
poisoning in children and adolescents", section on 'Iatrogenic IV overdose' and "Management of
acetaminophen (paracetamol) poisoning in children and adolescents", section on 'Iatrogenic
intravenous overdose'.)
Oral analgesics (eg, ibuprofen, acetaminophen, hydrocodone, or oxycodone) can be substituted once
the child is drinking well.
Intestinal dysfunction — Many patients with advanced appendicitis have a paralytic ileus or a
mechanical intestinal obstruction from fibrinous adhesions. Nasogastric drainage should be instituted
for patients with persistent vomiting or abdominal distension and not routinely.
Once intraperitoneal inflammation and infection have improved and the ileus has resolved, oral fluids
can be introduced. The diet may then be advanced to solid food as tolerated. Many pediatric
surgeons will start patients on a regular diet immediately following laparoscopic appendectomy for
both simple and perforated appendicitis.
Nutrition — Parenteral nutrition support is usually not needed in children with advanced
appendicitis. However, it is indicated in previously healthy children who are unable to eat after one
week [58]. Those who are already malnourished should begin parenteral nutrition within 48 to 72
hours following surgery. (See "Parenteral nutrition in infants and children".)
APPENDICEAL MASS OR ABSCESS
The approach to patients with an appendiceal mass or abscess depends upon their clinical
appearance.
Illappearing — Illappearing patients with evidence of an appendiceal mass or abscess warrant
early appendectomy as for advanced appendicitis. (See 'Appendectomy' above.)
Wellappearing — Patients who present late (more than five to seven days from the onset of the
illness) with a welllocalized abscess or inflammatory mass (phlegmon) may initially be treated
nonoperatively [2,5961]. However, some experts still prefer to perform early appendectomy in these
patients. Current evidence is insufficient to determine which approach is better. For example, a small
trial of 40 children with a welldefined abdominal abscess on computed tomography (CT) found no
difference in total length of hospitalization, recurrent abscess rates, or overall charges between
patients who received initial laparoscopic appendectomy or those treated with initial nonoperative
therapy (percutaneous drainage, antibiotic administration) followed by interval appendectomy
approximately 10 to 12 weeks later [62]. However, in a separate, retrospective study of over 200
children with advanced appendicitis of whom over twothirds had an intraabdominal abscess at
presentation, medical management was associated with significantly greater postadmission
complications (eg, bowel obstruction and recurrent appendicitis), total length of hospitalization, and
greater utilization of health care resources (eg, more imaging, longer duration of total parenteral
nutrition, and more unscheduled repeat hospitalizations) [63].
If nonoperative treatment (ie, intravenous [IV] antibiotics with or without percutaneous drainage) is
chosen, the surgeon must carefully monitor the patient’s clinical progress. There should be steady
improvement in abdominal pain, fever, appetite and intestinal function. If not, conversion to operative
treatment may be warranted.
The ideal patient for initial nonoperative management is not ill appearing and has a well localized,
tender mass in the right lower quadrant without signs of generalized peritonitis. The rationale for initial
nonoperative treatment was illustrated in a metaanalysis of 61 observational and small randomized
trials that included 55,593 adult and pediatric patients with acute appendicitis, 4 percent of whom had
appendiceal abscess or phlegmon [2]. Thirtysix percent of 886 patients with abscess or phlegmon
who underwent immediate surgery had morbidity, including postoperative infection, intestinal fistula,
small bowel obstruction, and recurrence. This frequency of complications was significantly higher than
for the 14 percent of 895 patients who initially were managed nonoperatively (odds ratio [OR] 3.4;
95% CI 2.05.6).
Nonoperative treatment includes the following:
● IV fluids should be administered. Oral intake may be resumed as tolerated.
● Parenteral nutrition is indicated if the child is unable to eat after one week or earlier if the child is
already malnourished.
● Antibiotics should be prescribed (as for advanced appendicitis) and continued until the child is
afebrile, tolerating a regular diet, and has a normal WBC count. (See 'Advanced appendicitis'
below.)
● Appropriate pain management.
A CT scan should be obtained upon admission in all cases selected for nonoperative management to
identify candidates for imageguided percutaneous drainage. Significant abscesses (>3 to 4 cm in
diameter) should be drained under image guidance (ultrasound or CT) by aspiration or placement of
an indwelling catheter. Even multiple intraabdominal abscesses may be managed in this fashion [64].
Smaller abscesses and those not amenable to percutaneous drainage can be treated with antibiotics,
at least initially.
Percutaneous drainage or laparotomy may be indicated in patients initially selected for nonoperative
management. Indications for intervention include lack of clinical improvement within 24 to 48 hours,
continued fever, worsening of localized tenderness, or increased abdominal mass size.
Although continued nonoperative management is advocated by some experts, we suggest interval
appendectomy 10 to 12 weeks following resolution of the initial episode, particularly for children with
an appendicolith. An interval appendectomy is often performed 8 to 12 weeks following resolution of
the initial episode of appendicitis in patients with appendiceal mass/phlegmon. The purpose of delay
is to avoid the morbidity of immediate appendectomy in these patients while definitively treating the
underlying appendicitis.
Evidence regarding the benefit of interval appendectomy is limited and conflicting:
● In a multicenter trial of 102 children randomized to observation after evaluation for appendiceal
mass for patients without a appendicolith or interval appendectomy, 77 percent of patients did not
have recurrent appendicitis within one year of enrollment [65]. Significant complications (eg,
wound infection, intestinal perforation, abscess formation, postoperative small bowel obstruction,
or prolonged ileus) occurred in 6 percent of patients undergoing interval appendectomy. No
patient underwent early appendectomy in this study.
● In one systemic review the frequency of morbidity (eg, postoperative infection, intestinal fistula,
small bowel obstruction) associated with interval appendectomy was not substantially different
than the risk of recurrence in patients who did not undergo interval appendectomy (11 versus 7
percent, respectively) [2]. Most recurrences developed within six months of hospital discharge. Of
those patients not undergoing interval appendectomy, 20 percent required percutaneous abscess
drainage. Nonoperative treatment delayed the diagnosis of Crohn disease and cancer in
approximately 2 percent of patients; delayed diagnosis was more common in adult patients.
● Another systematic review of 127 cases reported in three retrospective observational studies
found that the pooled risk of recurrent appendicitis among children not undergoing interval
appendectomy after an appendiceal mass was 21 percent. However, there was significant
heterogeneity among the studies for the risk of recurrent appendicitis (range 0 to 42 percent) [66].
The incidence of complications after interval appendectomy in 1247 children was 3.4 percent.
Among the 955 children for whom histopathologic findings were reported, 0.9 percent had a
carcinoid tumor. In one study included in this analysis, the recurrence of appendicitis was not
influenced by age, sex, type of appendicitis, or abscess drainage [67]. In another study included
in this review, the rate of recurrence in children with an appendicolith was significantly higher than
in those without an appendicolith (76 versus 26 percent, respectively) [39].
Thus, the need for interval appendectomy after initial nonoperative management of appendiceal
abscess/phlegmon is unclear. Many surgeons still recommend interval appendectomy. A strategy of
interval appendectomy or observation should be considered on a case by case basis after discussing
the risks and benefits of each approach.
COMPLICATIONS
Children with simple appendicitis have a risk of wound infection or abscess of approximately 1 to 5
percent depending upon the surgical approach [19,20]. Up to 55 percent of children with advanced
appendicitis have a complication, such as infection, bowel obstruction, or unplanned hospital
admission [42]. The most common complications are infectious. Risk factors for postoperative
abscess formation include [68,69]:
● Older age
● High body mass index
● History of diarrhea at presentation
● Fever on or after the third postoperative day
● Leukocytosis on or after the fifth postoperative day
Early
Infectious complications — Infectious complications are more likely after operation for advanced
appendicitis. With good surgical technique and appropriate use of antibiotics, wound abscesses occur
in approximately 2 to 9 percent of cases, even when the appendix is gangrenous or perforated
[70,71]. Wound abscesses are treated by opening the wound.
Intraabdominal and pelvic abscesses occur in about 5 percent of patients with appendicitis [57,72]. An
intraabdominal or pelvic abscess should be suspected if the patient remains febrile, complains of
abdominal pain, or is unable to tolerate a normal diet more than five to seven days after
appendectomy. In a casecontrol study comparing children with perforated appendicitis who
developed intraabdominal abscesses with those who did not, none of the patients who were afebrile
and eating on the third postoperative day developed intraabdominal abscesses [73].
Most abdominal and pelvic abscesses can be treated by percutaneous drainage under ultrasound or
computed tomography (CT) guidance. Pelvic abscesses, which point into the rectum, may be treated
by transrectal drainage.
Intestinal dysfunction — Intestinal dysfunction is the second most common complication of
appendicitis [24]. In the first few weeks it is usually caused by a combination of paralytic ileus from
peritonitis and mechanical obstruction from fibrinous adhesions. Most of these early bowel
"obstructions" resolve with gut rest including nasogastric suction and intravenous (IV) fluids.
Antibiotics are also helpful. Parenteral nutrition support is indicated if the patient is unable to eat for
more than five to seven days [58]. (See 'Postoperative care' above.)
In rare cases a small bowel to small bowel or cecocolic intussusception starting from the inverted
appendiceal stump may also occur, causing early mechanical obstruction [74]. This is often preceded
by a brief period where the gastrointestinal tract seems to be "open". The diagnosis can be
established with ultrasonography. Reoperation is usually required. (See "Intussusception in children".)
Fatal complications of appendicitis are exceedingly rare (less than 0.1 percent). Most deaths occur in
very young children and in those with complicated perforating appendicitis who undergo surgery
before they are adequately resuscitated or develop uncontrolled postoperative sepsis [75].
Late — Mechanical small bowel obstruction from postoperative and postinflammatory adhesions
occurs in less than 1 percent of children [76]. Most patients who present to the hospital with a
complete bowel obstruction more than a month after an appendectomy will require a laparotomy and
enterolysis.
Stump appendicitis refers to the inflammation of residual appendiceal tissue months to years after an
appendectomy [7779]. This rare condition has been attributed to incomplete appendectomy that
leaves an excessively long stump after open or laparoscopic surgery. Clinical findings are similar to
acute appendicitis, and the diagnosis should be considered in any patient with right lower quadrant
pain despite the prior history of appendectomy.
A retrospective observational report found three patients out of 2185 developed stump appendicitis
following primary appendectomy [79]. Ultrasound or CT of the abdomen with contrast assists in
establishing the diagnosis. A review of 36 case reports found that the median time to presentation is
one year after initial operation with a range of four months to 50 years [78]. Perforation occurred in 70
percent of patients.
SOCIETY GUIDELINE LINKS
Links to society and governmentsponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Appendicitis in children".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easytoread materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want indepth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e
mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient education: Appendicitis in adults (The Basics)" and "Patient
education: Appendicitis in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
Early appendicitis
● We suggest that children with early appendicitis undergo appendectomy within 24 hours of
diagnosis (Grade 2B). Preoperative management includes intravenous (IV) rehydration,
correction of electrolyte abnormalities, and timely administration of prophylactic antibiotics.
Nonoperative management may be appropriate in selected patients with early appendicitis and
according to caregiver preference. (See 'Preoperative care' above and 'Nonoperative
management' above.)
● We recommend that children with nonperforated appendicitis receive a prophylactic dose of a
broad spectrum antibiotic (eg, cefoxitin, piperacillin and tazobactam, or ceftriaxone and
metronidazole) 30 to 60 minutes before operation rather than no treatment (Grade 1A). (See
'Preoperative care' above.)
● We recommend that children with early appendicitis undergo laparoscopic appendectomy rather
than open appendectomy (Grade 1B). (See 'Laparoscopic or open approach' above.)
● When an apparently normal appendix is found, it should be removed. A careful search for other
causes of abdominal pain including tuboovarian pathology in girls should be performed. (See
'Intraoperative considerations' above.)
● Following surgery, oral fluids may be offered as soon as the child is awake. Analgesia may be
given orally as well. Most children are able to go home within 24 to 48 hours. (See 'Postoperative
care' above.)
Advanced appendicitis
● We recommend that children with perforated or gangrenous appendicitis, that do not have an
appendiceal mass or abscess, undergo urgent appendectomy rather than delayed appendectomy
(Grade 1B).
● Preoperative management of children with advanced appendicitis includes replacement and
maintenance fluid therapy and IV antibiotics. In addition, the clinician should place a nasogastric
tube in vomiting children and a urinary catheter to monitor urine output in children with severe
dehydration. (See 'Preoperative care' above.)
● We suggest that children with appendiceal perforation undergo laparoscopic appendectomy
rather than an open technique when surgeons who are well trained in laparoscopy are available
(Grade 2B). (See 'Laparoscopic or open approach' above.)
● We recommend that children receive IV antibiotics after appendectomy for advanced appendicitis
until they are tolerating a regular diet and are afebrile (Grade 1B). Children who are still febrile
and/or unable to tolerate a regular diet 7 to 10 days after surgery may have an abdominal or
pelvic abscess and should have diagnostic imaging studies. Other issues that must be addressed
in the postoperative period include pain control, nutrition, and management of intestinal
dysfunction. (See 'Postoperative care' above.)
Appendiceal mass/phlegmon
● Illappearing patients with an appendiceal mass or phlegmon warrant early appendectomy.
Patients who present more than five to seven days from the onset of the illness with a well
localized abscess or inflammatory mass (phlegmon), but are otherwise wellappearing, may
initially be treated nonoperatively. (See 'Appendiceal mass or abscess' above.)
● Although continued nonoperative management is advocated by some experts, we suggest
interval appendectomy 10 to 12 weeks following resolution of the initial episode, particularly for
children with an appendicolith (Grade 2C). In children without an appendicolith, clinicians and
parents may want to weigh the risk of morbidity versus recurrence when making the decision.
(See 'Appendiceal mass or abscess' above.)
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77. Waseem M, Devas G. A child with appendicitis after appendectomy. J Emerg Med 2008; 34:59.
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Topic 6481 Version 52.0
GRAPHICS
Diagnostic approach to pediatric appendicitis
PAS: Pediatric Appendicitis Score; WBC: white blood cell count; ANC: absolute neutrophil count; CRP: Creative protein;
RLQ: right lower quadrant.
* Classic signs of early appendicitis consist of abdominal pain for less than two days that begins periumbilically and then
begins to radiate and localize to the right lower quadrant. The pain is associated with anorexia, vomiting, and low grade
fever. RLQ tenderness is present on physical examination and the white blood cell count, absolute neutrophil count, and/or
creactive protein are elevated.
¶ For components of the pediatric appendicitis score refer to UpToDate graphics on pediatric appendicitis score and to the
UpToDate topic on clinical manifestations and diagnosis of appendicitis in children.
Δ Diagnostic imaging prior to surgical consultation is typically performed for these patients. For specific discussion of which
imaging tests to order, refer to UpToDate topics on diagnostic imaging in pediatric appendicitis. If local resources are
insufficient to adequately perform or interpret pediatric diagnostic imaging or if surgeons with pediatric expertise are not
available, the patient should be transferred to a facility with pediatric radiologic and surgical capability and no imaging
should be performed at the local institution.
Graphic 96236 Version 3.0
Contributor Disclosures
David E Wesson, MD Nothing to disclose Jonathan I Singer, MD Nothing to disclose James F Wiley, II, MD,
MPH Nothing to disclose
Contributor disclosures are reviewed for conﬂicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
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