What is the treatment for pediatric appendicitis?

Treatment of Pediatric Appendicitis

The standard treatment for pediatric appendicitis is laparoscopic appendectomy, which should be performed within 24 hours of admission to minimize complications, though non-operative management with antibiotics is a viable alternative for uncomplicated cases without appendicolith. 1

Diagnosis and Risk Stratification

Before determining treatment, proper diagnosis is essential:

• Use clinical scoring systems (Alvarado Score or Pediatric Appendicitis Score) combined with ultrasound to stratify patients into risk categories 1, 2
• Ultrasound should be the first-line imaging modality for children with suspected appendicitis 1, 2
• Consider CT scan (low-dose protocol) only if ultrasound is inconclusive 1

Treatment Algorithm Based on Appendicitis Classification

Uncomplicated Appendicitis

• Primary Treatment: Laparoscopic appendectomy within 24 hours of admission 1
• Alternative Treatment: Non-operative management (NOM) with antibiotics can be discussed with parents as a safe and effective alternative in selected cases 1
  • NOM should be avoided if appendicolith is present due to higher failure rates 1, 2
  • Parents should be informed about the possibility of failure and risk of misdiagnosing complicated appendicitis 1
• Antibiotic Protocol for NOM:
  • Initial intravenous antibiotics with subsequent switch to oral antibiotics based on clinical improvement 1
  • No postoperative antibiotics needed after appendectomy for uncomplicated appendicitis 1

Complicated Appendicitis (Perforated/Abscess)

• With Localized Abscess/Phlegmon:
  • Initial management: IV antibiotics and percutaneous drainage if indicated 1, 2
  • Follow with interval appendectomy after resolution of inflammation 1
• With Perforation without Abscess Formation:
  • Immediate laparoscopic appendectomy 1
  • Postoperative antibiotics:
    • IV antibiotics initially, with early switch (after 48 hours) to oral antibiotics 1
    • Total duration of antibiotic therapy should be less than 7 days 1

Specific Antibiotic Recommendations

• For Initial IV Therapy: Broad-spectrum antibiotics covering gram-negative and anaerobic organisms (e.g., ceftriaxone with metronidazole) 2
• For Oral Switch: Based on clinical improvement, typically after 48 hours of IV antibiotics 1, 2

Important Considerations

• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
• Early transition to oral antibiotics in complicated appendicitis is safe, effective, and cost-efficient 1
• Perforation rates are higher in younger children (<5 years), who often present with atypical symptoms 1
• Negative appendectomy rates have decreased from 15-25% to 1-3% with appropriate imaging 2

Follow-up Care

• For patients with complicated appendicitis treated non-operatively, consider subsequent colonoscopy screening 1
• Monitor for post-surgical complications including wound infections and intra-abdominal abscesses 1

The WSES guidelines provide a clear algorithm for diagnosis and management of pediatric appendicitis that balances surgical and non-operative approaches based on disease severity and patient characteristics 1.