Treatment of Pediatric Acute Appendicitis
The recommended treatment for pediatric acute appendicitis is laparoscopic appendectomy with appropriate perioperative antibiotic management tailored to whether the appendicitis is uncomplicated or complicated. 1
Diagnosis and Assessment
- Clinical scoring systems (Alvarado Score, Pediatric Appendicitis Score) should be used for initial risk stratification of pediatric patients with suspected appendicitis 1
- Laboratory tests and inflammatory biomarkers should complement the clinical assessment 1
- Ultrasound is the preferred initial imaging modality for children with suspected appendicitis, with CT reserved for cases where ultrasound is inconclusive 1
Surgical Management
- Laparoscopic appendectomy is strongly recommended over open appendectomy for both uncomplicated and complicated appendicitis in children where laparoscopic equipment and expertise are available 1
- Surgery should not be delayed beyond 24 hours from admission for uncomplicated appendicitis, and early appendectomy within 8 hours should be performed for complicated appendicitis 1
- In children with favorable anatomy, either single incision/transumbilical extracorporeal laparoscopic-assisted appendectomy or traditional three-port laparoscopic appendectomy can be performed based on local expertise 1
Antibiotic Management
For Uncomplicated Appendicitis:
- A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 1, 2
- Second or third-generation cephalosporins (such as cefoxitin or cefotetan) are appropriate choices 1
- Postoperative antibiotics are not recommended for uncomplicated appendicitis 1, 2
For Complicated Appendicitis (Perforated/Gangrenous):
- Preoperative broad-spectrum antibiotics should be initiated as soon as the diagnosis is established 1
- Intravenous antibiotics effective against enteric gram-negative organisms and anaerobes should be used 1, 3
- Options include:
- Early switch (after 48 hours) to oral antibiotics is recommended if the patient is clinically improving 1, 2
- Total antibiotic duration should be less than 7 days 1, 2, 4
- Extended-spectrum antibiotics offer no advantage over narrower-spectrum agents when adequate source control is achieved 1
Non-Operative Management
- For selected cases of uncomplicated appendicitis, non-operative management with antibiotics may be considered after informing parents about risks and potential failure 1
- Initial intravenous antibiotics with subsequent switch to oral antibiotics based on clinical condition is recommended for non-operative management 1
- In case of failure of non-operative management, laparoscopic appendectomy should be performed 1
Monitoring and Follow-up
- Clinical criteria for determining adequate antibiotic therapy include:
- Patient being afebrile for 24 hours
- Ability to tolerate regular diet
- Normalization of white blood cell count 5
- Patients with complicated appendicitis can be safely discharged to complete oral antibiotics when tolerating a regular diet, which can decrease hospitalization without increasing the risk of postoperative abscess formation 4
- Routine interval appendectomy after non-operative management is not recommended unless there are recurrent symptoms 2
Common Pitfalls and Considerations
- Atypical presentations are particularly common in preschool children, which may lead to delayed diagnosis 6
- Wound infection is the most common source of morbidity in appendicitis; proper antibiotic management and surgical technique are essential to minimize this risk 7
- Premature discontinuation of antibiotics before the patient is afebrile can lead to intra-abdominal abscess formation 5
- Antibiotic duration should be guided by clinical response rather than arbitrary time periods 5, 8
By following this evidence-based approach to the management of pediatric acute appendicitis, clinicians can optimize outcomes while minimizing unnecessary antibiotic exposure and hospital stays.