What are the clinical manifestations and management of acute appendicitis in pediatric patients?

From the Guidelines

Acute appendicitis in pediatric patients requires prompt diagnosis and surgical intervention, with laparoscopic appendectomy being a safe and effective approach, as it is associated with lower incidence of surgical site infections and bowel obstruction, although it may have a higher rate of intra-abdominal abscess formation compared to open appendectomy 1.

Diagnosis and Treatment

The condition presents with right lower quadrant pain that typically begins periumbilically and migrates, accompanied by fever, nausea, vomiting, and anorexia. Diagnosis relies on clinical evaluation using scoring systems like the Pediatric Appendicitis Score, supported by laboratory tests showing elevated white blood cell count and C-reactive protein, and imaging studies such as ultrasound as the first-line option, with CT reserved for unclear cases.

• Clinical evaluation:
  • Scoring systems: Pediatric Appendicitis Score
  • Laboratory tests: elevated white blood cell count and C-reactive protein
• Imaging studies:
  • Ultrasound as the first-line option
  • CT reserved for unclear cases Treatment involves fluid resuscitation with isotonic crystalloids (20 ml/kg boluses), broad-spectrum antibiotics (typically piperacillin-tazobactam 100 mg/kg/dose q8h or ceftriaxone 50 mg/kg/day plus metronidazole 30 mg/kg/day divided q8h), and timely appendectomy, either laparoscopic or open.
• Fluid resuscitation: isotonic crystalloids (20 ml/kg boluses)
• Broad-spectrum antibiotics:
  • Piperacillin-tazobactam 100 mg/kg/dose q8h
  • Ceftriaxone 50 mg/kg/day plus metronidazole 30 mg/kg/day divided q8h
• Appendectomy:
  • Laparoscopic appendectomy
  • Open appendectomy Pain management should include scheduled acetaminophen (15 mg/kg/dose q4-6h) and NSAIDs like ibuprofen (10 mg/kg/dose q6h), with opioids for breakthrough pain.
• Pain management:
  • Scheduled acetaminophen (15 mg/kg/dose q4-6h)
  • NSAIDs like ibuprofen (10 mg/kg/dose q6h)
  • Opioids for breakthrough pain Antibiotics should continue for 24 hours post-surgery in uncomplicated cases and 5-7 days for perforated appendicitis.
• Antibiotics duration:
  • 24 hours post-surgery in uncomplicated cases
  • 5-7 days for perforated appendicitis Early ambulation and diet advancement as tolerated are recommended postoperatively.
• Postoperative care:
  • Early ambulation
  • Diet advancement as tolerated Complications to monitor include wound infection, intra-abdominal abscess, and ileus.
• Complications:
  • Wound infection
  • Intra-abdominal abscess
  • Ileus Appendicitis in children differs from adults with more rapid progression to perforation due to their thinner appendiceal wall and less developed omentum, making timely diagnosis crucial to prevent complications 1.

From the Research

Diagnosis of Acute Appendicitis in Pediatrics

• Acute appendicitis is a serious condition in children, with an incidence of one to two cases per 10,000 in children less than four years old 2.
• The diagnosis of acute appendicitis in young children is challenging due to atypical presentations and the difficulty in obtaining a reliable history and physical examination findings 2.
• Concerns about radiation exposure may delay the diagnosis and increase the risk of perforation and peritonitis, highlighting the need for a high index of suspicion for acute appendicitis in young children 2.

Treatment of Acute Appendicitis in Pediatrics

• Treatment usually consists of a combination of surgery and antibiotics, but there is controversy regarding medical versus operative management in young patients 2.
• Antibiotic therapy can be effective in treating uncomplicated acute appendicitis, but the choice of antibiotics and duration of treatment are important considerations 3.
• A study found that poor compliance with antibiotic guidelines resulted in antibiotic overuse without benefit in terms of anti-infective efficacy, highlighting the need for better adherence to guidelines 3.

Management Strategies

• The management of acute appendicitis depends on the clinical state, with either immediate surgery or primarily antibiotic therapy, and combined with drainage of abscess, being followed by interval appendectomy in some cases 4.
• A shared decision based on the patient's preferences should be made in cases of uncomplicated appendicitis without risk factors for failure of non-operative management 4.
• Recent studies have shown the feasibility of antibiotic therapy for uncomplicated appendicitis, but the recurrence rates of non-operated patients within 1 year are as high as 20-30% 4.

Quality Improvement Initiatives

• A quality improvement study found that updating electronic health record orders and educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis can decrease the treatment of uncomplicated acute appendicitis with broad-spectrum antibiotics without increasing the rate of surgical site infections 5.
• The study highlights the importance of optimizing antibiotic management for patients with acute appendicitis to reduce antibiotic-resistant infections 5.