From the Guidelines
Pediatric acute appendicitis should be managed with prompt diagnosis and treatment to prevent complications, and the definitive treatment is appendectomy, either laparoscopic or open, with laparoscopic approach generally preferred due to faster recovery and fewer wound complications, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. The diagnosis of pediatric acute appendicitis typically involves clinical evaluation, laboratory tests, and imaging studies, with ultrasound as the first-line imaging modality, and CT scan if ultrasound is inconclusive, as suggested by the ACR Appropriateness Criteria for suspected appendicitis in children 1. Some key points to consider in the management of pediatric acute appendicitis include:
- Preoperative management with nil by mouth, intravenous fluids, and antibiotics, such as piperacillin-tazobactam or ceftriaxone plus metronidazole 1
- The use of clinical scoring systems, such as the Alvarado score or the Pediatric Appendicitis Score, to help diagnose and assess the severity of appendicitis, although these scores have limitations and should be used in conjunction with other diagnostic tools 1
- The consideration of non-operative management with antibiotics alone in select cases of uncomplicated appendicitis, although this approach carries a risk of recurrence, as discussed in the 2020 update of the WSES Jerusalem guidelines 1
- Post-operative care, including pain management, gradual diet advancement, and monitoring for complications, such as wound infection or intra-abdominal abscess, as outlined in the example answer. It is essential to prioritize the most recent and highest-quality study, which in this case is the 2020 update of the WSES Jerusalem guidelines 1, to ensure that the management of pediatric acute appendicitis is based on the best available evidence.
From the Research
Pediatric Acute Appendicitis
- Acute appendicitis is a serious and life-threatening condition in children, with an incidence of one to two cases per 10,000 in children under four years old 2.
- The diagnosis of acute appendicitis in young children is challenging due to atypical presentations, difficulty in obtaining a reliable history, and physical examination findings 2.
- Prompt diagnosis and management are crucial to prevent serious complications such as abscess formation, perforation, bowel obstruction, peritonitis, and sepsis 2.
Treatment Options
- Broad-spectrum antibiotic therapy is warranted in the care of pediatric patients with appendicitis, and a simplified once-daily regimen of ceftriaxone and metronidazole is cost-effective in perforated patients 3.
- The treatment of acute appendicitis in children can be either surgical appendectomy or nonoperative management with antibiotics, and the choice of treatment depends on various factors, including the severity of the condition and the patient's overall health 4, 5.
- Laparoscopic appendectomy is a common treatment for acute appendicitis in children, and clinical pathways should be used to diagnose and manage the condition 5.
Diagnosis and Management
- The diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging, and scoring systems can be used in combination with selective imaging and surgical examination to diagnose most children with appendicitis 6, 5.
- Concerns about radiation exposure may delay the diagnosis and increase the risk of perforation and peritonitis, and clinicians should have a high index of suspicion for acute appendicitis, particularly in young children 2.
- The management of acute appendicitis in children requires a multidisciplinary approach, and treatment options should be discussed with families and patients, taking into account the current state of the literature and the individual patient's needs 4.