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

From the Guidelines

Acute appendicitis in pediatric patients should be managed with prompt diagnosis and treatment, prioritizing laparoscopic appendectomy and broad-spectrum antibiotics, such as piperacillin-tazobactam or ceftriaxone plus metronidazole, to prevent complications and improve outcomes. The condition typically presents with periumbilical pain that migrates to the right lower quadrant, accompanied by fever, nausea, vomiting, and anorexia. Diagnosis involves clinical evaluation, laboratory tests (including complete blood count showing leukocytosis), and imaging studies, with ultrasound being the preferred initial imaging modality due to lack of radiation exposure, followed by CT scan if results are equivocal 1.

Key Considerations

• Preoperative management includes NPO status, intravenous fluids (typically normal saline at maintenance rates based on weight), and antibiotics 1.
• Pain management with acetaminophen (15 mg/kg/dose q4-6h) and/or morphine (0.05-0.1 mg/kg/dose IV q2-4h) should be provided.
• In uncomplicated cases, children can often be discharged within 24-48 hours post-surgery.
• For perforated appendicitis, a longer course of antibiotics (7-10 days) and hospital stay may be necessary.
• Non-operative management with antibiotics alone may be considered in select cases of uncomplicated appendicitis, though this approach remains controversial 1.

Diagnostic Approaches

• Clinical scoring systems, such as the Alvarado score and Samuel’s Pediatric Appendicitis Score (PAS), can be useful in diagnosing acute appendicitis in pediatric patients, but may not be sufficient on their own due to atypical clinical features and the difficulty of obtaining a reliable history and physical examination 1.
• The use of the Pediatric Appendicitis Laboratory Score (PALabS) including clinical signs, leucocyte and neutrophil counts, CRP, and calprotectin levels has been shown to accurately predict which children are at low risk of AA and could be safely managed with close observation 1.

Treatment Outcomes

• Laparoscopic appendectomy has been shown to be safe and effective in children, with lower incidence of surgical site infections and bowel obstruction compared to open appendectomy 1.
• The choice of antibiotics should be based on the severity of the disease and the presence of complications, with broader-spectrum coverage obtained with piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate, or imipenem-cilastatin 1.

From the Research

Diagnosis and Management of Acute Appendicitis in Pediatric Patients

• Acute appendicitis is a common abdominal surgical emergency that affects pediatric patients, with a significant annual incidence rate 2.
• The diagnosis of acute appendicitis in pediatric patients is based on history, physical examination, laboratory evaluation, and imaging findings, such as appendiceal dilatation and the presence of appendicoliths 2, 3.
• The management of acute appendicitis in pediatric patients can be either operative or non-operative, with the choice of treatment depending on the severity of the disease and the presence of complications 3, 4.

Non-Operative Management of Uncomplicated Appendicitis in Children

• Non-operative management (NOM) of uncomplicated appendicitis in children has been shown to be safe and feasible, with a similar success rate to operative management (OM) in patients without appendicoliths 3.
• A meta-analysis of randomized controlled trials found no statistically significant difference in complication risk between NOM and OM in pediatric patients with uncomplicated appendicitis 3.
• However, the length of hospital stay was significantly longer in the NOM group compared to the OM group 3.

Antibiotic Treatment for Acute Appendicitis in Children

• Antibiotic treatment is a crucial component of the management of acute appendicitis in children, with narrow-spectrum antibiotics being equivalent to anti-Pseudomonal agents in preventing organ space infections (OSI) in uncomplicated appendicitis 4.
• A study comparing ceftriaxone with metronidazole to piperacillin/tazobactam in the management of complicated appendicitis in children found similar rates of OSI and resource utilization between the two treatment groups 4.
• Conservative antibiotic treatment (CAT) has been shown to be safe and efficacious in children with uncomplicated acute appendicitis, but high rates of recurrent appendicitis and subsequent appendectomy have been reported 5.

Risk Factors for Recurrent Appendicitis after Conservative Treatment

• Older age, larger outer appendiceal diameter, and high white blood cell counts have been identified as risk factors for recurrent appendicitis and subsequent appendectomy in children treated with CAT 5.
• A decision tree model has been proposed to predict appendectomy probabilities for patients based on their prognostic measurements, which may help clinicians and parents make informed decisions about treatment 5.