What is the recommended treatment for appendicitis in school-age kids?

Treatment of Appendicitis in School-Age Children

Laparoscopic appendectomy is the recommended first-line treatment for acute appendicitis in school-age children, with surgery performed within 24 hours of admission for uncomplicated cases and within 8 hours for complicated appendicitis. 1, 2

Surgical Management: The Gold Standard

Laparoscopic appendectomy should be strongly preferred over open appendectomy when equipment and expertise are available, as it offers superior outcomes including lower postoperative pain, reduced surgical site infections, shorter hospital stays, and improved quality of life. 1, 2 The American College of Surgeons specifically endorses this approach for pediatric patients, noting better treatment success rates and lower recurrence compared to non-operative management. 1

Timing of Surgery

• For uncomplicated appendicitis: Surgery should be performed within 24 hours of admission, minimizing delay wherever possible. 3, 2
• For complicated appendicitis (perforation/abscess): Early appendectomy within 8 hours is recommended to reduce adverse outcomes. 1, 2
• Do not delay beyond 24 hours from admission, as delays are associated with increased risk of adverse outcomes including perforation. 3, 2

Technical Considerations

• Conventional three-port laparoscopic appendectomy is preferred over single-incision approaches due to shorter operative times, less postoperative pain, and lower wound infection rates. 1, 2
• Simple ligation of the appendicular stump is recommended over stump inversion in both open and laparoscopic procedures, as it results in shorter operative times, less postoperative ileus, and quicker recovery. 1
• Routine histopathology after appendectomy should be performed to identify unexpected findings, including the rare possibility of malignancy (0.3% incidence in some series). 1, 4

Antibiotic Management

Preoperative Antibiotics

A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision to decrease wound infection and postoperative intra-abdominal abscess rates. 2 Piperacillin-tazobactam is FDA-approved for complicated appendicitis in children 2 months and older, covering beta-lactamase producing organisms including E. coli and Bacteroides fragilis group. 5

Postoperative Antibiotics

• For uncomplicated appendicitis: Postoperative antibiotics are NOT recommended and should be discontinued after surgery. 3, 2
• For complicated appendicitis: Broad-spectrum antibiotics are indicated with early switch to oral antibiotics after 48 hours and total duration less than 7 days. 3, 2 This approach is safe, effective, and cost-efficient, with no increased risk of complications compared to prolonged intravenous therapy. 3

Non-Operative Management: A Selective Alternative

Non-operative management (NOM) with antibiotics can be discussed as an alternative to surgery in selected children with uncomplicated appendicitis, but only in the absence of an appendicolith. 3, 2 However, families must be clearly advised about:

• The possibility of treatment failure (approximately 30.7% require appendectomy within one year, though conversely two-thirds avoid surgery). 4
• The risk of misdiagnosing complicated appendicitis. 3, 2
• Higher rates of negative appendectomies if surgery becomes necessary later (3.16 times higher risk). 4

When NOM is Chosen

• Initial intravenous antibiotics with subsequent conversion to oral antibiotics based on clinical improvement. 3, 1, 2
• Close monitoring for treatment failure requiring surgical intervention. 3

Management of Complicated Appendicitis with Abscess/Phlegmon

• Where advanced laparoscopic expertise is available: Laparoscopic approach is the treatment of choice. 2
• In settings without laparoscopic expertise: Non-operative management with antibiotics and percutaneous drainage (if available) is suggested. 2
• Routine interval appendectomy is NOT recommended after successful non-operative management; it should only be performed for children with recurrent symptoms. 2

Critical Diagnostic Considerations

Ultrasound is the recommended first-line imaging method for suspected appendicitis in school-age children, with clinical scoring systems (Alvarado Score, Pediatric Appendicitis Score) helping to risk-stratify patients. 3, 2 Point-of-care ultrasound (POCUS) is appropriate if imaging is indicated based on clinical assessment. 3, 2

Common Pitfalls to Avoid

• Younger children (<5 years) present atypically with higher perforation rates due to delayed diagnosis—maintain high clinical suspicion even with non-classic presentations. 1, 2, 6, 7
• Perforation is found in nearly all children under 3 years due to diagnostic delays averaging 3-5 days, often initially misdiagnosed as upper respiratory infections, otitis media, or urinary tract infections. 7
• The classic triad of abdominal pain, tenderness, and vomiting should prompt serious consideration of appendicitis even in very young children. 7
• Do not withhold pain control—opioids, NSAIDs, and acetaminophen should be prioritized as they do not result in delayed or unnecessary intervention. 8

Special Populations

• Patients >40 years with complicated appendicitis treated non-operatively should undergo colonic screening and interval full-dose contrast-enhanced CT scan to exclude malignancy, though this is less relevant for school-age children. 3
• Prophylactic abdominal drainage after laparoscopic appendectomy for complicated appendicitis is NOT recommended in children, as it does not prevent complications and may be associated with negative outcomes. 1