What is the recommended management for pediatric patients with suspected appendicitis?

Management of Pediatric Appendicitis

Laparoscopic appendectomy is the preferred treatment for children with acute appendicitis, and should be performed within 24 hours of admission for uncomplicated cases and within 8 hours for complicated/perforated appendicitis. 1

Diagnostic Approach

Clinical Assessment

• Children under 5 years present with atypical symptoms significantly more frequently than older children, making clinical diagnosis particularly unreliable in this age group, with higher rates of delayed diagnosis and perforated appendicitis. 2
• Look for the constellation of characteristic abdominal pain (particularly migratory pain to the right lower quadrant), localized abdominal tenderness, fever, and laboratory evidence of acute inflammation. 3, 4
• Positive psoas sign, fever, or migratory pain to the right lower quadrant increases likelihood of appendicitis, while vomiting before pain makes appendicitis less likely. 4
• Urinalysis is essential to exclude urinary tract infection as an alternative diagnosis in children with abdominal pain. 2

Imaging Strategy

Ultrasound is the initial imaging modality of choice for diagnosing appendicitis in children because it provides no radiation exposure and has excellent accuracy when results are definitive. 2, 4

• Ultrasound has a sensitivity of approximately 76% and specificity of 95% for diagnosing acute appendicitis. 4
• Key ultrasound findings include appendiceal diameter ≥7 mm, non-compressibility of the appendix, and appendiceal tenderness during examination. 4
• If ultrasound is non-diagnostic or equivocal and clinical suspicion persists, proceed directly to CT with IV contrast or MRI rather than repeating ultrasound. 2
• CT imaging is preferred for definitive diagnosis when ultrasound is inconclusive, although MRI can be used to avoid radiation exposure. 3, 2
• Ultrasound can identify alternative diagnoses such as intussusception, mesenteric adenitis, ovarian pathology, and constipation. 2

Follow-up for Negative Imaging

• For patients with imaging findings negative for suspected appendicitis, follow-up at 24 hours is recommended to ensure resolution of signs and symptoms, because of the low but measurable risk of false-negative results. 3

Antibiotic Management

Timing and Indications

Antimicrobial therapy should be administered to all patients who receive a diagnosis of appendicitis. 3

Antibiotic Selection

Acceptable broad-spectrum antimicrobial regimens for pediatric patients with complicated intra-abdominal infection include: 3

• Aminoglycoside-based regimen (gentamicin 3-7.5 mg/kg/day every 8-24 hours + metronidazole 30-40 mg/kg/day every 8 hours + ampicillin 200 mg/kg/day every 6 hours)
• Carbapenem: ertapenem (15 mg/kg twice daily for 3 months to 12 years, not to exceed 1 g/day; 1 g/day for ≥13 years), meropenem (60 mg/kg/day every 8 hours), or imipenem-cilastatin (60-100 mg/kg/day every 6 hours)
• β-lactam/β-lactamase inhibitor combination: piperacillin-tazobactam (200-300 mg/kg/day of piperacillin component every 6-8 hours) or ticarcillin-clavulanate (200-300 mg/kg/day of ticarcillin component every 4-6 hours)
• Advanced-generation cephalosporin with metronidazole: cefotaxime (150-200 mg/kg/day every 6-8 hours), ceftriaxone (50-75 mg/kg/day every 12-24 hours), ceftazidime (150 mg/kg/day every 8 hours), or cefepime (100 mg/kg/day every 12 hours) PLUS metronidazole (30-40 mg/kg/day every 8 hours)

Special Considerations

• For children with severe reactions to β-lactam antibiotics, use ciprofloxacin (20-30 mg/kg/day every 12 hours) plus metronidazole or an aminoglycoside-based regimen. 3
• Initial intravenous antibiotics with subsequent conversion to oral antibiotics is recommended based on the patient's clinical condition. 1
• Routine use of broad-spectrum agents is not indicated for all children with fever and abdominal pain for whom there is a low suspicion of complicated appendicitis. 3

Surgical Management

Preferred Surgical Approach

Conventional three-port laparoscopic appendectomy is preferred over single-incision approaches due to shorter operative times, less postoperative pain, and lower incidence of wound infection. 1

• Laparoscopic appendectomy offers better treatment success rates, lower recurrence rates, and improved quality of life compared to open appendectomy. 1
• In pediatric patients with favorable anatomy, single incision/transumbilical extracorporeal laparoscopic-assisted appendectomy may be considered as an alternative. 1

Timing of Surgery

• Surgery should be performed within 24 hours of admission for uncomplicated appendicitis. 1
• Early appendectomy within 8 hours is recommended for complicated/perforated appendicitis. 1
• Delaying appendectomy beyond 6 hours after admission demonstrates no differences in surgical site infection or perforation rates compared with immediate appendectomy. 5

Technical Considerations

• Simple ligation of the appendicular stump is recommended over stump inversion in both open and laparoscopic appendectomy, as it is associated with shorter operative times, less postoperative ileus, and quicker recovery. 1
• Wound ring protectors are recommended in open appendectomy to decrease the risk of surgical site infection. 1
• Prophylactic abdominal drainage after laparoscopic appendectomy for complicated appendicitis is not recommended as it does not prevent postoperative complications and may be associated with negative outcomes. 1
• Routine histopathology after appendectomy is recommended to identify unexpected findings. 1

Non-Operative Management Alternative

Non-operative management with antibiotics can be discussed as an alternative to surgery in selected children with uncomplicated appendicitis in the absence of an appendicolith. 1

• When choosing non-operative management, patients and families should be advised about the possibility of treatment failure and the risk of misdiagnosing complicated appendicitis. 1
• Success rates for antibiotics-first strategy are approximately 63-73% at one year. 4

Clinical Pathway Implementation

Local hospitals should establish clinical pathways to standardize diagnosis, in-hospital management, discharge, and outpatient management. 3

• Pathways should be designed by collaborating clinicians including surgeons, infectious diseases specialists, primary care practitioners, emergency medicine physicians, radiologists, nursing providers, and pharmacists. 3
• Clinical pathways reduce unwarranted clinical variation, prevent avoidable patient morbidity, and reduce hospital stays. 3

Common Pitfalls

• Ultrasound accuracy is highly operator-dependent, and both MRI and ultrasound may incorrectly classify up to half of all patients with perforated appendicitis as having simple appendicitis. 4
• Children under 5 years have significantly higher rates of atypical presentations, leading to delayed diagnosis and higher perforation rates. 2, 1
• Clinical scores such as the Pediatric Appendicitis Score can help risk-stratify patients but cannot eliminate the need for imaging. 2