What is the management approach for pediatric patients with appendicitis?

Management of Pediatric Appendicitis

Laparoscopic appendectomy is the preferred treatment for pediatric appendicitis, offering superior outcomes compared to open surgery and non-operative management, with surgery performed within 24 hours for uncomplicated cases and within 8 hours for complicated/perforated appendicitis. 1, 2

Initial Diagnostic Approach

Clinical Assessment:

• Evaluate for the triad of abdominal pain, localized right lower quadrant tenderness, and vomiting—these features significantly increase likelihood of appendicitis 3, 4
• Children under 5 years require particularly careful evaluation as they present with atypical symptoms significantly more frequently, leading to higher rates of delayed diagnosis and perforation 5, 3
• Key clinical findings that increase diagnostic probability include positive psoas sign, fever, and migratory pain to the right lower quadrant 5
• Obtain urinalysis to exclude urinary tract infection as an alternative diagnosis 5

Imaging Strategy:

• Ultrasound is the first-line imaging modality, with 76% sensitivity and 95% specificity for acute appendicitis 5
• Diagnostic ultrasound findings include appendiceal diameter ≥7 mm, non-compressibility of the appendix, and appendiceal tenderness during examination 5
• Point-of-care ultrasound (POCUS) is appropriate as a first-line diagnostic tool when imaging is indicated 2

Antibiotic Management

Preoperative Antibiotics:

• Administer a single dose of broad-spectrum antibiotics 0-60 minutes before surgical incision to decrease wound infection and intra-abdominal abscess rates 2
• Acceptable regimens include aminoglycoside-based combinations, carbapenems, β-lactam/β-lactamase inhibitor combinations (such as piperacillin-tazobactam), or advanced-generation cephalosporins with metronidazole 5, 6
• For intra-abdominal infections, amoxicillin/clavulanate or ceftriaxone plus metronidazole are appropriate empiric choices 7

Postoperative Antibiotics:

• For uncomplicated appendicitis: postoperative antibiotics are NOT recommended 2
• For complicated/perforated appendicitis: administer broad-spectrum antibiotics with early switch to oral antibiotics after 48 hours and total duration less than 7 days 2

Surgical Management

Laparoscopic Approach (Preferred):

• Laparoscopic appendectomy is strongly recommended over open appendectomy when expertise and equipment are available, offering lower postoperative pain, fewer surgical site infections, and higher quality of life 1, 2
• Conventional three-port laparoscopic appendectomy is preferred over single-incision approaches due to shorter operative times, less postoperative pain, and lower wound infection incidence 1, 5, 2
• In pediatric patients with favorable anatomy, single-incision/transumbilical extracorporeal laparoscopic-assisted appendectomy may be considered as an alternative 1

Timing of Surgery:

• Uncomplicated appendicitis: perform surgery within 24 hours of admission 1, 2
• Complicated/perforated appendicitis: perform early appendectomy within 8 hours to reduce adverse outcomes 1, 2

Technical Considerations:

• Simple ligation of the appendicular stump is recommended over stump inversion, as it is associated with shorter operative times, less postoperative ileus, and quicker recovery 1, 5, 2
• Use wound ring protectors in open appendectomy to decrease surgical site infection risk 1
• Routine histopathology after appendectomy is recommended to identify unexpected findings 1
• Prophylactic abdominal drainage after laparoscopic appendectomy for complicated appendicitis is NOT recommended, as it does not prevent complications and may be associated with negative outcomes 1, 2

Non-Operative Management (Selected Cases Only)

When to Consider:

• Non-operative management (NOM) with antibiotics can be discussed as an alternative to surgery in selected children with uncomplicated appendicitis in the absence of an appendicolith 7, 1, 5
• Success rates are approximately 63-73% at one year, with NOM avoiding appendectomy in 62-81% of children after 1-year follow-up 7, 5

Critical Limitations:

• The presence of an appendicolith significantly increases failure rate (more than twice the rate), and surgery is recommended in such cases 7
• NOM is associated with higher readmission rates (relative risk 6.98) compared to appendectomy 7
• Patients and families must be advised about the possibility of treatment failure and risk of misdiagnosing complicated appendicitis 7, 1, 5

Antibiotic Protocol for NOM:

• Minimum 48 hours of inpatient intravenous antibiotics followed by oral antibiotics for total duration of 7-10 days 7
• Initial intravenous antibiotics with subsequent conversion to oral antibiotics based on clinical condition 1, 5

Management of Complicated Appendicitis with Abscess/Phlegmon

Treatment Options:

• In settings with advanced laparoscopic expertise: laparoscopic approach is the treatment of choice for appendiceal abscess or phlegmon 2
• In settings without laparoscopic expertise: non-operative management with antibiotics and percutaneous drainage (if available) is suggested 2
• Routine interval appendectomy after successful non-operative management is NOT recommended in children; perform only for children with recurrent symptoms 2

Outpatient Management Considerations

• Outpatient laparoscopic appendectomy may be considered for uncomplicated appendicitis when an appropriate ambulatory setting is available with well-defined enhanced recovery after surgery (ERAS) protocols and proper patient/family information and consent 2

Common Pitfalls and Caveats

Age-Related Considerations:

• Children under 3 years have a 100% perforation rate in some series due to diagnostic delays averaging 3-5 days, resulting in 59% complication rates 3
• Preschool children under 5 years present with atypical symptoms more frequently, leading to delayed diagnosis and higher perforation rates 5, 2, 4
• Initial misdiagnosis is common, with children often treated for upper respiratory infections, otitis media, or urinary tract infections before correct diagnosis 3

Clinical Pathway Implementation:

• Establish standardized clinical pathways involving surgeons, infectious disease specialists, emergency physicians, radiologists, nursing providers, and pharmacists to optimize diagnosis and management 5