AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Appendicitis is acute inflammation and infection of the vermiform appendix, which is usually referred to as the appendix. The appendix is a blind-ending structure that arises from the cecum. Acute appendicitis is one of the most common causes of abdominal pain and is the most frequent condition that leads to emergent abdominal surgery in children.

Pathophysiology

Appendicitis is due to a closed-loop obstruction of the appendix. The obstruction is usually due to either lymphoid hyperplasia within the appendix or impacted fecal matter, which is referred to as a fecalith. Obstruction of the appendix leads to bacterial overgrowth and an increase in intraluminal pressure, which obstructs the venous blood flow and leads to congestion in the appendix. Over time, this congestion leads to ischemia in the appendix, allowing for bacterial translocation and infection. The ischemia and bacterial infection cause inflammation of the appendix. As the disease progresses, the inflammation advances from mild inflammation to a gangrenous appendix. When the appendix becomes gangrenous, it may perforate. This process usually takes place over 72 hours. This is an important point when considering the patient's history for differential diagnoses and is discussed in the Clinical section.

When the appendix perforates, inflammatory fluid and bacterial contents are released into the abdominal cavity. This fluid may infect the peritoneum, and the patient may develop generalized peritonitis. Concomitantly, the patient develops more intense and generalized abdominal pain. However, the omentum and loops of the small intestine may wall off the fluid and form an abscess. In this case, the patient may continue to have localized abdominal pain in the area of the abscess.

Frequency

United States

Appendicitis occurs in all age groups but is rare in infants. If an infant has appendicitis, a diagnosis of Hirschsprung disease should also be considered. In the United States, the incidence of appendicitis is 4 per 1000 children. Overall, 7% of the US population eventually have their appendices removed.

Mortality/Morbidity

At the time of diagnosis, the rate of perforation is 17-40%. Younger children have a higher rate of perforation, with reported rates of 50-85%. The mortality rate for children with appendicitis is 0.1-1%. Mortality is most commonly seen in neonates and infants. This is due to 2 factors. First, appendicitis is rare in this age group, so, unless the physician's index of suspicion is high, it is often low on the list of differential diagnoses. Second, very young patients are unable to communicate the location and nature of their pain. Some neonates may not even become febrile. The patient's only symptom is often irritability or inconsolability.

Sex

The male-to-female ratio is approximately 2:1.

Age

Appendicitis occurs in all age groups. The mean age in the pediatric population is 6-10 years. Appendicitis is rare in the neonate, and the diagnosis is typically made after perforation for the reasons discussed above (see Mortality/Morbidity). Younger children have a higher rate of perforation (50-85% reported).

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

As with almost any clinical entity, the best place to start is with the patient's history. The classic description of appendicitis is a patient who develops vague periumbilical pain followed by nausea, vomiting, and anorexia. Over time, the pain relocates to the right lower quadrant. If the patient's appendix perforates, an interval of pain relief is followed by the development of generalized abdominal pain and peritonitis. While certain cases develop in the classic fashion, some patients deviate from the classic model. Fifteen percent of patients have a retrocecal appendix; thus, their signs and symptoms may not localize to the right lower quadrant. Instead, they localize to the psoas muscle. Other patients may have the tip of their appendix deep in the pelvis, and their signs and symptoms localize to the rectum or bladder.

• Pain: The initial symptom is poorly defined periumbilical pain. Acute onset of severe pain is not typical in acute appendicitis but is seen with acute ischemic conditions such as volvulus, testicular torsion, ovarian torsion, or intussusception. If the pain is initially located in the right lower quadrant, severe constipation should be considered.
• Nausea and vomiting: Generally, vomiting that occurs prior to pain is unusual. However, in retrocecal appendices, particularly those that extend cephalad along the posterior surface of the right colon, inflammation of the appendix irritates the nearby duodenum, resulting in nausea and vomiting prior to the onset of right lower quadrant pain.
• Diarrhea: Likewise, significant diarrhea is atypical in appendicitis, and the physician should consider other diagnoses while not ruling out appendicitis. In patients with an appendix in a pelvic location, inflammation of the appendix occasionally results in an irritative stimulation of the rectum. These patients often report diarrhea. However, upon closer questioning, such patients relate symptoms of frequent, small-volume, soft stools and usually not true diarrhea.
• Shift to right lower quadrant pain: After a few hours, pain shifts to the right lower quadrant because of inflammation of the parietal peritoneum. This pain is more intense, continuous, and localized than in the initial pain.
• Fever: Most children with appendicitis are afebrile or have a low-grade fever and characteristic flushness of their cheeks. Severe fever is not a common presenting feature unless perforation has occurred, in which case it may still be a rare finding. According to one study, vomiting and fever are more frequent findings in children with appendicitis than in children with other causes of abdominal pain.

Physical

The physical examination in children may vary depending on age. Irritability may be the only sign of appendicitis in a neonate. Older children often seem uncomfortable or withdrawn. They may prefer to lie still because of peritoneal irritation. Teenaged patients often present in a classic or near-classic fashion.

• General: The patient's general state should be observed before interacting with them. The patient's state of activity or withdrawal may provide information. A patient with abdominal pain who is in obvious distress gives the impression of an infectious process; however, other causes must be ruled out.
• Cardiac and pulmonary: The evaluation of the patient's heart and lungs reflects the patient's overall state more than it indicates the appendix as a cause. Patients are often dehydrated or in pain and, therefore, may be tachycardic or tachypneic. Pediatric patients have great physiological reserve and may not show any general symptoms until they are very sick.
• Abdominal examination
• • The child's abdomen should be examined in the same way an adult's abdomen is examined. Full exposure of the abdomen is key. Localization of the pain is also key but may depend on the position of the appendix.
  • Observing the patient cough and asking them to localize their pain with one finger often localizes their discomfort to the right lower quadrant. Typically, maximal tenderness can be found at the McBurney point in the right lower quadrant. However, the appendix may lie in many positions.
    • A medially positioned appendix may present as suprapubic tenderness.
    • A laterally positioned appendix often presents as flank tenderness.
    • A retrocecal appendix may not have any tenderness until it is advanced or perforated.
  • The abdomen should be palpated with a gentle touch to search for involuntary guarding of the rectus or oblique muscles. Eliciting rebound tenderness is cruel and is an unnecessary part of the abdominal examination.
  • Rovsing sign is pain in the right lower quadrant in response to left-sided palpation or percussion and strongly suggests peritoneal irritation.
  • To perform the psoas sign, place the child on the left side and hyperextend the right leg at the hip. A positive response suggests an inflammatory mass overlying the psoas muscle (retrocecal appendicitis).
  • Perform the obturator sign by internally rotating the flexed right thigh. A positive response suggests an inflammatory mass overlying the obturator space (pelvic appendicitis).
  • The cough sign (ie, sharp pain in the right lower quadrant after a voluntary cough) suggests peritoneal irritation.
• Rectal examination
• • A rectal examination is important and should be performed in all patients who are evaluated for appendicitis.
  • The caliber of the patient's anus should be taken into consideration, and smaller digits should be used for examining younger patients.
  • The rectal examination in a young child may be completely objective, as they may not be able to communicate variations in tenderness or may have general discomfort from the examination.
  • Objective information to ascertain includes impacted stool or an inflammatory mass.
  • A patient who is able to communicate during a subjective examination should be asked if any tenderness is present in different areas of the rectum.
  • Right-sided tenderness of the rectum is the classic finding in pelvis appendicitis or in pus that pools in the pelvis from an inflamed appendix elsewhere in the abdomen.

Causes

• Appendicitis is caused by a closed-loop obstruction of the appendix. Most cases are caused either by impacted fecal material, called a fecalith or appendicolith, or by hyperplasia of submucosal lymphoid follicles. Rarely, foreign objects or nematodes may cause luminal obstruction.
• Obstruction leads to increasing intraluminal pressure from bacterial overgrowth. This leads to vascular compression, initially on the venous side, which then leads to congestion and decreased wall perfusion. This decreased perfusion leads to necrosis and inflammation of the appendix.
• During the initial stage, the patient feels only periumbilical pain because of the appendix's T10 innervation. As the inflammation continues, an exudate forms on the appendiceal serosal surface. When the exudate touches the parietal peritoneum, a more intense and localized pain develops. The location of this pain is described above (see History).
• As the obstruction continues, bacteria within the appendix proliferate and increase intraluminal pressure. The bacteria then infiltrate the wall of the appendix. If the diagnosis is not made early, the obstruction progresses, and the wall of the appendix stretches.
• Over time, the intraluminal pressure in the appendix increases, the strength of the appendiceal wall decreases because of the necrosis, and perforation occurs. At this point, inflammatory fluid and bacterial contents release into the abdominal cavity. This further inflames the peritoneal surface, and peritonitis develops. The location and extent of peritonitis (diffuse or localized) depends on the degree to which the omentum and adjacent bowel loops can contain the spillage of luminal contents.
• If the contents become walled off and form an abscess, the pain and tenderness may be localized to the abscess. If the contents are not walled off and the fluid is able to travel throughout the peritoneum, a general peritonitic state is observed.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Ovarian cyst
Ovarian torsion
Pelvic inflammatory disease (PID)
Pregnancy
Ectopic pregnancy
Renal calculi
Mesenteric lymphadenitis
Mittelschmerz
Pneumonia (right lower lobe)
Neutropenic typhilitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory findings may increase suspicion of appendicitis but are not diagnostic. The minimum laboratory workup for a patient with possible appendicitis includes a WBC count with differential and urinalysis.
• CBC count
• • The WBC count is elevated in approximately 70-90% of patients with acute appendicitis; however, it is also elevated in many other abdominal conditions. Furthermore, the elevation is usually only mild, and the increase of the WBC count occurs only as the disease process progresses.
  • The WBC count is often within the reference range during the first 24 hours of symptoms. Therefore, its predictive value is limited.
  • If the WBC count exceeds 15,000 cells/µL, perforation is more likely. However, one study found no difference between the WBC counts of children with simple appendicitis and those of children with perforated appendicitis.
  • A WBC count within the reference range does not exclude appendicitis because this is typical in at least 10% of patients with appendicitis.
  • In the immunocompromised patient, a neutrophil count of less than 800 may suggest typhilitis.
• Urinalysis
• • Urinalysis is useful for detecting urinary tract disease, including infection and renal stones. However, irritation of the bladder or ureter caused by an inflamed appendix may result in few urinary WBCs. The presence of 20 WBCs suggests a urinary tract infection.
  • Hematuria may be caused by renal stones, urinary tract infection, Henoch-Schönlein purpura, or hemolytic uremic syndrome. However, small numbers of RBCs also can occur in appendicitis when an overlying phlegmon or abscess lies adjacent to the ureter (up to 20% of patients). Typically, the RBC count is less than 20 per high-power field.
  • Normal urinalysis results do not provide any diagnostic value for appendicitis, although a grossly abnormal result may suggest an alternative cause of abdominal pain.
• Electrolytes: Electrolyte assessments and renal function tests are more helpful for management than diagnosis. Indications include a significant history of vomiting or clinical suspicion of significant dehydration.
• Additional studies
• • Liver function tests and amylase and lipase assessments are helpful when the etiology is unclear.
  • A beta-human chorionic gonadotropin (beta-HCG) test should be performed to rule out pregnancy or ectopic pregnancy in female patients.

Imaging Studies

• Abdominal radiography
• • Abdominal radiograph findings are normal in many individuals with appendicitis. However, plain films may be helpful in the setting of severe constipation.
  • Calcified appendiceal fecalith is present in less than 10% of persons with inflammation, but its presence confirms the diagnosis of appendicitis.
  • Radiographic signs suggestive of appendicitis include convex lumbar scoliosis, obliteration of right psoas margin, right lower quadrant air-fluid levels, air in the appendix, or localized ileus. Rarely, a perforated appendix may produce pneumoperitoneum.
  • If no other imaging studies are to be performed, an abdominal series is strongly suggested.
• Ultrasonography
• • Prior to the advent of CT scanning, graded compression ultrasonography was the preferred imaging modality in the evaluation of pediatric acute appendicitis. This technique involves locating the appendix using ultrasonography and then attempting to compress the lumen of the appendix.
  • The advantages of ultrasonography include its noninvasiveness, lack of radiation, no contrast medium, and minimal pain.
  • The downside of ultrasonography is that the examination is operator dependent. In experienced hands, ultrasonography has an overall sensitivity of 85% and specificity of 94% in pediatric patients.
  • For ultrasonography to be diagnostic of appendicitis, it must locate and visualize the appendix. Ultrasonography that does not visualize the appendix does little to rule in or out appendicitis.
  • Specific ultrasonography findings can support the diagnosis of appendicitis.
  • The finding of a noncompressible dilated appendix is a strong indicator of nonperforated appendicitis.
  • After perforation, ultrasonography can reveal a periappendiceal phlegmon or abscess formation.
  • Additional supportive findings include an appendicolith, fluid in the appendiceal lumen, focal tenderness over the inflamed appendix (sonographic McBurney point), and a transverse diameter of 6 mm or larger.
  • Ultrasonography is also useful in diagnosing alternate pathology (eg, tubo-ovarian abscess, ovarian torsion, ovarian cyst, mesenteric adenitis).
• CT scanning
• • CT scanning has become the modality of choice for diagnosing appendicitis in children.
  • While radiation exposure is a concern, CT scanning has been shown to carry an accuracy of 97% in diagnosing appendicitis.
  • Other advantages include the ability to evaluate the entire abdomen and to locate abscesses and phlegmon, the lack of dependence on operator skill, and physician familiarity with reading CT scans.
  • Disadvantages include radiation exposure, the need for oral and intravenous contrast and its related disadvantages, and the need for the patient to stay still, which is often difficult for young children.
  • Because of the advantages of CT scanning, 62% of surveyed North American pediatric surgeons preferred it for evaluation of appendicitis. Of note, less than 1% of pediatric surgeons favored CT scanning for every patient with suspected appendicitis. Most preferred the use of CT scanning on a selected basis, with 51-58% of patients with suspected appendicitis undergoing the modality.
  • Despite the current widespread use of CT scanning for evaluation of appendicitis, with its superior sensitivity and specificity, the rate of children who undergo appendectomy has not shown a statistically significant reduction. 
• Chest radiography: If the history, physical examination, laboratory tests, and imaging studies have failed to produce a satisfactory differential diagnosis, an anteroposterior (AP) and lateral chest radiograph should be performed to look for right lower lobe pneumonias.

Histologic Findings

Histologic findings typically range from acute inflammatory infiltrate, most apparent in the submucosal level in early appendicitis, to transmural infarction in perforated appendicitis. The finding of an apparently normal appendix during surgery requires careful follow-up of the histologic findings. Occasionally, early appendicitis is histologically identified and clinically correlates with the resolution of preoperative symptoms. Additionally, unsuspected findings of luminal nematodes should indicate further anthelmintic therapy (eg, mebendazole [Vermox]).

Staging

The clinical staging of appendicitis has important implications in the postoperative treatment of the child. While somewhat subjective during surgery, appendicitis may be divided into 3 broad categories: acute (nongangrenous) appendicitis, suppurative or gangrenous (nonperforated) appendicitis, and perforated appendicitis. Perforated appendicitis can be divided further into cases with diffuse peritonitis and those with localized peritonitis.

• Acute (nongangrenous): This stage of appendicitis is referred to as early appendicitis. No mural gangrene or infarction is present. This type requires no further antibiotic therapy in most settings. The child may be discharged home as soon as diet and oral pain medications can be tolerated.
• Suppurative or gangrenous (nonperforated): Patients with exudative appendicitis, particularly individuals with mural gangrene, have an increased rate of postoperative intra-abdominal and wound infections, even in the absence of demonstrable perforations. Microperforations are often present, as demonstrated on routine culture findings. However, if the Gram stain and cultures are negative, antibiotics can be stopped after approximately 24 hours, and the child may be discharged as soon as diet and oral pain medications can be tolerated.
• Perforated: Perforated appendicitis (diagnosed based on intraoperative findings or positive intraoperative cultures) is associated with postoperative infection in as many as 30% of patients. Children with perforated appendicitis require antibiotic therapy for a minimum of 10 days. Often, patients develop intra-abdominal abscesses that require drainage. A high index of suspicion for a postoperative abscess is required in the patient with perforated appendicitis who has fever or ileus for more than 5 days.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Making a timely diagnosis is a difficult challenge when evaluating children with abdominal pain. Classifying patients with abdominal pain into the following 3 major categories may be helpful:

• Diagnosis not consistent with appendicitis
• • This group includes patients whose history and physical examination findings are not consistent with appendicitis or any significant abdominal process.
  • Performing a complete physical examination, including rectal palpation and urinalysis, before discharge is important.
  • Few patients require sophisticated radiological evaluation. However, as discussed above (see Chest radiography), radiographic evaluation of the kidney, ureters, bladder, and chest may lead to the correct diagnosis (constipation or pneumonia) and treatment.
• Classic history for appendicitis
• • Patients with a classic history require prompt surgical consultation.
  • Maintain nothing-by-mouth status in patients with suspected appendicitis and start intravenous fluids to restore intravascular volume.
  • Ensure adequate hydration for patients who present with suspected appendicitis.
  • Even in early acute appendicitis, children frequently have not had sufficient oral intake and present with some degree of intravascular dehydration.
  • Antibiotic therapy is an important aspect of the preoperative treatment of appendicitis but should not be administered until consulting with a surgeon.
  • Direct antibiotic therapy against gram-negative and anaerobic organisms (eg, Escherichia coli, Bacteroides species).
  • Most of these patients do not require radiological evaluation if their history, physical, and laboratory evaluations are convincing. However, some surgeons still prefer ultrasonography in female patients because of the possibility of a gynecological etiology.
• Unclear diagnosis
  • In these children, the history may be consistent with appendicitis; however, the examination is not supportive. In other children, the inverse may be true.
  • This is the main group who benefit from double-contrast abdominal CT scanning. Serial examinations and test results may also help to clarify the diagnosis.
  • Reevaluate the patient over a few hours to determine the need for surgical consultation. If uncertainty persists after a period of observation, obtain a consultation with a surgeon.

Surgical Care

• Appendectomy
• • The definitive treatment for appendicitis is appendectomy.
  • Historically, appendectomy had a 10-20% false-positive rate, but the frequent use of radiologic imaging has reduced this rate.
  • Patients with a history of symptoms for several days, a localized walled-off abscess that is revealed by CT or ultrasonography, a functioning GI tract, and no signs of sepsis may be candidates for interval appendectomy. This involves admitting the patient to the hospital for initial medical treatment with intravenous antibiotics.
  • The routine use of peripherally inserted catheter (PIC) lines may lessen the morbidity of both the hospital and home care for these children.
  • If the abscess is accessible, an interventional radiologist performs percutaneous drainage.
  • Once symptoms resolve and regular diet is tolerated, the patient can be discharged home with intravenous or oral antibiotics to complete the course. The patient should then have their appendix electively removed in 8-12 weeks.
• Open versus laparoscopic appendectomy
• • The classic operation for removing the appendix is an open appendectomy. This involves making a McBurney, Rocke-Davis, or Fowler-Weir incision. Dissection then proceeds through the external oblique, internal oblique, and transversalis in a muscle-spreading or muscle-splitting fashion. The peritoneum is entered. The appendix is then brought out into the field, clamped, ligated, and divided. The exposed mucosa is then cauterized. Some perform stump inversion. The cecum is then returned to the abdomen, and the incision is closed.
  • The use of laparoscopic appendectomy has now come into favor. In this procedure, port placement consists of first putting the camera port in the umbilicus. Then, under direct visualization, two 5-mm ports are placed. Based on surgeon preference, either (1) one port is placed in the right lower quadrant and the other in the left lower quadrant or (2) both are placed in the left lower quadrant. The cecum and appendix are laterally to medially mobilized. Various methods (eg, electrocautery, endo loops, stapling devices) are available to remove the appendix, and the choice of method should be left to the discretion of the surgeon. The appendix is then removed from the abdomen using an endobag.
  • After an appropriate learning curve, the difference in operative time of open versus laparoscopic appendectomy has shown no statistical significance.
  • Potential advantages of laparoscopic appendectomy include reduced postoperative pain, lower wound infection rate, and quicker return to normal activities.
  • Length of stay has shown to be 0.6 days shorter with laparoscopic versus open appendectomy. Patients also have a faster return to daily activities, including school and gym.
  • The other advantage of laparoscopic appendectomy is the ability to evaluate the entire abdomen, which can be useful or diagnostic in the adolescent female, in whom gynecological etiologies can often imitate appendicitis.

Consultations

• Pediatrician
• General surgeon

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Administer one dose of preoperative antibiotics to children with suspected appendicitis and stop administration after surgery if no perforation exists. Patients who present with perforated appendicitis may be volume depleted and in need of aggressive fluid resuscitation. Administer a combination of ampicillin, clindamycin (or metronidazole), and gentamicin to prevent infection from aerobic and anaerobic organisms. Alternative regimens include ampicillin and sulbactam, cefoxitin, cefotetan, piperacillin and tazobactam, ticarcillin and clavulanate, and imipenem and cilastatin. Fifteen percent of patients with a ruptured appendix may have resistant organisms and require a change in the initially chosen antibiotics.

Drug Category: Antibiotics

Antibiotic regimens should cover most commonly encountered organisms, including E coli and Bacteroides, Klebsiella, Enterococcus, and Pseudomonas species.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• The main postappendectomy considerations include continued fluid resuscitation, use of antibiotics, possible percutaneous drainage of intra-abdominal abscesses, and resumption of diet and bowel function.
• Fluid resuscitation
• • Patients with appendicitis are dehydrated in most cases. These patients usually receive preoperative fluid boluses. However, continued fluid resuscitation, appropriate to fluid status and severity of appendicitis, is needed.
  • The spectrum ranges from (1) patients with early appendicitis who are started on clear fluids postoperatively and can have intravenous fluids removed when advanced to regular diet to (2) patients with perforated appendicitis who need postoperative fluid boluses.
  • If fluid status is unclear, urine output is the most common measure. The patient's urine output should be no less than 0.5 mL/kg/hr.
  • If dehydration is suspected, Foley catheter placement, monitoring of urine output, and correct fluid replacement are indicated.
• Antibiotics
• • As described above (see Medication), patients who are diagnosed with appendicitis and are taken immediately to the operating room receive 1 dose of preoperative antibiotics.
  • If the appendix is not gangrenous of perforated, no postoperative antibiotics are indicated.
  • A gangrenous appendix warrants antibiotics for 24-72 hours, depending on Gram stain and culture results.
  • Perforated appendicitis requires intravenous antibiotics for an extended period. See Medication for a discussion of antibiotic options.
• Percutaneous drainage
• • Patients with gangrenous or perforated appendicitis often develop intra-abdominal abscesses. These may be present at the time of presentation or may develop postoperatively or during hospitalization if the patient is scheduled for an interval appendectomy.
  • A patient with a prolonged ileus or fever for more than 5 days postoperatively commonly has an intra-abdominal abscess.
  • The most common treatment is to perform a CT scan of the abdomen and pelvis with oral and intravenous contrast to define the presence of an abscess.
  • If present and in an accessible location, percutaneous drainage should be performed.
  • A drain is commonly left in the abscess cavity, and continued drainage is monitored.
  • Once drainage decreases and repeated CT scans show resolution of the abscess cavity and no fistulous tract to the bowel, the drain can be removed.
• Diet and bowel function
• • Patients with nonperforated appendicitis may be started on clear fluids postoperatively; diet can be advanced as tolerated.
  • Once a regular diet is tolerated, the patient may be discharged. These patients have minimal delay in the return of bowel function and do not need to have a bowel movement prior to discharge.
  • Patients with perforated appendicitis who undergo immediate appendectomy should maintain nothing-by-mouth status until bowel function returns. Once this occurs, patients should then be started on clear fluids, and the diet should be advanced as tolerated.

In/Out Patient Meds

• Antibiotics: The patient may be discharged with antibiotics, according to the severity of the appendicitis.
• Pain medication
• • If the patient has undergone an appendectomy, pain medication should be prescribed upon discharge.
  • Liquid acetaminophen usually suffices in smaller children, with liquid acetaminophen with codeine administered for breakthrough pain. The same medication combination can be used in older patients in a tablet form, assuming they are able to swallow them.
  • Patients who received inpatient narcotics or who are discharged with outpatient narcotic pain medications should be cautioned about the possibility of becoming constipated and should be prescribed stool softeners.

Complications

• Intra-abdominal abscess
• Perforation
• Sepsis
• Shock

Prognosis

• Generally, prognosis is excellent.

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Appendicitis and Abdominal Pain in Children.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Performing a complete examination, including examination of the genitals, is important. Testicular torsion and ectopic pregnancy present similarly to appendicitis, and both have serious morbidity if not quickly diagnosed.
• Do not diagnose gastroenteritis in patients unless they have nausea, vomiting, and diarrhea.
• • Even with the presence of vomiting and diarrhea, consider the unusual presentations of retrocecal or pelvic appendicitis.
  • Additionally, appendicitis can develop as a sequela of gastroenteritis associated with lymphoid hyperplasia.
• Diagnose abdominal pain of unknown etiology in patients with nonspecific abdominal symptoms.
• Instruct patients to be re-evaluated in 8-12 hours by their primary care physician or to return to the emergency department.
• Keep patients with equivocal examination findings for observation and perform serial abdominal examinations or consider performing a double-contrast abdominal CT scanning.
• Avoid treating vague abdominal pain with parenteral opiates and subsequent discharge.
• Avoid narcotics and potent nonsteroidals until after surgical consultation.
• Antibiotics are generally withheld until the decision is made for surgical intervention or another appropriate indication is identified.
• If the constipation is diagnosed and treated with enemas and/or stool softeners with resolution of the signs and symptoms, inform the patient and family members that recurrence of abdominal pain in the future could be recurrent constipation or acute appendicitis and to seek medical advice in that situation.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Acosta R, Crain EF, Goldman HS. CT can reduce hospitalization for observation in children with suspected appendicitis. Pediatr Radiol. May 2005;35(5):495-500. [Medline].
• Brender JD, Marcuse EK, Koepsell TD, Hatch EI. Childhood appendicitis: factors associated with perforation. Pediatrics. Aug 1985;76(2):301-6. [Medline].
• Chung RS, Rowland DY, Li P, Diaz J. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg. Mar 1999;177(3):250-6. [Medline].
• Crady SK, Jones JS, Wyn T, Luttenton CR. Clinical validity of ultrasound in children with suspected appendicitis. Ann Emerg Med. Jul 1993;22(7):1125-9. [Medline].
• Doherty GM, Lewis FR Jr. Appendicitis: continuing diagnostic challenge. Emerg Med Clin North Am. Aug 1989;7(3):537-53. [Medline].
• Eldar S, Nash E, Sabo E, et al. Delay of surgery in acute appendicitis. Am J Surg. Mar 1997;173(3):194-8. [Medline].
• Hagendorf BA, Clarke JR, Burd RS. The optimal initial management of children with suspected appendicitis: a decision analysis. J Pediatr Surg. Jun 2004;39(6):880-5. [Medline].
• Jabra AA, Shalaby-Rana EI, Fishman EK. CT of appendicitis in children. J Comput Assist Tomogr. Jul-Aug 1997;21(4):661-6. [Medline].
• Kosloske AM, Love CL, Rohrer JE, et al. The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation. Pediatrics. Jan 2004;113(1 Pt 1):29-34. [Medline]. [Full Text].
• Martin AE, Vollman D, Adler B, Caniano DA. CT scans may not reduce the negative appendectomy rate in children. J Pediatr Surg. Jun 2004;39(6):886-90; discussion 886-90. [Medline].
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Article Last Updated: Sep 15, 2006