Appendicitis

48
Jurgen Schleef and Prem Puri

Contents 48.1 Introduction

48.1 Introduction .............................................. 477 Acute appendicitis is the most common surgical
48.2 Epidemiology ............................................ 477 emergency in childhood. Appendicitis may present at
any age, although it is uncommon in preschool chil-
48.3 Etiology ..................................................... 477
dren. Approximately one-third of children with acute
48.4 Diagnosis ................................................... 478 appendicitis have perforation by the time of operation.
48.5 Differential Diagnosis .............................. 479 Despite improved fluid resuscitation and better antibi-
otics, appendicitis in children, especially in preschool
48.6 Operative Techniques .............................. 479 children, is still associated with significant morbidity.
48.7 Open Appendectomy ............................... 480
48.8 Laparoscopic Appendectomy .................. 480
48.9 Appendicitis in Preschool Children ........ 480 48.2 Epidemiology
48.10 Perforated Appendicitis ........................... 481
The incidence of acute appendicitis has been reported
48.11 Appendix Mass ......................................... 482
to vary substantially by country, geographic region,
48.12 Mortality ................................................... 483 race, sex and season, but the reasons for these varia-
48.13 Long-Term Outcomes .............................. 483 tions are unknown. An epidemiological study of acute
appendicitis in California revealed that the incidence
Further Reading .................................................... 483
of appendicitis in blacks and Asians was less than half
that in whites. Epidemiological studies of acute appen-
dicitis and perforation rates in California and New
York have shown higher incidence rates of appendici-
tis among Hispanics than African Americans and
Whites with Hispanics, Asians and African Americans
having a higher risk of perforation than whites.

48.3 Etiology

The exact etiology and pathogenesis of appendicitis are

poorly understood. While invasion of the appendiceal
wall by micro-organisms is the ultimate pathological
event, the primary initiating condition is not known.

P. Puri and M. Höllwarth (eds.), Pediatric Surgery: Diagnosis and Management, 477
DOI: 10.1007/978-3-540-69560-8_48, © Springer-Verlag Berlin Heidelberg 2009
478 Part VI Gastrointestinal

Obstruction of the appendix lumen, from whatever

cause, with resulting distension and disturbance of blood
flow, is still considered the major factor in the pathogen-
esis of acute appendicitis. Other factors include low
dietary fiber intake and bacterial and viral infections.
Andersson et al. investigated temporospatial clustering
and outbreaks (characteristics of infectious diseases)
among appendicitis cases and found that appendicitis
does occur in space-time clusters and outbreaks, thus
supporting an infectious etiology theory. Recently,
Gauderer et al. investigated the relationship between
heredity and appendicitis and found that children with
appendicitis are at least twice as likely to have a positive
family history of appendicitis as compared with chil-
dren with right lower quadrant pain without appendicitis
or controls without abdominal pain.

48.4 Diagnosis

The diagnosis of acute appendicitis in childhood can Fig. 48.1 Ultrasonography in a 12-year-old patient with acute
sometimes be difficult. Definite diagnosis is made in appendicitis—enlarged and thickened (1.1 cm) appendix
only 43–72% of patients at the time of initial assess-
ment. The rate of negative pediatric appendectomy is
in the range 4–50% in various reports. The patient’s
history and clinical examination are the most impor- delineating gynecologic disease. However, it is of
tant tools for the diagnosis of appendicitis. Periumbilical limited use in obese adolescents and is highly user-
pain is often the first symptom, followed by vomiting dependent. The only sonographic sign that is specific
and fever. When the inflammation progresses, the pain for appendicitis is an enlarged, non-compressible
localizes to the right lower quadrant, and right lower appendix measuring greater than 6 mm in maximal
quadrant tenderness develops. Appendices located in diameter (Fig. 48.1). The appendix may not be visible
the retrocaecal position may cause pain, radiating to following perforation. Recently, computed tomogra-
the back. Appendices in pelvic position may present phy (CT) has been used as an adjunct to the diagnosis
with diarrhea. Clinical examination in a typical case of appendicitis and appeared to have an immediate
with appendicitis reveals tenderness, guarding and impact, reducing negative appendectomy rates to
rigidity in the right lower quadrant of abdomen. 4.1% and perforation rates to 14.7%. The principal
Laboratory investigations and plain radiographs advantages of CT are its operator independency and
are neither sensitive nor specific in the diagnosis of enhanced delineation of disease extent in perforated
appendicitis. Barium enema is an unreliable test appendicitis. Sensitivity, specificity and accuracy for
because of its high false-positive and false-negative unenhanced limited CT have approached 97%, 100%
rates. In recent years, graded compression ultrasonog- and 99%, respectively. However, with this improved
raphy of the right lower quadrant has been shown to diagnostic accuracy came a reduction in the degree of
be a useful tool in the evaluation of patients with clini- significance put on the initial clinical evaluation by
cal findings that are suggestive but not diagnostic of the responsible surgical team. This management strat-
appendicitis, with a sensitivity of 80–100%, a speci- egy must take into account the significant risk of
ficity of 78–98%, and an overall accuracy of 91%. exposure of the child to the CT dose of ionizing radia-
Ultrasound is portable, fast, and free of irradiation tion. Recent studies have suggested that CT has not
exposure, of modest incremental cost and of use in increased the accuracy of diagnosing appendicitis
48 J. Schleef and P. Puri ● Appendicitis 479

when compared to a careful history and physical Table 48.1 Appendicitis

examination performed by an experienced surgeon. Most frequent differential diagnosis
In patients with an uncertain diagnosis of acute • Abdominal pain of unknown origin
abdominal pain, a policy of active observation in • Gastroenteritis
• Mesenteric lymphadenitis
hospital is usually practiced. A repeated structured
• Intussusception
clinical examination is simple and noninvasive. • Meckel’s diverticulitis
However, the argument against this policy is that it • Primary peritonitis
may lead to a delay in specific management of these • Inflammatory bowel disease
patients and may result in a high incidence of perfora- • Neoplasm (carcinoid, lymphoma)
tion. Bachoo et al. achieved a positive predictive value • Urinary tract infection
of 97.9% and a normal appendectomy rate of 2.6% • Testicular torsion
• Omental torsion
with active observation alone and showed no correla-
• Ruptured ovarian cyst
tion between post-operative morbidity and timing of • Ovarian torsion
surgery with this protocol. We have shown that the • Ectopic pregnancy
delay in appendectomy in children observed in a hos- • Pelvic inflammatory disease
pital setting does not increase the incidence of com-
plicated appendicitis.

48.5 Differential Diagnosis 48.6 Operative Techniques

Several conditions must be considered where an Children with appendicitis are assessed for degree of
infant is being evaluated for appendicitis. Table 48.1 sepsis and dehydration. Intravenous fluids are indi-
gives the list of common differential diagnoses. cated preoperatively because most patients would have
Differential diagnoses are more frequent in small vomited and not eaten for over 24 h. Broad-spectrum
children (connatal malformations, intussusceptions) antibiotics should be administered pre- and postopera-
and adolescent girls (ovarian pathology, pelvic tively in order to prevent infectious complications
inflammatory disease). (Table 48.2).

Table 48.2 Appendicitis

480 Part VI Gastrointestinal

48.7 Open Appendectomy

A transverse right lower quadrant skin crease incision is

recommended. The muscular layers are split in the
direction of their fibers. The peritoneum is opened and
fluid sent for culture. Recent studies have suggested it is
unnecessary to send routine peritoneal fluid cultures.
The mesoappendix is divided and the appendiceal base
clamped and ligated. Stump inversion is optional.
Engstrom and Fenyo found no difference as regards to
wound infection and postoperative fever between one
group in which the appendix was ligated and doubly
invaginated and another group in which it was simply
ligated. If pus is present, the abdomen should be irri-
Fig. 48.2 A 14-year-old boy with phlegmon appendicitis dur-
gated with saline. The abdominal wall is closed in lay- ing laparoscopy
ers. The skin is usually closed by subcuticular absorbable
sutures even in the case of perforation. Primary wound
closure after perforated appendicitis is safe, economical The increased operative expense of laparoscopic
and advantageous in pediatric practice. appendectomy appear to be offset by an earlier return
to normal daily activities.

48.8 Laparoscopic Appendectomy

48.9 Appendicitis in Preschool Children
An infraumbilical port is inserted using an open rather
than percutaneous technique. Two 5 mm infraumbilical Acute appendicitis in the preschool child accounts for
incisions are placed on either side of the midline. A a small fraction of all pediatric admissions with this
third right lower quadrant incision is optional. After diagnosis. In children under 2 years of age, it repre-
mobilization of the appendix, the mesoappendix is sents 1% of all cases of appendicitis in childhood. In a
divided, the appendiceal stump is ligated with endoloops large series from Dublin, Puri et al. found that only
or an endoscopic stapler, and the appendix is removed. 4.3% of their patients with appendicitis presented dur-
In recent years, laparoscopic appendectomy has ing the first 3 years of life. A recent 28-year review of
become an option as a safe alternative in the pediatric appendicitis in children less than 3 years of age from
age group (Fig. 48.2). Although the rate at which Toronto showed that all children had perforated appen-
laparoscopy is utilized in the treatment of appendicitis dicitis at presentation. This resulted in very high mor-
varies dramatically from center to center (range bidity (wound infection/abscess/dehiscence, pneumonia,
0–95%), it is undoubtedly a reasonable surgical alter- small bowel obstruction, incisional hernia and entero-
native to open appendectomy for the treatment of acute cutaneous fistula) affecting 59% of these patients and
appendicitis in children. Recent studies have demon- although appendicitis is uncommon in this age group,
strated that laparoscopic appendectomy is at least as it should be considered in the differential diagnosis of
safe and effective as open appendectomy. Despite the preschool children presenting with abdominal pain,
fact that laparoscopic appendectomy takes longer to tenderness or vomiting.
perform at a marginally increased cost compared to The diagnosis of appendicitis in preschool children
open appendectomy, it has multiple advantages. can be difficult, resulting in delay and more severe dis-
A large database study of adults and children in the ease. The young child’s inability to communicate ade-
United States showed laparoscopic appendectomy to quately with the parents, atypical disease presentation,
be associated with a shorter median hospital stay and and other associated illnesses may delay the diagnosis.
lower rates of wound infection, gastrointestinal com- Surana et al. reviewed 132 patients under 5 years of
plications and overall complications. age treated for acute appendicitis in the two Dublin
48 J. Schleef and P. Puri ● Appendicitis 481

children’s hospitals between 1987 and 1991, in order and has been associated with an increased risk of infec-
to identify factors that contribute to more serious dis- tion. Current opinion overwhelmingly favors the
ease in this age group. Of the 132 preschool children, approach of confining the use of drains to only those
63 (48%) had perforated appendicitis and 29 (22%) cases in which a clearly localized abscess cavity can be
had an appendix mass, 36 (27%) had uncomplicated demonstrated. The placement of a peritoneal drain fol-
appendicitis and 4 (3%) had a normal appendix. All lowing perforated appendicitis has not been shown to
the classic symptoms were present in the majority of improve outcome, with no reduction in the duration of
patients. Atypical symptoms were found in many chil- hospitalization or nasogastric drainage time and is
dren and included diarrhea, cough/sore throat, dysuria, therefore not advocated. Intraoperative irrigation of
headache and earache. A diagnosis other than appendi- the peritoneal cavity is a valuable procedure in perfo-
citis was suspected in 53 (40%) patients, leading to a rated appendicitis. The majority of pediatric surgeons
delay in management. Mean duration of symptoms nowadays favor a protocol of irrigation, with or with-
before admission was as follows: acute appendicitis 39 out antibiotics, until a clear effluent is returned.
hours, perforated appendicitis 53 h, and appendix mass Subcuticular skin closure is safe after perforated
82 h. Postoperatively an intra-abdominal abscess appendicitis; wound infection rates are low and thus
occurred in 5% of the patients with perforated appen- there is no compelling reason to opt for delayed clo-
dicitis and none with uncomplicated appendicitis: sure of the appendectomy incision.
these patients were treated using antimicrobial agents, In Dublin, the protocol for the management of per-
with complete resolution clinically and on ultrasound forated appendicitis consists of preoperative adminis-
in all cases. One patient required laparotomy for adhe- tration of antibiotics that are continued for 5 days
sive intestinal obstruction. There were no deaths. postoperatively. Intraoperative irrigation of the perito-
In view of the frequency of atypical presentation neal cavity is carried out and the appendectomy wound
and the increased incidence of advanced appendicitis, is closed using subcuticular absorbable sutures. During
a high index of suspicion is necessary in preschool a 5-year period (1987–1991), a total of 870 patients
children presenting with acute abdominal pain. Early underwent emergency appendectomy for appendicitis
diagnosis is the key to reducing morbidity from appen- at Our Lady’s Hospital for Sick Children. One hundred
dicitis in this age group. and fifty-eight (18%) of the patients (98 boys) were
found to have a perforated appendix. Their ages ranged
from 18 months to 15 years (mean 7.8 years). Thirteen
patients (8%) developed postoperative complications.
48.10 Perforated Appendicitis Nine (5.6%) had a wound infection, which was man-
aged by local drainage and antibiotics. Five children
The reported incidence of perforated appendicitis in (3.2%), including one with a wound infection, devel-
children is 18–40%. Two recent large series of appen- oped an intra-abdominal abscess, which was confirmed
dicitis in children have reported 18% and 20% inci- by ultrasonography and resolved with antibiotic ther-
dence respectively. The incidence is much higher in apy (Fig. 48.3). Nine of the 13 patients with postopera-
preschool children (see above). tive infective complications were readmitted to
Nowadays mortality is very rare. Several controver- hospital; their mean hospital stay was 9.4 days (range
sies have arisen over the years regarding the best 3–18). The mean duration of hospital stay in the 158
approach to reduce the morbidity from appendicitis, patients with perforated appendicitis, including those
especially infectious complications such as intra- who were readmitted, was 6.8 days (range 3–47).
abdominal abscess and wound infection. Many of the There were no deaths.
controversies relating to perforated appendicitis have An analysis of three recent studies of perforated
been resolved. Several studies have confirmed the appendicitis, using a protocol of preoperative antibio-
efficacy of antibiotics in reducing morbidity. Probably, tics, intraoperative irrigation of the peritoneal cavity,
the first preoperative dose of antibiotics is the most primary subcuticular skin closure and a short course of
important. There is still some disagreement about the postoperative antibiotics showed an intra-abdominal
duration of antibiotic therapy and which drugs to use. abscess rate of 1.3–3.2%, a wound infection rate of
Wound drainage is no longer thought to be beneficial, 1.3–5.7%, no deaths, and a mean hospital stay of
482 Part VI Gastrointestinal

antibiotics followed by delayed appendectomy as the

treatment of choice. Others favor immediate appen-
dectomy in every case of appendicitis. Controversy
around conservative management of appendiceal mass
has arisen mainly from the belief that children, and
particularly infants, have a poor ability to localize
intraperitoneal inflammatory processes, and so chil-
dren with an appendiceal mass should be managed
operatively. The senior author has previously shown
that a child’s ability to localize appendiceal inflamma-
tion is well developed, even in infancy, and that one
half of the patients developing appendicitis during the
first 2 years of life, and one-third of those developing
appendicitis during the first 3 years of life, have an
appendiceal mass at the time of presentation.
Initial conservative management of appendiceal
masses, followed by interval appendectomy, has been
practiced at the author’s institution for over 30 years.
Gillick et al. recently reviewed the results of conser-
vative management of patients with an appendix mass
from Dublin. During the period 1982–2000, 427 chil-
Fig. 48.3 Ultrasonography of a subdiaphragmatic abscess after dren presented to one of Dublin’s three pediatric hos-
complicated appendicitis (same patient as in Fig. 1) pitals with a diagnosis of appendix mass. There were
222 boys and 205 girls. Their ages ranged from 2
months to 18 years (mean 7.3 years). The duration of
6.8–11.4 days. These results set new standards in symptoms ranged from a few hours to 21 days, with
wound management, infectious complications and 266 (62.3%) having had symptoms for longer than 3
length of hospital stay in perforated appendicitis. days. The diagnosis was made clinically in 136
(31.9%) children, by ultrasonography in 61 (14.3%),
by examination under anesthesia in 229 (53.6%) and
by computed tomography in one child (0.2%). All
48.11 Appendix Mass were initially managed conservatively with intrave-
nous antibiotics, nasogastric suction as required and
An appendix mass results from appendicitis that is intravenous fluids until oral fluids and diet were toler-
localized by edematous, adherent omentum and loops ated. In 346 (84.2%) of the 411 patients the mass
of small bowel. In contrast, the appendiceal abscess is resolved completely. The mean duration of hospital
a localized suppurative process that may occur at any stay in this group was 6 days. Three hundred and
time in the course of appendicitis, or may complicate thirty-one children had an elective appendectomy as
an appendiceal mass. Clinically, it is not possible in planned, 4–6 weeks after discharge. Of these elective
most cases to distinguish with certainty between the appendec-tomies, 15 (4.5%) were performed laparo-
two conditions. An appendiceal mass at the time of scopically. The complication rate following elective
presentation is discovered in about 10% of children appendectomy was 2.3% (five wound infections, two
with appendicitis. The incidence is higher during the intra-abdominal abscesses and one hematoma).
first 3 years of life, when one-third of the patients with Histological assessment of the appendices removed
appendicitis have been reported to present with an electively demonstrates acute of subacute inflamma-
appendiceal mass. tion in 51% of the specimens. Two specimens had a
The management of an appendiceal mass in chil- carcinoid tumor. Sixty-five (16%) children with an
dren is controversial. Many authors recommend non- appendix mass failed to respond to initial non-opera-
operative management of an appendix mass, with tive management: 17 required early appendectomy for
48 J. Schleef and P. Puri ● Appendicitis 483

ongoing symptoms and 27 developed an appendix 85% decrease in the hospital case-fatality rate. This
abscess that required drainage and subsequent appen- almost certainly reflects improvements in clinical
dectomy. These data, as well as other studies, support care, which have occurred in parallel with expansion
the contention that initial nonoperative management of specialist pediatric surgery and anesthesia. Delay
of appendiceal mass, followed by an appendectomy, is in referral to hospital and/or diagnosis of acute
a safe and effective policy. appendicitis are the dominant factors responsible for
We recommend interval appendectomy following the residual small number of avoidable deaths.
resolution of the appendiceal mass. Some investigators
have questioned the need for appendectomy after
conservative management, on the assertion that the 48.13 Long-Term Outcomes
incidence of recurrent appendicitis is low and the
complication rate with interval appendectomy is high. The long-term outcome of the vast majority of patients
However, complications following interval appendec- who undergo appendectomy for childhood appendici-
tomy in children in our series were uncommon. tis is excellent. A small number of patients develop
Moreover, histological evidence of inflammation was late adhesive intestinal obstruction. The belief that per-
present in almost 51% of these appendices. It is possi- forated appendicitis in girls is associated with reduced
ble that the inflammation in some cases might have fertility rate in later life has been based on a few reports
resolved spontaneously, but some patients develop that do not stand up to critical analysis.
recurrent appendicitis. Therefore, we recommend ini-
tial nonoperative management of appendiceal masses
with antibiotics, followed by appendectomy 6–8 weeks Further Reading
later.
Esposito C, Borzi P, Valla JS et al (2007) Laparoscopic versus
open appendectomy in children: A retrospective comparative
study of 2,332 cases. World J Surg 31:750–755
48.12 Mortality Kosloske AM, Love CL, Rohrer JE, Goldthorn JF, Lacey SR
(2004) The diagnosis of appendicitis in children: Outcomes
of a strategy based on pediatric surgical evaluation. Pediatrics
In the United Kingdom, the number of deaths from 113:29–34
Morrow SE, Newman KD (2007) Current management of
acute appendicitis in children has decreased dramati-
appendicitis. Semin Pediatr Surg 16:34–40
cally since the 1930s, largely as a result of the decline Puri P, Mortell A (2007) Appendicitis. In MD Stringer, KT
in incidence of appendicitis but also because of a Oldham, PDE Mouriquand (eds) Paediatric Surgery and
marked reduction in the hospital case-fatality rate Urology: Long-term outcomes, 2nd edn. Cambridge
University Press, New York, pp 374–384
during the last 30 years. Three national audits
Jasonni V (2006) Appendectomy. In P Puri, ME Höllwarth (eds)
between 1963 and 1997 covering all children dying Pediatric Surgery, Springer Surgery Atlas Series. Springer-
of appendicitis in England and Wales showed an Verlag, Berlin, Heidelberg, New York, pp 321–326