Advances in Pediatrics 70 (2023) 105–122

ADVANCES IN PEDIATRICS

Appendicitis in Children
Lindsay A. Gil, MD, MPHa,
Katherine J. Deans, MD, MHScb,
Peter C. Minneci, MD, MHScc,*
a
Pediatric Surgery Research Fellow, Nationwide Children’s Hospital, The Ohio State University
Wexner Medical Center, 700 Children’s Drive, Columbus, OH 43206, USA; bDepartment of
Surgery, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE
19803, USA; cDivision of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State
University Wexner Medical Center, 611 East Livingston Avenue, Columbus, OH 43206, USA

Keywords

Pediatric appendicitis
Non-operative management
Shared decision-making
Key points

Patient history, physical exam, laboratory results, and ultrasound as first-line
diagnostic imaging modality should be considered together to improve diag-
nostic accuracy of pediatric appendicitis.

Treatment options primarily depend on whether the patient has uncomplicated or
complicated appendicitis.

Patient/family shared decision-making should be utilized in the treatment choice
between non-operative and operative management for uncomplicated
appendicitis.

INTRODUCTION
Pediatric appendicitis constitutes a considerable burden of disease in children
and is associated with substantial health care cost and resource utilization.
Research surrounding the diagnosis and management of pediatric appendicitis
has led to continued advancement in practices, development of standardized
evidence-based treatment algorithms, and promotion of patient-centered ap-
proaches to management. This review summarizes the current evidence and
controversies surrounding contemporary approaches to the management of
acute appendicitis in children.

*Corresponding author. E-mail address: [email protected]

https://doi.org/10.1016/j.yapd.2023.03.003
0065-3101/23/ª 2023 Elsevier Inc. All rights reserved.
106 GIL, DEANS, & MINNECI

EPIDEMIOLOGY OF PEDIATRIC APPENDICITIS

Appendicitis is one of the most common surgical conditions in children with an
estimated annual incidence of 83 per 100,000 [1]. In the United States, it is the
fifth most common reason for hospitalization in children. Appendectomy is one
of the most common surgical procedures performed accounting for approxi-
mately 40,000 hospital stays with aggregate costs, totaling $492 million in
2018 [2,3]. Globally, peak incidence occurs in the 15 to 19-year-old age group,
and there has been an overall steady increase in incidence and concurrent
decrease in mortality rate over the last two decades [4].

PATHOPHYSIOLOGY OF PEDIATRIC APPENDICITIS

Although the exact pathogenesis of acute appendicitis remains uncertain, the
most frequently cited etiology entails a pathophysiologic process originating
with luminal obstruction due to stool, lymphoid hyperplasia, or in rare cases,
an appendiceal neoplasm. Luminal obstruction then results in an increase in in-
traluminal pressure, vascular compromise with mucosal ischemia, and bacterial
invasion of the appendiceal wall [5,6]. A number of bacterial, viral, fungal, and
parasitic organisms have been shown to infect the appendix, resulting in a wide
range of specific and non-specific histologic pathologic findings [7]. However,
the exact pathogenesis of inflammation and mechanism of bacterial invasion
into the appendiceal wall remain unknown. Prior studies have also demon-
strated a wide variety of environmental and genetic risk factors associated
with appendicitis including a three-fold greater relative risk in those with a pos-
itive family history [5,6,8].

DIAGNOSIS OF PEDIATRIC APPENDICITIS

Clinical presentation
Children with acute appendicitis commonly present with periumbilical abdom-
inal pain with migration to the right lower quadrant typically within 24 hours
of the onset of symptoms. They also may present with fever, anorexia, nausea,
and vomiting. Signs of localized or generalized peritonitis include involuntary
guarding, rebound tenderness, Rovsing sign (palpation of the left lower quad-
rant elicits right lower quadrant pain), obturator sign (flexion and internal rota-
tion of the right hip elicits pain), and iliopsoas sign (right hip extension elicits
pain) [9–13]. Previous studies have evaluated the accuracy of these signs and
symptoms and have found that the Rovsing, obturator, and iliopsoas signs
have low sensitivity (16%–44%) and high specificity (86–98%) in diagnosing
appendicitis [9–11]. Symptoms also have varying accuracy depending on the
age group. The likelihood of appendicitis in those with a history of focal right
lower quadrant pain, history of migration of pain, and diarrhea is greater for
younger patients (3–6-year-old age group) [11]. A systematic review of 21
studies including 8605 pediatric patients found that migration of pain to the
right lower quadrant and presence of pain with coughing or hopping were
most strongly associated with appendicitis with a positive likelihood ratio of
4.81 and 7.64, respectively [14].
APPENDICITIS IN CHILDREN 107

Laboratory tests
There is no known biomarker that is specific for appendicitis. Commonly used
laboratory tests such as white blood cell count (WBC), absolute neutrophil
count (ANC), and c-reactive protein (CRP), are limited in their ability to
discriminate between appendicitis and other inflammatory conditions and
cannot be used in isolation to diagnose appendicitis. Although reported values
for sensitivity and specificity for these tests vary widely [14–17], they have been
shown to be useful in improving diagnostic accuracy when used in combination
with radiographic imaging [18]. A recent retrospective study investigating chil-
dren with suspected appendicitis demonstrated that among children with a non-
diagnostic ultrasound, the combination of having >72 hours of symptoms and
a normal WBC had an NPV of 100% [19]. Lab tests also have been shown to
have time-dependent accuracy with a prospective cohort study demonstrating
that WBC peaked at <24 hours and CRP peaked at 24 to 48 hours of pain for
non-perforated appendicitis, and WBC peaked at 24 to 48 hours and CRP
peaked at >48 hours of pain for perforated appendicitis [20].

Radiographic imaging studies

Ultrasound is the diagnostic imaging modality of choice in children due to its
low cost, lack of need for sedation, and avoidance of radiation [21,22]. Re-
ported sensitivity ranges from 72.5% to 94.8%, and specificity ranges from
95% to 99% [21,23–25]. In a systematic review and meta-analysis, pooled sensi-
tivity and specificity were 89% and 97%, respectively, when performed by
Emergency Medicine physicians and 96% and 97%, respectively, when per-
formed by non-Emergency Medicine physicians [26]. Diagnostic accuracy of ul-
trasound is operator-dependent with previous studies demonstrating lower
accuracy in children with obesity and improved accuracy with specialized pe-
diatric sonographers [23,25,27]. Standardized reporting systems and templates
for radiologists have also been associated with improvement in diagnostic accu-
racy with one study reporting an increase in sensitivity from 66.7% to 92.2%
[28]. Fallon and colleagues developed the Appy-Score where 1 is a normal
completely visualized appendix, 2 is a normal partially visualized appendix, 3
is a non-visualized appendix, 4 is equivocal, 5a is non-perforated appendicitis,
and 5b is perforated appendicitis. In their initial experience with the implemen-
tation of this scoring system, there was no significant improvement in diag-
nostic accuracy, but the rate of computed tomography (CT) imaging after
implementation decreased by 31% [29]. Another study evaluating the imple-
mentation of a standardized reporting system for ultrasound findings similarly
found a decrease in the rate of CT imaging from 44.3% to 9.6% and an annual
cost reduction of $300,527 [30]. Additionally, previous studies have demon-
strated that the implementation of diagnostic algorithms for appendicitis is asso-
ciated with decreased rates of CT imaging [31,32].
Although ultrasound is the first-line diagnostic imaging modality of choice
for appendicitis, CT is still performed in >50% of children with a majority
of CT scans being performed at non-pediatric hospitals [33]. A meta-analysis
108 GIL, DEANS, & MINNECI

comparing ultrasound and CT demonstrated a pooled sensitivity and speci-

ficity of ultrasound of 88% and 94%, respectively, and 94% and 95% for CT
[34]. Despite CT having greater diagnostic accuracy and previous studies
demonstrating that CT imaging can be performed with reduced doses of radi-
ation [35,36], there is no evidence that CT is associated with lower rates of
negative appendectomy [37], and overall sensitivity and specificity for detecting
appendiceal perforation in the absence of a well-formed abscess is reported to
be only 62% and 81%, respectively [38]. CT can be a useful adjunct in the
setting of indeterminate findings or non-visualized appendix on ultrasound
[22,39]. MRI similarly can be a useful adjunct in the setting of a non-
visualized appendix on ultrasound with similar sensitivity and specificity to
CT imaging [40–42]. However, it is not utilized as frequently due to higher
costs, slower acquisition time, the potential need for sedation, and limited avail-
ability [22]. Furthermore, in most children’s hospitals with MRI availability, ul-
trasound is utilized as the first-line diagnostic imaging modality of choice and
MRI is used when results are indeterminate.

Pediatric appendicitis risk scores

Given the limitations of the aforementioned diagnostic testing modalities and
the potential consequences of missed or delayed diagnosis, several composite
risk scores have been developed to help improve the diagnostic accuracy of pe-
diatric appendicitis. The most commonly studied scores include the Alvarado
score, Pediatric Appendicitis Score (PAS), Appendicitis Inflammatory Response
(AIR) score, and the pediatric Appendicitis Risk Calculator (pARC).
The Alvarado score, also known as MANTRELS (Migration, Anorexia-
acetone, Nausea-vomiting, Tenderness in right lower quadrant, Rebound
pain, Elevation of temperature, Leukocytosis, Shift to the left), is a 10-point
clinical scoring system for the diagnosis of acute appendicitis based on clinical
signs and symptoms in patients presenting with abdominal pain. The scoring
system is coupled with recommendations regarding patient disposition
including discharge (score 1–4), observation (score 5–6), or surgical interven-
tion (score 7–10) [43]. It has been validated in a number of different popula-
tions including adults and children [44]. In a systematic review and
meta-analysis, at the cutoff point of 5 for differentiating between discharge
and admission for observation, the Alvarado score had a sensitivity of 0.99
and a specificity of 0.57 in children [45]. A subsequent meta-analysis demon-
strated that in children with pretest probabilities  60%, a score < 4 is associ-
ated with a 3% probability of appendicitis, and thus, can be used to rule out
appendicitis [46].
The PAS is a scoring system ranging from 0 to 10 based on patient history,
physical exam, and laboratory testing including migration of pain, anorexia,
nausea/vomiting, fever >38 C, cough/percussion/hopping tenderness, right
lower quadrant tenderness, leukocytosis >10,000 cells/mm3, and polymorpho-
nuclear neutrophilia >7,500 cells/mm3. In his initial experience with the scoring
system, Samuel found that a score 6 was highly associated with appendicitis
APPENDICITIS IN CHILDREN 109

[47]. The PAS was externally validated and found to be useful in ruling out
appendicitis with a score 2 and ruling in appendicitis with a score 7 [48].
The AIR score is an 8-point scoring system developed via weighted ordered
logistic regression analysis involving characteristics of the patient history, phys-
ical exam, and laboratory testing, including vomiting, right lower quadrant
tenderness, rebound tenderness, fever  38.5 C, the proportion of polymorpho-
nuclear leukocytes, WBC, and CRP [49]. The score was recently validated by the
authors in a large prospective study involving 3878 children and adult patients
presenting with <5 days of abdominal pain. The authors found that the AIR
scoring system was more accurate in detecting appendicitis in patients <15 years
of age with a receiver operating curve (ROC) area of 0.87. It performed even
better when detecting complicated appendicitis with an ROC area of 0.93 [50].
The most recently developed scoring system for pediatric appendicitis is the
pediatric Appendicitis Risk Calculator (pARC) which includes age, sex, tem-
perature, nausea/vomiting, pain duration, pain location, pain with walking,
pain migration, guarding, WBC, and ANC. The score ranges from 0% to
100% and stratifies patients across seven clinically actionable risk categories
(<5%, 5%–14%, 15%–24%, 25%–49%, 50%–74%, 75%–84%, and 85%),
each corresponding to a negative appendectomy rate of 8.8%, 7.7%, 6.8%,
5.2%, 5.5%, 2.6%, and 1.2%, respectively. In the authors’ validation sample,
the pARC had an AUC of 0.85, outperforming the PAS which had an AUC
of 0.77 [51]. The pARC was externally validated across 11 community emer-
gency departments in patients 5 to 20.9 years of age who presented with
abdominal pain. In this patient population, the pARC similarly outperformed
the PAS with a ROC curve of 0.89 versus 0.80 [52].
Several comparative studies have investigated differences in diagnostic accu-
racy of the various pediatric appendicitis risk scores [53–55]. Based on these
studies, pediatric appendicitis risk scores do not appear to be sufficient alone
to determine the diagnosis of appendicitis without imaging. The scores can
be valuable tools in clinical algorithms for triaging patients with a higher likeli-
hood of appendicitis to undergo additional workup including imaging to deter-
mine if appendicitis is the cause of the patient’s symptoms.

MANAGEMENT OF PEDIATRIC APPENDICITIS

Management strategies for uncomplicated appendicitis
Uncomplicated acute appendicitis in children can be managed non-operatively
with antibiotics alone or operatively with appendectomy, with laparoscopy be-
ing the preferred approach (Fig. 1). Laparoscopic appendectomy is now the
current standard of care with an average length of stay of 1 day [56,57].
Same-day discharge is possible in many patients with a recent study demon-
strating no differences in rates of readmission or complications between those
undergoing same-day discharge and those discharged on post-operative day 1
or 2 in pediatric patients with uncomplicated appendicitis [58].
Over the last decade, there has been mounting evidence demonstrating that
non-operative management with antibiotics is safe and effective for uncomplicated
110 GIL, DEANS, & MINNECI

Fig. 1. Clinical treatment algorithm for acute appendicitis in children.

acute appendicitis in children (Table 1) [59–75]. Several meta-analyses have re-

ported overall pooled treatment success rates ranging from 60 to 90% and no in-
crease in treatment-associated complications with an initial non-operative
management strategy compared to surgery [76–81]. The most recent meta-
analysis involving 5727 children across 21 studies demonstrated that 8% of pa-
tients had early failure and underwent appendectomy during their initial hospital
stay, and 16% of patients underwent appendectomy after discharge. There was no
statistically significant difference in length of stay between non-operative and oper-
ative management groups across seven studies. Two studies reported total hospi-
tal stay, which included the initial hospital admission and hospital readmission,
and there were still no differences between groups [79]. Huang and colleagues per-
formed a meta-analysis of randomized clinical trials and prospective clinical
controlled trials investigating non-operative management of pediatric appendi-
citis. 404 patients were included across five studies; 168 patients underwent
non-operative management, and pooled analysis demonstrated that 11 (6.5%) pa-
tients had early failure of non-operative management. Of the 157 patients with
early success, 5 (3.2%) patients had late failure, resulting in an overall treatment
 APPENDICITIS IN CHILDREN
Table 1
Cohort studies and trials investigating the effectiveness of non-operative management of acute uncomplicated appendicitis in children
Overall
treatment Early treatment Early failure Late failure
Author, year Study design Study population Antibiotics success success NOM NOM
Armstrong Retrospective 12 children <18 years Ciprofloxacin 5/12 10/12 2/12 (16.7%) 5/10
et al [59], review undergoing NOM of þ metronidazole or (41.7%) (83.3%) (50%)
2014 early uncomplicated Ampicillin
acute appendicitis þ gentamycin
þ metronidazole
Caruso Prospective 362 children with Cefotaxime 103/197 115/197 82/197 12/115
et al, case series appendicitis, 197 (52.4%) (58.4%) (41.6%) (10.4%)
2016 undergoing NOM of
uncomplicated
appendicitis
Gorter Multi-institutional 25 patients 7–17 years Amoxicillin/clavulanic 23/25 25/25 0/25 (0.0%) 2/25
et al, prospective of age undergoing acid þ gentamycin (92.0%) (100.0%) (8.0%)
2014 cohort study NOM of uncomplicated
appendicitis
Hartwich Prospective 75 patients 5–18 years of Piperacillin-tazobactam 19/24 21/24 3/24 (12.5%) 2/21
et al [63], nonrandomized age with uncomplicated (79.2%) (87.5%) (9.5%)
2016 controlled trial appendicitis (24 NOM)
Koike Retrospective 130 children 1–15 years Cefoperazone 101/130 125/130 5/130 (3.8%) 24/125
et al [64], review of age undergoing NOM (77.7%) (96.2%) (19.2%)
2014 of uncomplicated
appendicitis
Lee et al [65], Prospective 83 children 3–17 years of Ceftriaxone 26/51 35/51 16/51 9/35
2017 age with uncomplicated þ metronidazole (51.0%) (68.6%) (31.4%) (25.7%)
appendicitis (51 NOM)

111
(continued on next page)
 112
Table 1
(continued )

Overall
treatment Early treatment Early failure Late failure
Author, year Study design Study population Antibiotics success success NOM NOM
Mahida Prospective 14 children 7–17 years of Piperacillin-tazobactam 2/5 (40%) 3/5 (60%) 2/5 (40%) 1/3
et al [67], nonrandomized age with uncomplicated or ciprofloxacin (33.3%)
2016 controlled trial appendicitis (5 NOM) þ metronidazole
Minneci Prospective 102 children 7–17 years Piperacillin-tazobactam 28/37 35/37 2/37 (5.5%) 7/35
et al [68], nonrandomized of age with uncomplicated or ciprofloxacin (75.7%) (94.6%) (20.0%)
2016 controlled trial appendicitis (37 NOM) þ metronidazole
Minneci Prospective 1068 children 7–17 years Piperacillin-tazobactam 245/370 317/370 53/370 72/317
et al [69], nonrandomized of age with uncomplicated or ciprofloxacin (66.2%) (85.7%) (14.3%) (22.7%)
2020 controlled trial appendicitis (370 NOM) þ metronidazole
Mudri Retrospective 52 children 6–17 years of Ceftriaxone 17/26 26/26 0/26 (0.0%) 9/26
et al [70], review age with uncomplicated þ metronidazole (65.4%) (100.0%) (34.6%)
2017 appendicitis (26 NOM)
Perez Otero Randomized 39 children 6–17 years of Piperacillin-tazobactam 14/20 17/20 3/20 3/17
et al [71], controlled trial age with uncomplicated (70.0%) (85.0%) (15.0%) (17.6%)
2022 appendicitis (20 NOM)
Sajjad Randomized 180 children 5–15 years of Meropenem 75/90 85/90 5/90 (5.6%) 10/85
et al., controlled trial age with uncomplicated þ metronidazole (83.3%) (94.4%) (11.8%)

GIL, DEANS, & MINNECI

2021 appendicitis (90 NOM)
Steiner Prospective 45 children 4–15 years of Ceftriaxone 40/45 42/45 3/45 (6.7%) 2/42
et al [72], cohort study age undergoing NOM for þ metronidazole (88.9%) (93.3%) (4.8%)
2015 uncomplicated appendicitis
Steiner Prospective 197 children 4–15 years Ceftriaxone 157/197 187/197 10/197 20/187
et al [73], cohort study of age undergoing NOM þ metronidazole (79.7%) (94.9%) (5.1%) (10.7%)
2017 of uncomplicated
appendicitis
 APPENDICITIS IN CHILDREN
Svensson Randomized 55 children 5–15 years of Meropenem 15/24 23/24 1/24 (4.2%) 8/23
et al [74], controlled trial age with uncomplicated þ metronidazole (62%) (95.8%) (34.8%)
2015 appendicitis (24 NOM)
Tanaka Prospective 164 children 6–15 years of Cefmetazole 55/78 77/78 1/78 (1.2%) 22/77
et al [75], nonrandomized age with uncomplicated þ ampicillin (70.5%) (98.7%) (28.6%)
2015 controlled trial appendicitis (78 NOM)

113
114 GIL, DEANS, & MINNECI

success rate of 90.5%. The authors also demonstrated that appendicolith was asso-
ciated with increased risk of treatment failure with a risk ratio of 10.43 (95% CI
1.36–74.26) [78]. Other studies have demonstrated that factors such as rebound
tenderness, muscle guarding, appendiceal diameter >9 mm, intraluminal appen-
diceal fluid, higher pain scores, and longer duration of pain are significantly asso-
ciated with recurrence [64,73,82].
The largest prospective clinical trial investigating non-operative management of
pediatric appendicitis to date includes 1068 children 7 to 17 years of age across 10
tertiary children’s hospitals. Non-operative management consisted of hospital
admission with a minimum of 24 hours of intravenous antibiotics and observation
with subsequent discharge home with oral antibiotics for a total course of 7 days of
therapy. Of the 370 patients who underwent initial non-operative management, 53
(14.3%) patients had early treatment failure and required appendectomy during
their initial hospitalization. Of the 317 patients with early treatment success, 72
(22.7%) had late treatment failure requiring appendectomy. After adjusting for
baseline patient sociodemographic and clinical characteristics, the overall success
rate of non-operative management at 1 year was 67.1%. The authors also
compared disability days between groups and found that non-operative manage-
ment was associated with significantly fewer patient and caregiver disability days
compared to surgery at 30 days and 1 year and higher quality-of-life scores at
30 days [69]. Given the results of this study and the previous evidence demon-
strating the safety and efficacy of non-operative management of pediatric appendi-
citis, many have advocated that the decision surrounding treatment approach
should be the patient/family’s choice and shared decision-making should be the
standard of care [83–90]. Through this approach, patients and their families are em-
powered to make a treatment decision that is aligned with their unique priorities
and values based on the different risks and benefits associated with surgery (ie,
higher disability days, post-operative pain, risk of post-operative complications)
as compared to non-operative management (ie, risk of early treatment failure or
subsequent recurrence) with antibiotics alone.
Operative management of uncomplicated appendicitis is associated with
complication rates ranging from 5% to 15%, including intra-abdominal abscess,
superficial and organ space surgical site infections, small bowel obstruction, and
ileus [91,92]. Given the time-dependent pathophysiology of acute appendicitis
with increasing risk of appendiceal perforation as time passes without interven-
tion, several studies have investigated the association of operative timing and
risk of post-operative complications. One study including 2429 children who
underwent appendectomy within 24 hours of presentation across 29 hospitals
in the National Surgical Quality Improvement Program-Pediatric (NSQIP-Pedi-
atric) database demonstrated that there was no evidence of a significant associ-
ation between timing of operative intervention and post-operative
complications [93]. However, a subsequent study including 18,927 children
who underwent appendectomy within 24 hours of presentation found that pa-
tients who underwent appendectomy 16 to 24 hours after presentation were
more likely to have operative findings of complicated appendicitis, higher rates
APPENDICITIS IN CHILDREN 115

of post-operative percutaneous drain placement, increased use of post-operative

total parenteral nutrition (TPN), and increased length of stay compared to
those who underwent appendectomy within 16 hours of presentation. There
were no significant differences in the rates of organ space surgical site infections
or readmissions between groups [94]. An additional study across 16 NSQIP-
Pediatric hospitals demonstrated that institutions in the longest quartile of
time to appendectomy had significantly longer lengths of stay and higher
average total costs compared to institutions in the shortest quartile of time to
appendectomy [95]. Given the results of the aforementioned studies, when pa-
tients/families decide to pursue operative management, while immediate appen-
dectomy confers no benefit, appendectomy should be performed within
16 hours of presentation to minimize complications associated with appendiceal
perforation and its associated increase in health care resource utilization.

Management strategies for complicated appendicitis

Complicated appendicitis can be defined as appendicitis with either a grossly
identifiable hole in the appendix, a fecalith in the abdomen, or the presence
of a well-formed abscess or frank pus in the abdomen. [96]. Complicated
appendicitis is observed in about 30% of hospital admissions for appendicitis
[97], and is associated with overall worse outcomes and an increase in resource
utilization with a three-fold increase in length of stay and 50% increase in total
cost [98–100]. Complicated appendicitis can be managed in one of three ways:
antibiotics alone, antibiotics and subsequent interval appendectomy, and early
appendectomy at the time of initial presentation (see Fig. 1). Management with
antibiotics alone remains controversial as the risk of incidental significant path-
ologic findings and risk of recurrence remain uncertain. With regard to the risk
of pathologic findings, a recent study investigating histopathologic findings in
149 children who underwent interval appendectomy 6 to 8 weeks after initial
presentation found no neoplasms were identified, however, all children had ev-
idence of persistent inflammation on histopathology [101]. Pooled results from
a systematic review and meta-analysis demonstrated the incidence of carcinoid
tumor was low at 0.9% [102]. With regard to the risk of recurrence, if interval
appendectomy is not performed, the same meta-analysis revealed that the inci-
dence of recurrence ranged from 0% to 42% with an overall pooled risk of
20.5%. However, there was an overall lack of rigorous studies comparing an-
tibiotics alone and antibiotics with interval appendectomy [102]. Based on
the available data, a shared decision-making process with the patient and their
caregiver about interval appendectomy should be performed that allows them
to evaluate the risks and benefits of interval appendectomy versus the approx-
imately 20% risk of developing recurrent appendicitis.
There is also a paucity of rigorous prospective data comparing the effectiveness
of antibiotics with subsequent interval appendectomy and early appendectomy
at the time of initial presentation. Previous studies report heterogeneous results
[103–107], likely due to the wide variety of characteristics and range of disease
severity in the presentation of complicated appendicitis. Overall, complicated
116 GIL, DEANS, & MINNECI

appendicitis can be categorized into two groups: perforation without abscess/

phlegmon and perforation with abscess/phlegmon. A recent systematic review
and meta-analysis investigated the non-operative management of complicated
pediatric appendicitis and specifically stratified the results by disease category
(presence of abscess/phlegmon vs no abscess or phlegmon [‘‘free perforated’’])
[108]. A total of 1288 patients across 14 studies were included in the analysis.
The authors found that the relative risk (RR) of complications in those with ab-
scess/phlegmon undergoing initial non-operative management (NOM) versus
early appendectomy was 0.7. Conversely, the RR of complications in those
with free perforated appendicitis undergoing initial NOM versus early appendec-
tomy was 1.56. Similarly, readmission rates were favorable to initial NOM in the
abscess/phlegmon group (RR 0.35) and favorable to surgery in the free perfo-
rated appendicitis group (RR 1.49). The overall pooled success rate of the initial
NOM was 90%. With regard to cost, there were no significant differences be-
tween initial NOM versus surgery. The authors concluded that children present-
ing with complicated appendicitis with abscess/phlegmon have better outcomes
with initial NOM and interval appendectomy whereas those presenting with
free perforation without abscess/phlegmon have better outcomes with early ap-
pendectomy during initial hospitalization [108].

SUMMARY
The management of pediatric appendicitis continues to advance with the devel-
opment of evidence-based treatment algorithms and a recent shift toward
patient-centered treatment approaches. The available evidence can be used to
develop standardized institution-specific diagnostic and treatment algorithms
based on available resources (eg, use of scoring system to triage to imaging;
choice of secondary imaging modality after ultrasound) to decrease rates of
missed diagnosis and appendiceal perforation, and to promote patient-
centered care that can minimize disability, complications, and health care
resource utilization.

CLINICS CARE POINTS

Ultrasound is the diagnostic imaging modality of choice in children and should be

performed to diagnosis and differentiate between uncomplicated and complicated
appendicitis.

Non-operative management of uncomplicated pediatric appendicitis is safe and
effective with reported overall treatment success rates ranging from 40% to 92%.

Complicated appendicitis with abscess or phlegmon should be managed with an-
tibiotics with or without interval appendectomy, while early appendectomy is indi-
cated in the absence of abscess or phlegmon.

For complicated appendicitis, early appendectomy is indicated in the absence of
abscess/phlegmon, while non-operative management is more appropriate if
phlegmon or abscess is present.
APPENDICITIS IN CHILDREN 117

DISCLOSURE
The authors have nothing to disclose.

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