eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Appendicitis: Follow-up

Author: Michael S Katz, MD, Research Fellow, Department of Pediatric Surgery, St Christopher's Hospital for Children
Coauthor(s): Michael Stephen Freitas, MS, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center; Philip Glick, MD, MBA, Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Research and Development, Department of Surgery, State University of New York at Buffalo
Contributor Information and Disclosures

Updated: Jan 7, 2009

Follow-up

Further Inpatient Care

After appendectomy, the main 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 fluid boluses prior to operation. However, continued fluid resuscitation appropriate to their fluid status and severity of appendicitis is needed.
    • The spectrum ranges from patients with early appendicitis who are started on clear fluids postoperatively and can have intravenous (IV) fluids removed when advanced to regular diet to patients with perforated appendicitis who require postoperative fluid boluses.
    • If fluid status is unclear, urine output is the most common measure. The patients urine output should be no lower than 0.5 mL/kg/h.
    • 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 or 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
    • Often, patients with gangrenous or perforated appendicitis develop intra-abdominal abscesses. These may be present at the time of presentation or may develop after operation or during hospitalization if patient is planned for an interval appendectomy.
    • Commonly, a patient who has a prolonged ileus or fever for more than 5 days postoperatively 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, and diet is advanced as tolerated.
    • Patients who can tolerate regular diet may be discharged home. 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 have immediate appendectomy should remain on a diet of nothing by mouth (NPO) until their bowel function returns. They should then be started on clear fluids, and the diet should be advanced as tolerated.

Inpatient & Outpatient Medications

  • 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 on outpatient narcotics 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

Miscellaneous

Medicolegal 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 their family that recurrence of the abdominal pain in the future could be recurrent constipation or acute appendicitis and to seek medical advice.
 


More on Appendicitis

Overview: Appendicitis
Differential Diagnoses & Workup: Appendicitis
Treatment & Medication: Appendicitis
Follow-up: Appendicitis
References
[ CLOSE WINDOW ]

References

  1. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg. Nov 2007;246(5):741-8. [Medline].

  2. Whyte C, Tran E, Lopez ME, Harris BH. Outpatient interval appendectomy after perforated appendicitis. J Pediatr Surg. Nov 2008;43(11):1970-2. [Medline].

  3. 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].

  4. Brender JD, Marcuse EK, Koepsell TD, Hatch EI. Childhood appendicitis: factors associated with perforation. Pediatrics. Aug 1985;76(2):301-6. [Medline].

  5. Chen C, Botelho C, Cooper A, Hibberd P, Parsons SK. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg. Feb 2003;196(2):212-21. [Medline].

  6. 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].

  7. 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].

  8. Doherty GM, Lewis FR Jr. Appendicitis: continuing diagnostic challenge. Emerg Med Clin North Am. Aug 1989;7(3):537-53. [Medline].

  9. Ein SH, Langer JC, Daneman A. Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis. J Pediatr Surg. Oct 2005;40(10):1612-5. [Medline].

  10. Ein SH, Shandling B. Is interval appendectomy necessary after rupture of an appendiceal mass?. J Pediatr Surg. Jun 1996;31(6):849-50. [Medline].

  11. Eldar S, Nash E, Sabo E, et al. Delay of surgery in acute appendicitis. Am J Surg. Mar 1997;173(3):194-8. [Medline].

  12. Erdogan D, Karaman I, Narci A, et al. Comparison of two methods for the management of appendicular mass in children. Pediatr Surg Int. Feb 2005;21(2):81-3. [Medline].

  13. Fisher M, Meates-Dennis M. Is interval appendectomy necessary after successful conservative treatment of appendiceal mass in children?. Arch Dis Child. Jul 2008;93(7):631-3. [Medline].

  14. 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].

  15. Jabra AA, Shalaby-Rana EI, Fishman EK. CT of appendicitis in children. J Comput Assist Tomogr. Jul-Aug 1997;21(4):661-6. [Medline].

  16. Keckler SJ, Tsao K, Sharp SW, Ostlie DJ, Holcomb GW 3rd, St Peter SD. Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis with abscess. J Pediatr Surg. Jun 2008;43(6):977-80. [Medline].

  17. 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].

  18. Kumar S, Jain S. Treatment of appendiceal mass: prospective, randomized clinical trial. Indian J Gastroenterol. Sep-Oct 2004;23(5):165-7. [Medline].

  19. 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].

  20. Meshikhes A. Management of appendiceal mass: controversial issues revisited. J Gastrointest Surg. Apr 2008;12(4):767-775.

  21. Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: a survey of North American Pediatric Surgeons. J Pediatr Surg. Jun 2004;39(6):875-9; discussion 875-9. [Medline].

  22. Newman K, Ponsky T, Kittle K, Dyk L, Throop C, Gieseker K. Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg. Mar 2003;38(3):372-9; discussion 372-9. [Medline].

  23. Newman K, Ponsky T, Kittle K, et al. Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg. Mar 2003;38(3):372-9; discussion 372-9. [Medline].

  24. O'Shea JS, Bishop ME, Alario AJ, Cooper JM. Diagnosing appendicitis in children with acute abdominal pain. Pediatr Emerg Care. Sep 1988;4(3):172-6. [Medline].

  25. O'Toole SJ, Karamanoukian HL, Allen JE, et al. Insurance-related differences in the presentation of pediatric appendicitis. J Pediatr Surg. Aug 1996;31(8):1032-4. [Medline].

  26. Partrick DA, Janik JE, Janik JS, et al. Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children. J Pediatr Surg. May 2003;38(5):659-62. [Medline].

  27. Pearl RH, Caty MG, Glick PL. Appendicitis. In: Glick PL, Pearl RH, Irish MS, Caty MG, eds. Pediatric Surgical Secrets. 2000.

  28. Pearl RH, Hale DA, Molloy M, Schutt DC, Jaques DP. Pediatric appendectomy. J Pediatr Surg. Feb 1995;30(2):173-8; discussion 178-81. [Medline].

  29. Pena BM, Taylor GA, Lund DP, Mandl KD. Effect of computed tomography on patient management and costs in children with suspected appendicitis. Pediatrics. Sep 1999;104(3 Pt 1):440-6. [Medline].

  30. Ponsky TA, Huang ZJ, Kittle K, Eichelberger MR, Gilbert JC, Brody F. Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children. JAMA. Oct 27 2004;292(16):1977-82. [Medline].

  31. Puapong D, Lee SL, Haigh PI, Kaminski A, Liu IL, Applebaum H. Routine interval appendectomy in children is not indicated. J Pediatr Surg. Sep 2007;42(9):1500-3. [Medline].

  32. Reynolds SL. Missed appendicitis in a pediatric emergency department. Pediatr Emerg Care. Feb 1993;9(1):1-3. [Medline].

  33. Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of acute appendicitis: common features discovered in cases after litigation. Am J Emerg Med. Jul 1994;12(4):397-402. [Medline].

  34. Schwartz MZ, Bulas D. Acute abdomen. Laboratory evaluation and imaging. Semin Pediatr Surg. May 1997;6(2):65-73. [Medline].

  35. Stovroff MC, Totten M, Glick PL. PIC lines save money and hasten discharge in the care of children with ruptured appendicitis. J Pediatr Surg. Feb 1994;29(2):245-7. [Medline].

  36. Stringel G. Appendicitis in children: a systematic approach for a low incidence of complications. Am J Surg. Dec 1987;154(6):631-5. [Medline].

  37. Tantoco JG, Levitt MA, Hollands CM, et al. Reduced social morbidity of laparoscopic appendectomy in children. Am Surg. Sep 2004;70(9):779-82. [Medline].

  38. Taqi E, Al Hadher S, Ryckman J, et al. Outcome of laparoscopic appendectomy for perforated appendicitis in children. J Pediatr Surg. May 2008;43(5):893-5. [Medline].

  39. Tekin A, Kurtoglu HC, Can I, Oztan S. Routine interval appendectomy is unnecessary after conservative treatment of appendiceal mass. Colorectal Dis. Jun 2008;10(5):465-8. [Medline].

  40. Tsao K, St Peter SD, Valusek PA, et al. Management of pediatric acute appendicitis in the computed tomographic era. J Surg Res. Jun 15 2008;147(2):221-4. [Medline].

  41. Urbach DR, Marrett LD, Kung R, Cohen MM. Association of perforation of the appendix with female tubal infertility. Am J Epidemiol. Mar 15 2001;153(6):566-71. [Medline].

  42. Whyte C, Levin T, Harris BH. Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management. J Pediatr Surg. Aug 2008;43(8):1459-63. [Medline].

  43. Yacoe ME, Jeffrey RB Jr. Sonography of appendicitis and diverticulitis. Radiol Clin North Am. Sep 1994;32(5):899-912. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

appendicitis, acute inflammation of the appendix, appendix, abdominal pain, acute appendicitis, acute appendicitis, perforated appendix, peritonitis, fecalith, peritonitis, retrocecal appendix, volvulus, testicular torsion, ovarian torsion, intussusception, appendicolith, diarrhea, right lower quadrant pain, closed-loop obstruction, nematodes

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Michael S Katz, MD, Research Fellow, Department of Pediatric Surgery, St Christopher's Hospital for Children
Michael S Katz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Stephen Freitas, MS, State University of New York at Buffalo School of Medicine and Biomedical Sciences
Michael Stephen Freitas, MS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Physical Therapy Association, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

Philip Glick, MD, MBA, Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Research and Development, Department of Surgery, State University of New York at Buffalo
Philip Glick, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, Central Surgical Association, Federation of American Societies for Experimental Biology, Medical Society of the State of New York, Phi Beta Kappa, Physicians for Social Responsibility, Royal College of Surgeons of England, Sigma Xi, Society for Pediatric Research, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, and Society of University Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey J DuBois, MD, Consulting Staff, Division of Pediatric Surgery, Kaiser Permanente, North Sacramento Medical Center
Jeffrey J DuBois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, California Medical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

David A Piccoli, MD, Chief, Division of Gastroenterology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine
David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.