eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Appendicitis

Michael S Katz, MD, Research Fellow, Department of Pediatric Surgery, St Christopher's Hospital for Children
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

Updated: Jan 7, 2009

Introduction

Background

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

Pathophysiology

Appendicitis is due to a closed-loop obstruction of the appendix. Most commonly, the obstruction is due to either lymphoid hyperplasia within the appendix or impacted fecal matter, referred to as a fecalith. Obstruction of the appendix leads to bacterial overgrowth and an increase in intraluminal pressure. The increased intraluminal pressure obstructs the venous blood flow in the appendix 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 the bacterial infection cause the inflammation of the appendix. As the disease progresses, the inflammation progresses from a 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.

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 small bowel 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, the diagnosis of Hirschsprung disease should also be considered. The incidence in the United States is 4 cases per 1000 children. Overall, 7% of people in the United States have their appendix removed during their life.

Mortality/Morbidity

At the time of diagnosis, the rate of perforation is 20-35%. 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%. This is most commonly seen in neonates and infants. This is due to 2 factors. First, appendicitis is rare in this age group; thus, unless the physician’s index of suspicion is high, appendicitis is often low on the list of suspected differential diagnoses. Second, very young patients are unable to communicate the location and nature of their pain. Some neonates may not even become febrile. Often, the patient’s only symptom is 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

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 migrates to the right lower quadrant. If the appendix perforates, an interval of pain relief is followed by development of generalized abdominal pain and peritonitis. Although some patients progress in the classical fashion, some patients deviate from the classic model. Fifteen percent of patients have a retrocecal appendix, and their signs and symptoms may not localize to the right lower quadrant, localizing instead 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 typically present 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.
• 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 and 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 findings 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 examination: Patient’s general state should be observed before interacting with them. The patient’s state of activity or withdrawal may lend information into their state. A patient in obvious distress with abdominal pain gives the impression of an infectious process; however, other causes must be ruled out.
• Cardiac and pulmonary examination: The evaluation of the heart and lungs of the patient reflects the overall state more than suggests the appendix as a cause. Patients are often dehydrated or in pain and may be tachycardic or tachypneic. Pediatric patients have great physiological reserve and may not show any general symptoms until they are very ill.
• 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.
    • Patients with a laterally positioned appendix often have flank tenderness.
    • Patients with a retrocecal appendix may not have any tenderness until it is advanced or perforated.
  • Palpation of the abdomen should be performed with a gentle and light touch, searching for involuntary guarding of the rectus or oblique muscles. Eliciting rebound tenderness is an unnecessary part of the abdominal examination. 
  • The 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).
• 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 because 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 able to communicate should be asked if they have tenderness in different areas of the rectum. 
  • Right-sided tenderness of the rectum is the classic finding in pelvic 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 increase in pressure leads to vascular compression initially on the venous side. This causes congestion and decreased wall perfusion. This decreased perfusion leads to necrosis and inflammation of the appendix. 
• During this initial stage the patient feels only periumbilical pain due to the T10 innervation of the appendix. 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 has been 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 and the strength of the appendiceal wall decreases due to 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. At this point, 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 very 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.

Differential Diagnoses

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

Laboratory 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, remember that this is 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 within the first 24 hours of symptoms. Therefore, its predictive value is limited. 
  • If the WBC count exceeds 15,000 cells/μL, the patient is more likely to have a perforation. However, one study found no difference in the WBC counts of children with simple appendicitis and those 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 by an inflamed appendix may result in a 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 can also occur in appendicitis in as many as 20% of patients when an overlying phlegmon or abscess lies adjacent to the ureter. Typically, RBCs are less than 20 per high power field. 
  • Normal urinalysis results do not provide any diagnostic value for appendicitis, although a grossly abnormal result may be suggestive of 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 radiography findings are normal in many individuals with appendicitis. However, plain films may be helpful in the setting of severe constipation.
• A calcified appendiceal fecalith is present in less than 10% of persons with inflammation, but its presence confirms the diagnosis.
• 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. In rare incidents, 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 scans, 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 a 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 scans have become the modality of choice for diagnosing appendicitis in children. 
• Although radiation exposure is a concern, CT scans have been shown to have an accuracy of 97% in diagnosing appendicitis.
• Other advantages include the ability to evaluate the entire abdomen and locate abscesses and phlegmon, lack of dependence on operator skill, and physician familiarity with reading CT scans.
• Disadvantages include the aforementioned radiation exposure, the need for oral and intravenous contrast and its related disadvantages, and the need for the patient to be still, which is often difficult for small children.
• Because of the advantages of CT scans, 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 case of suspected appendicitis. Most preferred CT scanning on a selected basis, with 51-58% of patients with suspected appendicitis undergoing CT scanning.
• However, despite now widespread use of CT scanning for evaluation of appendicitis with its superior sensitivity and specificity, the negative appendectomy rate in children 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, anteroposterior (AP) and lateral chest radiography should be performed to look for right lower lobe pneumonias.

Histologic Findings

Typically, histologic findings 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 at 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]).   
• The authors have recently seen a small group of patients with “early appendicitis” based on history, physical examination findings, and/or CT scans with minimal changes found in the appendix in the operating room or based on only intraluminal inflammatory cells on histology; these patients have complete resolution of their signs and symptoms after appendectomy. Whether this is because the appendectomy is performed at an earlier stage in the pathophysiologic sequence of appendicitis or whether the patients' signs and symptoms resolve due to the placebo effect of the appendectomy is unknown. 

Staging

The clinical staging of appendicitis has important implications in the postoperative treatment of the child. Although somewhat subjective at the time of 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): Persons with exudative appendicitis, particularly in individuals with mural gangrene, have an increased rate of postoperative intraabdominal and wound infections, even in the absence of demonstrable perforations.  Often, microperforations are present, as evident on routine cultures findings. However, if the gram stain and culture findings are negative, the antibiotics can be stopped in approximately 24 hours, and the child may be discharged home as soon as diet and oral pain medications can be tolerated. 
• Perforated: Perforated appendicitis (either diagnosed by intraoperative findings or positive intraoperative cultures) is associated with a postoperative infection rate in as many as 30% of patients. Children with perforated appendicitis require antibiotic therapy for a minimum of 10 days. Often, the patient may 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 fevers of ileus that last more than 5 days.

Treatment

Medical Care

Making a timely diagnosis of appendicitis 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, radiographic evaluation of the kidney, ureters, bladder, and chest may assist in 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 surgical consultation.

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.
• 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. Inversion of the stump may be performed. 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. According to surgeon preference, one is placed in the right lower quadrant and one is placed in the left lower quadrant or both are placed in the left lower quadrant. The cecum and appendix are laterally to medially mobilized. Various methods (ie, electrocautery, endo-loops, stapling devices) are used to remove the appendix and 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.
• Surgical treatment of perforated appendicitis
  • Because of the short time from obstruction of the appendix to perforation, 20-35% of patients who present with acute appendicitis have already perforated. In fact, estimates suggest that most patients perforate within 72 hours of symptom onset. If a patient presents beyond 72 hours from symptom onset, perforation is highly suggested. However, if a patient presents with symptoms of appendicitis beyond 72 hours and has not perforated, diagnoses other than appendicitis must be entertained. 
  • Controversy surrounds the ideal management of patients with perforated appendicitis, including laparoscopic versus open appendectomy performed emergently or initial conservative management with appendectomy at a later date when the acute inflammation has subsided. This delayed surgical treatment is referred to as interval appendectomy and is generally performed 8-12 weeks after the initial episode.
    • Interval appendectomy has gained popularity because of the perceived challenges in operating on potentially distorted anatomy and difficulties in closing the inflamed appendiceal stump. These challenges can result in ileocecal resection, right hemicolectomy, and/or temporary ileostomy.
    • Recently, the need for interval appendectomy has been questioned because of the relatively small recurrence rate of appendicitis after the initial episode.
    • This area is a popular topic of current research; however, no large scale prospective randomized trials have compared continued conservative management with interval laparoscopic appendectomy for perforated appendicitis.
  • Patients with perforated appendicitis can be divided into 2 cohorts; those who are discovered to be perforated in the operating room during appendectomy and those with radiographic evidence of perforation, most commonly seen on CT scan findings. The management of these two cohorts is different and the latter group has been the focus of much research.
  • Patients discovered to have perforated appendicitis in the operating room during appendectomy should be treated in the same fashion as those with nonperforated appendicitis. The surgeon should complete the appendectomy in a normal fashion. If a laparoscopic appendectomy is being performed, perforation alone is not a reason for conversion to open appendectomy. However, if an abscess is encountered and drained, placement of a drain in the abscess cavity should be considered. Also, when an open appendectomy is being performed on a patient with a perforated appendix, the high incidence of wound infection should be considered in terms of skin closure. 
  • Because CT scans are commonly used in the diagnosis of appendicitis, many patients are diagnosed with perforated appendicitis prior to undergoing operative management. CT scan findings that suggest perforated appendicitis include periappendiceal or pericecal air, abscess, phlegmon, and extensive free fluid. Because the etiology of the disease is due to obstruction of the appendix and the inflammation occurs distal to the obstruction, extravasation of contrast or extensive free air is rarely seen. If a patient is found to have free air throughout the abdomen or under the diaphragm, other diagnoses should be entertained.
  • Historically, a patient with perforated appendicitis was rushed to the operating room for appendectomy; however this is no longer the case. 
    • Conservative management with interval appendectomy is now recommended. A patient found to have perforated appendicitis on imaging study findings should be admitted to the hospital, be placed on a nothing-by-mouth (NPO) diet, and given intravenous (IV) fluid resuscitation.
    • If the patient is hemodynamically unstable or is unable to have their urine output measured, a Foley catheter should be placed.
    • The patient should be started on IV antibiotics. Generally, antibiotics for this condition are targeted at enteric flora (eg, second-generation cephalosporin, gentamicin, metronidazole), and discharge from the hospital is based on demonstration of lack of fever, tolerance of pain on oral medications, and adequate oral intake.
    • If the patient has an abscess that is accessible, percutaneous drainage is performed. 
    • Despite the use of conservative management, as many as 38% of children with perforated appendicitis fail medical therapy. If the patient does not improve after admission and use of IV antibiotics, they should undergo immediate appendectomy. Factors that suggest failure of conservative management include bandemia on admission CBC count, fever of more than 38.3 º C after 24 hours of medical therapy, and multisector involvement on CT scan findings. Medical therapy is deemed to have failed at a median of 3 days.
    • Most patients do well with this conservative approach alone, and recurrence rates range from 0-20%, with a pooled rate of 8.9% found by one large meta-analysis.¹  A much higher recurrence rate (72%) is seen in pediatric patients with an appendicolith present during the initial acute episode. This overall low recurrence rate in patients without appendicolith has caused many to advocate that interval appendectomy is not needed. Recurrence is noted in most patients within the first 6 months; the longest follow-up to date is 13 years. However, the status of future recurrence as adults in pediatric patients with appendicitis is unknown. Because of this uncertainty, many pediatric surgeons prefer to perform interval appendectomy.
  • When a patient undergoes interval appendectomy, the laparoscopic approach is preferred because of the ability to visualize a wider area of the abdomen, to lyse any postinflammatory adhesions that may be present, and to avoid the need for extending an open incision in case of abnormal anatomy. However, the complication rate is reported to be 12-23%, which is less than the 26% complication rate for emergent appendectomy in perforated appendicitis. These numbers are based on relatively small studies with different protocols, which limits their usefulness for direct comparison. However, a large meta-analysis did show a significantly greater morbidity with immediate surgery versus conservative treatment with interval appendectomy (35.6% vs 13.5%).
  • A recent study by Whyte et al suggested that interval laparoscopic appendectomy may be performed as an outpatient procedure; 12 of 24 patients were discharged the evening of the procedure.²  Of the patients who stayed, 9 stayed only one night. Although this report is encouraging, well-known complications of laparoscopic appendectomy should not be forgotten, including wound infection, abscess, sepsis, and ileus.
  • Delaying definitive surgery is associated with significant resource use, with increased imaging, drainage procedures, and additional admissions. A potential drawback of conservative management with laparoscopic appendectomy performed at a later date is the risk of misdiagnosis. The major differential diagnoses for acute appendiceal abscess or mass include Crohn disease and malignancy. The increased use of CT scanning or ultrasonography in the emergent setting has decreased this risk of misdiagnosis. This has helped to confirm the diagnosis of appendiceal mass and also guides drainage interventions. The increased use of technology, combined with improvements in antibiotics, makes conservative management a more attractive and less risky choice from a misdiagnosis or treatment failure perspective.

Consultations

• Pediatrician
• General surgeon

Medication

Administer one dose preoperative antibiotics to children with suspected appendicitis and stop administration after surgery if no perforation is noted. 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/sulbactam, cefoxitin, cefotetan, piperacillin/tazobactam, ticarcillin/clavulanate, and imipenem/cilastatin. Fifteen percent of patients with a ruptured appendix may develop resistant organisms and require a change in the antibiotics initially chosen.

Antibiotics

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

Ampicillin (Marcillin, Omnipen, Polycillin, Principen)

Beta-lactam antibiotic with activity against some gram-positive and gram-negative organisms. Inhibits bacterial cell wall synthesis during active multiplication.

Dosing

Adult

1-2 g IV/IM q4-8h

Pediatric

100-200 mg/kg/d IV/IM divided q4-6h

Interactions

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Gentamicin (Garamycin, Gentacidin)

Aminoglycoside antibiotic with activity against gram-negative bacteria including Pseudomonas species. Synergistic with beta-lactams against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.

Dosing

Adult

1-1.5 mg/kg/dose IV/IM q8-24h; dose and frequency based on patient's age and renal function

Pediatric

1.5-2.5 mg/kg/dose IV/IM q8h; dose and frequency based on patient's age and renal function

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents (thus, prolonged respiratory depression may occur); coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; nondialysis-dependent renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Clindamycin (Cleocin)

Lincosamide effective against gram-positive aerobic and anaerobic bacteria (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

600-1200 mg/d IV/IM divided q6-8h

Pediatric

20-40 mg/kg/d IV/IM divided tid/qid

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Ampicillin/sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria.

Dosing

Adult

1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h, not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Pediatric

3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults, not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Piperacillin/tazobactam (Zosyn)

Drug combination of beta-lactamase inhibitor with piperacillin. Activity against some gram-positive organisms, gram-negative organisms, and anaerobic bacteria. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Dosing

Adult

3.375 g IV q6h

Pediatric

300-400 mg piperacillin/kg/d IV divided q6-8h

Interactions

Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase piperacillin levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not FDA approved for patients <12 y; dosage adjustment may be necessary with renal impairment

Cefoxitin (Mefoxin)

Second-generation cephalosporin with activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria. Inhibits bacterial cell wall synthesis during active multiplication by binding 1 or more penicillin-binding proteins.

Dosing

Adult

1-2 g IV q6-8h

Pediatric

80-100 mg/kg/d IV divided q6-8h

Interactions

Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Dosage adjustment may be necessary with renal impairment; caution with previously diagnosed colitis

Cefotetan (Cefotan)

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

Dosing

Adult

1-2 g IV q12h for 5-10 d

Pediatric

20-40 mg/kg/dose IV q12h for 5-10 d

Interactions

Consumption of alcohol within 72 h of administration may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer q24h if creatinine clearance 10-30 mL/min and q48h if <10 mL/min; (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive and gram-negative organisms and most anaerobes.

Dosing

Adult

3 g (based on ticarcillin component) IV q4-6h; not to exceed 18-24 g/d

Pediatric

Severe infections
<3 months: 200-300 mg/kg/d (based on ticarcillin component) IV divided q6-8h
>3 months: 300 mg/kg/d IV divided q4-6h; not to exceed 18 g/d

Interactions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Obtain CBC count prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; monitor urinalysis, BUN, and creatinine results during therapy and adjust dose if values become elevated

Imipenem and cilastatin (Primaxin)

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated because of potential for toxicity.

Dosing

Adult

Base initial dose on severity of infection and administer in equally divided doses; dose may range from 250-500 mg (based on imipenem component) q6h IV; not to exceed 3-4 g/d

Pediatric

Note: Dose is based on imipenem component
Neonates: 40-50 mg/kg/d IV divided q12h
Infants and children:
1-3 months: 100 mg/kg/d IV divided q6h
>3 months: 60-100 mg/kg/d IV divided q6h; not to exceed 4 g/d

Interactions

Coadministration with cyclosporine, ganciclovir, theophylline, or probenecid may increase CNS adverse effects (eg, seizures, tremors)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal insufficiency; caution with history of seizure disorder

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

• 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

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.

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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

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.

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