eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Appendicitis: Treatment & Medication

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

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.

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.

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.

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.

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.

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.

Cefotetan (Cefotan)

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

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.

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.

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