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Appendicitis in children. A review of the current literature. Richard Wood Paediatric Surgery Registrar Red Cross Children’s Hospital. Demographics. Most common acute surgical condition Life-time risk: 8.7% in boys; 6.7% in girls[ 1 ]

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Appendicitis in children

Appendicitis in children

A review of the current literature

Richard Wood

Paediatric Surgery Registrar

Red Cross Children’s Hospital


  • Most common acute surgical condition

  • Life-time risk: 8.7% in boys; 6.7% in girls[1]

  • Age specific risk: extremely low neonates to peak 12-18 years

  • Higher family risk in children under 6 years[2]

  • Rupture rate significantly increased in poorer children[3]

1/Addiss D.G., Shaffer N., Fowler B.S., et al: The epidemiology of appendicitis and appendectomy in the United States.Am J Epidemiol  1990; 132:910-924. 2/Brender J.D., Marcuse E.K., Weiss N.S., et al: Is childhood appendicitis familial?.Am J Dis Child  1985; 139:338-340.

3/Jablonski K.A., Guagliardo M.F.: Pediatric appendicitis rupture rate: A national indicator of disparities in healthcare access.Popul Health Metr  2005; 3:4.

Natural history
Natural History

  • Inflammation 2° to luminal obstruction[4]

  • Fecalith, lymphoid tissue, parasites, foreign body

  • Fecaliths related to dietary fiber content[5]

  • Post obstruction mucous accumulation and contained bacterial proliferation

  • Pressure leads to lymphatic, venous & arterial occlusion. Pressure necrosis and perforation

4/Wangensteen O.H., Dennis C.: Experimental proof of obstructive origin of appendicitis.Ann Surg  1939; 110:629-647.

5/Jones B.A., Demetriades D., Segal I.: The prevalence of appendiceal fecoliths in patients with and without appendicitis: A comparative study from Canada and South Africa.Ann Surg  1985; 202:80-82.

Appendicitis in children

  • Relapsing /chronic appendicitis[6]

  • Acute inflammation -› perforation -› abscess

  • Definition of perforation controversial

  • <5years perforation 82%

  • <1year perforation +/- 100% [7]

  • Wide range for perforation in literature

  • 20-76% in 30 paediatric hospitals in the US

6/Mattei P., Sola J.E., Yeo C.J.: Chronic and recurrent appendicitis are uncommon entities often misdiagnosed.J Am Coll Surg  1994; 178:385-389.

7/Nance M.L., Adamson W.T., Hedrick H.L.: Appendicitis in the young child: A continuing diagnostic challenge.Pediatr Emerg Care  2000; 16:160-162


  • Classic Triad

  • WBC 11-16000/mm³ significantly higher in cases of perforation[8]

  • RBC’s, WBC’s and protein common in urine

  • No evidence CRP superior to WBC count in children – unnecessary expence[9]

  • Normal WBC and CRP doesn’t exclude Dx [10]

8/Guraya S.Y., Al-Tuwaijri T.A., Khairy G.A., et al: Validity of leukocyte count to predict the severity of acute appendicitis.Saudi Med J  2005; 26:1945-1947.

9/Rodríguez-Sanjuán J.C., Martín-Parra J.I., Seco I., et al: C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in children.Dis Colon Rectum  1999; 42:1325-1329.

10/Gronroos J.M.: Do normal leukocyte count and C-reactive protein value exclude acute appendicitis in children?.Acta Pediatr  2001; 90:649-651.

Appendicitis in children

11/McKay R., Shepherd J.: The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED.Am J Emerg Med  2007; 25:489-493.

Alvarado score
Alvarado Score

  • Abdominal pain that migrates to the right iliac fossa

  • Anorexia (loss of appetite) or ketones in the urine

  • Nausea or vomiting

  • Pain on pressure in the right iliac fossa

  • Rebound tenderness

  • Fever of 37.3 °C or more

  • Leukocytosis, or more than 10000 white blood cells per microliter in the serum

  • Neutrophilia, or an increase in the percentage of neutrophils in the serum white blood cell count

    RIF pain and leucocytosis score 2 points each

0-3: Sensitivity no AA 96% -› Discharge

4-6: Sensitivity of AA 36% -› Imaging

>7: Sensitivity of AA 78% -› +/- theatre [11]

Radiological imaging
Radiological imaging

  • Abdominal X-ray, no benefit except in setting of bowel obstruction and young patients

  • Ultrasound, safe, non-invasive, radiation and contrast free, but operator dependent

  • Review of multiple paediatric series (N=5000+)

  • Sensitivity 78-94% Specificity 89-98%[13]

  • CT Scan Sensitivity and Specificity 95%[14]

  • MRI extremely accurate (no radiation) [15]

13/Vignault F., Filiatrault D., Brandt M.L., et al: Acute appendicitis in children: Evaluation with US.Radiology  1990; 176:501-504.

14/Horton M.D., Counter S.F., Florence M.G., et al: A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient.Am J Surg  2000; 179:379-381.

15/Horman M., Paya K., Eibenberger K., et al: MR imaging in children with nonperforated acute appendicitis: Value of unenhanced MR imaging in sonographically selected cases.AJR Am J Roentgenol  1998; 171:467-470.

Medical management
Medical Management

  • Treatment starts with IV fluid and antibiotics

  • Uncomplicated appendicitis: current evidence suggests single pre-op dose sufficient[16]

  • Post-op antibiotics indicated in perforation

  • Duration of treatment determined by resolution of symptoms

  • CDC guidelines for peritonitis 7-10 days

16/Mui L.M., Ng C.S., Wong S.K., et al: Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis.Aust NZ J Surg  2005; 75:425-428.

Antibiotic regimens
Antibiotic regimens

  • Triple therapy (ampicillin,gentamycin,metronidazole)

  • Piptaz as effective as triples[17]

  • Ceftriaxone and metronidazole daily as effective as triples (cost and time benefit)[18]

  • Early transition to oral antibiotics as effective as prolonged IV’s [19]

17/Nadler E.P., Reblock K.K., Ford H.R., et al: Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children.Surg Infect (Larchmt)  2003; 4:327-333.

18/St Peter S.D., Little D.C., Calkins C.M., et al: A simple and more cost-effective antibiotic regimen for perforated appendicitis.J Pediatr Surg  2006; 41:1020-1024.

19/Adibe O.O., Barnaby K., Dobies J., et al: Postoperative antibiotic therapy for children with perforated appendicitis: Long course of intravenous antibiotics versus early conversion to an oral regimen.Am J Surg  2008; 195:141-143.

Surgical management acute appendicitis
Surgical Management Acute Appendicitis

  • Acute appendicitis cured with surgery

  • Prompt appendicectomy treatment of choice

  • Appendicitis can be treated with antibiotics alone[20]

  • Antibiotics change from emergency to elective

  • Appendicectomy in the middle of the night not justified[21]

20/Styrud J., Eriksson S., Nilsson I., et al: Appendectomy versus antibiotic treatment in acute appendicitis: A prospective multicenter randomized controlled trial.World J Surg  2006; 30:1033-1037.

21/Surana R., Quinn F., Puri P.: Is it necessary to perform appendectomy in the middle of the night in children?.BMJ  1993; 306:1168.

Surgical management perforated appendicitis
Surgical ManagementPerforated Appendicitis

  • Appendicectomy in the presence of known perforation is controversial

  • Antibiotics alone; Antibiotics and interval appendicectomy; Appendicectomy at presentation

  • Recurrent appendicitis(8-14%) short term [22]

  • APSA 86% responders perform interval appendicectomy[23]

22/Puapong D., Lee S.L., Haigh P.I., et al: Routine interval appendectomy in children is not indicated.J Pediatr Surg  2007; 42:1500-1503.

23/ Chen C., Botelho C., Cooper A., et al: Current practice patterns in the treatment of perforated appendicitis in children.J Am Coll Surg  2003; 196:212-221.

Surgical management perforated appendicitis1
Surgical ManagementPerforated Appendicitis

  • Causes of failure of nonoperative management

  • Band count >15% at presentation[24]

  • Appendicolith present on imaging[25]

  • Contamination beyond RIF on imaging[26]

  • Experienced surgeon should be able to deal with situation at presentation

  • APSA survey: Senior surgeons base practice on personal preference

24/Kogut K.A., Blakely M.L., Schropp K.P., et al: The association of elevated percent bands on admission with failure and complications of interval appendectomy.J Pediatr Surg  2001; 36:165-168.

25/Aprahamian C.J., Barnhart D.C., Bledsoe S.E., et al: Failure in the nonoperative management of pediatric ruptured appendicitis: Predictors and consequences.J Pediatr Surg  2007; 42:934-938.

26/Levin T., Whyte C., Borzykowski R., et al: Nonoperative management of perforated appendicitis in children: Can CT predict outcome?.Pediatr Radiol  2007; 37:251-255.

Surgical management abscess at presentation
Surgical ManagementAbscess at presentation

  • Open surgery high morbidity

  • Percutaneous drainage and interval appendicectomy[27]

  • Long course of treatment, cost burden[28]

  • Prospective trial currently in progress comparing early laparoscopic surgery with percutaneous drain and delayed surgery[29]

27/Chen C., Botelho C., Cooper A., et al: Current practice patterns in the treatment of perforated appendicitis in children.J Am Coll Surg  2003; 196:212-221.

28/Keckler S.J., St Peter S.D., Tsao K., et al: Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis.J Pediatr Surg  2008; 43:977-980.

29/ National Institutes of Health: Early versus delayed operation for perforated appendicitis. Available at—NCT# 00414375

Surgical management abscess at presentation1
Surgical ManagementAbscess at presentation

  • Regardless of route of drainage cultures not of benefit[30]

  • One study showed that changing according to cultures had a worse outcome (N=308)[31]

  • Lavage with saline or antibiotic solution not shown to be of benefit[32]

  • Post-op intra-peritoneal AB’s may benefit (48h)

  • Drains only useful in walled off collections[33]

30/Bilik R., Burnweit C., Shandling B.: Is abdominal cavity culture of any value in appendicitis?.Am J Surg  1998; 175:267-270.

31/Kokoska E.R., Silen M.L., Tracy T.F., et al: The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis.J Pediatr Surg  1999; 34:749-753.

32/Sherman J.O., Luck S.R., Borger J.A.: Irrigation of the peritoneal cavity for appendicitis in children: A double blind study.J Pediatr Surg  1976; 11:371-374.

33/Kokoska E.R., Silen M.L., Tracy T.F., et al: Perforated appendicitis in children: Risk factors for the development of complications.Surgery  1998; 124:619-625.

Laparoscopic appendicectomy
Laparoscopic Appendicectomy

  • Umbilical port and two working ports (open)

  • Initial data, longer operative time and more intra-abdominal complications in LA[34]

  • Newer evidence suggests no difference in operative time and IAA in the 2 groups[35]

  • Risk of abscess formation justification for continued use of open surgery

  • Substantially lower risk of wound infection[36]

34/Horwitz J.R., Custer M.D., May B.H., et al: Should laparoscopic appendectomy be avoided for complicated appendicitis in children?.J Pediatr Surg  1997; 32:1601-1603.

35/Aziz O., Athanasiou T., Tekkis P.P., et al: Laparoscopic versus open appendectomy in children: A meta-analysis.Ann Surg  2006; 243:17-27.

36/Sauerland S., Lefering R., Neugebauer E.A.: Laparoscopic versus open surgery for suspected appendicitis.Cochrane Database Syst Rev  2004; 18:CD001546

Laparoscopic appendicectomy1
Laparoscopic Appendicectomy

  • Substantially lower complication rate in obese patients[37]

  • Shorter duration of hospital stay[36]

  • Earlier return to work and normal activity[36]

  • Prospective RCT quality of life, GIT complication and overall complications lower for laparoscopy (N=43757)[38]

  • Recent Cochrane review: LA 1° operation[36]

36/Sauerland S., Lefering R., Neugebauer E.A.: Laparoscopic versus open surgery for suspected appendicitis.Cochrane Database Syst Rev  2004; 18:CD001546

37/Corneille M.G., Steigelman M.B., Myers J.G., et al: Laparoscopic appendectomy is superior to open appendectomy in obese patients.Am J Surg  2007; 194:877-880.

38/Guller U., Hervey S., Purves H., et al: Laparoscopic versus open appendectomy: Outcomes comparison based on a large administrative database.Ann Surg  2004; 239:43-52.

Appendicitis key anatomical points
AppendicitisKey anatomical points

Appendicitis key anatomical points1
AppendicitisKey anatomical points

Laparoscopic appendicectomy5
Laparoscopic Appendicectomy

  • Most recent prospective RCT had a mean operation time of 44min in laparoscopic perforated appendicectomy[39]

  • Evidence heavily in favour of LA

39/St Peter S.D., Tsao K., Spilde T.L., et al: Single daily dosing ceftriaxone and metronidazole vs. standard triple antibiotic regimen for perforated appendicitis in children: A prospective randomized trial.J Pediatr Surg  2008; 43:981-985.

Open appendicectomy
Open Appendicectomy

  • Transverse incision

  • Protect wound

  • Swab out pelvis

  • Muscle cutting laparotomy in presence of peritonitis