Appendicitis in children

A review of the current literature

Faisol Darmawan
Paediatric Surgery Registrar
Abdul Moeluk Hospital
Demographics
 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
 Inflammation 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.
 Relapsing /chronic appendicitis[6]
 Acute inflammation -› perforation -› abscess
 <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
Diagnosis
 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.

Classic Presentation

 Seen in 60 %
 Anorexia
 Periumbilical pain, nausea, vomiting
 Mc Burney pain developing over 24 hrs.
 Anorexia and pain are most frequent
 Usually nausea, sometimes vomiting
 Diarrhea, esp. with pelvic location
 Usually tender to palpation
 Rebound is a later finding
Physical Exam

 Tenderness at McBurney's point

 Cutaneous hyperesthesia in T 10 to 12
dermatomes
 Rovsing's sign
 Psoas sign
 Obturator sign
 Scoring systems may be of use
 Stratify patients into 3 groups
 Surgery (high score)
 Imaging (intermediate score)
 Discharge (low score) [11]

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.
Pediatric Appendicitis Score
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
 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
 Triple therapy
(ampicillin,gentamycin,metronidazole)
 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

 Acute appendicitis cured with surgery

 Prompt appendicectomy treatment of choice
 Appendicitis can be treated with antibiotics
alone[20]
 Antibiotics change from emergency to elective

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
 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 Appendicitis
 Causes of failure of nonoperative management
1. Band count >15% at presentation[24]
2. Appendicolith present on imaging[25]
3. 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
 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

www.clinicaltrials.gov—NCT# 00414375
Surgical Management
Abscess 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.

Radiological imaging
Laparoscopic Appendicectomy
Laparoscopic Appendicectomy
Laparoscopic Appendicectomy
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
 Transverse incision
 Protect wound
 Swab out pelvis
 Muscle cutting laparotomy in presence of
peritonitis
Differential diagnostics

Gastrointestinal Gynecologic
1. Cholecystitis 1. Ectopic pregnancy
2. Crohn's disease 2. Endometriosis
3. Duodenal ulcer 3. Ovarian torsion
4. Gastroenteritis 4. Pelvic inflammatory
5. Intestinal obstruction disease
6. Meckel's diverticulitis 5. Ruptured ovarian cyst
7. Mesenteric lymphadenitis 6. Tubo-ovarian abscess
8. Neoplasm (carcinoid,
carcinoma, lymphoma)
Prognosis
 Mortality rate is 0.06% in unruptured
appendix.
 3% in case of rupture.
 15% in case of rupture in elderly
Summary
 Appendicitis is a common surgical emergency
with a varied clinical presentation
 Several patient groups are at high risk of
misdiagnosis
 Lab and imaging studies are helpful, but no
single study is a substitute for good clinical
judgement