How is pediatric appendicitis treated?

Updated: Oct 25, 2018
  • Author: Adam C Alder, MD; Chief Editor: Carmen Cuffari, MD  more...
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Answer

Given that patients with possible appendicitis may have an equivocal history and physical examination findings and inconclusive supporting test results, the following measures are key to any evaluation and treatment plan:

  • Relieve the patient's pain and discomfort early and consistently

  • Communicate with the patient and family about the plans

  • Repeat the examination often

  • Adjust the differential diagnosis as appropriate

  • Keep the patient for observation if a firm diagnosis is not made or for follow-up

Algorithms, scoring systems, imaging studies, and consultation reports are part of the clinician's armamentarium. Documentation of medical decision making is important, as is knowledge of the current literature. Consultations with a pediatrician or general surgeon may be appropriate.

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. A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one study and was found to increase with duration of symptoms. While perforation was directly related to the duration of symptoms before surgery, the risk was associated more with prehospital delay than with in-hospital delay. [1]

If a patient presents beyond 72 hours from symptom onset, perforation is highly likely. However, if a patient presents with symptoms of appendicitis beyond 72 hours and has not perforated, diagnoses other than appendicitis must be entertained.

Avoid treating vague abdominal pain by administering parenteral opiates and then discharging the patient. Narcotics and potent nonsteroidal anti-inflammatory drugs may be needed for pain control. Large doses or ongoing use should be avoided until after surgical consultation.

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. Antibiotics should be started upon diagnosis of appendicitis.

Emergency medical service (EMS) personnel are well trained and cognizant of how to assess and begin treatment of the febrile, vomiting child with abdominal pain. Intravenous fluid administration, pain management, and antiemetic medication should be administered based on local EMS protocols.

The insertion of nasogastric tubes (when necessary), intravenous lines, and urethral catheters (when necessary) and the administration of antibiotics, antiemetic drugs, antipyretic drugs, and analgesia should ideally be part of the emergency department protocol for preoperative management.


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