What is included in conservative management of pediatric appendicitis?

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

Historically, a patient with appendicitis, especially perforated appendicitis, was rushed to the operating room for appendectomy; however, this is no longer the case. Conservative management with interval appendectomy may be appropriate for perforated appendicitis. Whyte et al have suggested that interval appendectomy may be safely performed as an outpatient procedure. [19]

Conservative management begins with a trial of medical therapy. A patient found to have perforated appendicitis based on imaging study findings should be admitted to the hospital, should be placed on a nothing-by-mouth (NPO) diet, and should be given intravenous (IV) fluid resuscitation.

If the patient is hemodynamically unstable or if urine output cannot be measured, a Foley catheter should be placed. IV antibiotics should be started. Generally, antibiotics for this condition are targeted at enteric flora (eg, second-generation cephalosporin, gentamicin, metronidazole; see Medication). If the patient has an abscess that is accessible, percutaneous drainage is performed. Discharge from the hospital is based on lack of fever, tolerance of pain on oral medications, and adequate oral intake.

A patient who does not improve after admission and intravenous antibiotic therapy should undergo surgery for drainage of the infection and appendectomy, if technically feasible. Factors that suggest failure of conservative management include bandemia on admission CBC count, fever of more than 38.3° C after 24 hours of medical therapy, and multisector involvement on CT scan. Medical therapy is deemed to have failed at a median of 3 days. Medical therapy fails in as many as 38% of children with perforated appendicitis.

In children who recover with medical therapy, an alternative to interval appendectomy is to postpone surgery indefinitely. Most patients do well with this approach. Appendicitis recurrence rates range from 0-20%, with a pooled rate of 8.9% found by one large meta-analysis. [20]

A much higher recurrence rate (72%) is seen in pediatric patients with an appendicolith present during the initial acute episode. Consequently, many experts suggest that interval appendectomy may be needed only in patients with appendicolith.

Most patients who experience recurrence do so within the first 6 months after their initial episode of appendicitis; the longest follow-up to date is 13 years. However, it is not known whether pediatric patients who receive conservative treatment for appendicitis are at risk for recurrence during adulthood. Because of this uncertainty, many pediatric surgeons prefer to perform interval appendectomy.

Delaying definitive surgery is associated with significant resource use, including increased imaging, drainage procedures, and additional admissions. In addition, conservative management with laparoscopic appendectomy performed at a later date poses 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. These studies help to confirm the diagnosis of appendiceal mass and also guide drainage interventions. The increased use of technology, combined with improvements in antibiotics, makes conservative management a more attractive and less risky choice in terms of misdiagnosis or treatment failure.

Nonoperative management with antibiotics for early appendicitis is a new concept in the pediatric population and further studies are required prior to routine recommendation of this practice.

A study by Minneci et al looked to determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. The study enrolled 102 patients, 65 patients/ families chose appendectomy and 37 patients/families chose nonoperative management. The success rate of nonoperative management was 89.2% at 30 days and 75.7% at 1 year. The incidence of complicated appendicitis was 2.7% in the nonoperative group and 12.3% in the surgery. After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days and lower appendicitis-related health care costs. [21]

A study by Bachur et al reported that of the 4,190 out of 99,001 pediatric appendicitis patients managed nonoperatively, nonoperative management patients were more likely during the 12-month follow-up period to have advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). The study also found that 46% of the patients managed nonoperatively had a subsequent appendectomy. [22]


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