1. Appendicitis in childrenAppendicitis in children
A review of the current literatureA review of the current literature
Richard WoodRichard Wood
Paediatric Surgery RegistrarPaediatric Surgery Registrar
Red Cross Children’s HospitalRed Cross Children’s Hospital

2. DemographicsDemographics
 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.

3. Natural HistoryNatural 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.

4.  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

5. DiagnosisDiagnosis
 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.:

6.  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 append
Am J Emerg Med 2007; 25:489-493.

7. Alvarado ScoreAlvarado 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]

8. Radiological imagingRadiological 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.

9. Medical ManagementMedical 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.

10. Antibiotic regimensAntibiotic 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 conver

11. Surgical ManagementSurgical 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.

12. Surgical ManagementSurgical 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.

13. Surgical ManagementSurgical 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

14. Surgical ManagementSurgical 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

15. Surgical ManagementSurgical 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.

16. Radiological imagingRadiological imaging

17. Laparoscopic AppendicectomyLaparoscopic 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

18. Laparoscopic AppendicectomyLaparoscopic 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.

19. AppendicitisAppendicitis
Key anatomical points

20. AppendicitisAppendicitis
Key anatomical points

21. Laparoscopic AppendicectomyLaparoscopic Appendicectomy

22. Laparoscopic AppendicectomyLaparoscopic Appendicectomy

23. Laparoscopic AppendicectomyLaparoscopic Appendicectomy

24. Laparoscopic AppendicectomyLaparoscopic 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.

25. Open AppendicectomyOpen Appendicectomy
 Transverse incision
 Protect wound
 Swab out pelvis
 Muscle cutting laparotomy in presence of
peritonitis