Acute appendicitis in children: Management

Authors:
David E Wesson, MD
Mary L Brandt, MD
Section Editor:
Jonathan I Singer, MD
Deputy Editor:
James F Wiley, II, MD, MPH

Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2019. | This topic last updated: Apr 04, 2019.

INTRODUCTION — This topic will review the management of appendicitis in children. The evaluation,
diagnosis, and diagnostic imaging of acute appendicitis in children and management of appendicitis in adults
are discussed separately:

●(See "Acute appendicitis in children: Clinical manifestations and diagnosis".)

●(See "Acute appendicitis in children: Diagnostic imaging".)

●(See "Management of acute appendicitis in adults".)

DIAGNOSIS — The diagnostic approach to children with suspected appendicitis is provided in the
algorithm (algorithm 1) and is discussed separately. (See "Acute appendicitis in children: Clinical
manifestations and diagnosis" and "Acute appendicitis in children: Diagnostic imaging".)

APPROACH — Once appendicitis is diagnosed, further management is determined by whether the

appendix is intact, has undergone perforation (advanced appendicitis), or has developed into an appendiceal
mass (phlegmon) or abscess. All children with appendicitis warrant fluid resuscitation as determined by
their degree of dehydration, intravenous (IV) antibiotics targeting gut flora, and analgesia. Once stabilized
as needed, patients with early or advanced appendicitis warrant urgent appendectomy as do ill-appearing
patients with an appendiceal mass or abscess. Well-appearing patients with an appendiceal mass or
phlegmon may initially be managed nonoperatively or undergo appendectomy. (See 'Early appendicitis'
below and 'Advanced appendicitis' below and 'Appendiceal mass or abscess' below.)

The status of the appendix (intact, perforated, localized mass [phlegmon], or abscess) is determined by
clinical findings as follows:

●Patients with early appendicitis typically have a recent onset (one to two days) of abdominal pain that over
time has migrated from the periumbilical region to the right lower quadrant (RLQ) followed by low-grade
fever, vomiting, and anorexia associated with RLQ tenderness on physical examination. White blood cell
(WBC) count, absolute neutrophil count, and/or C-reactive protein are typically elevated. In addition, some
patients with early appendicitis may have equivocal findings of appendicitis by history and physical
examination but have diagnostic imaging that confirms the diagnosis. (See "Acute appendicitis in children:
Clinical manifestations and diagnosis", section on 'Clinical suspicion' and "Acute appendicitis in children:
Diagnostic imaging", section on 'Imaging approach'.)

●The combination of clinical findings of appendicitis as described above for early appendicitis with
additional findings of peritonitis (eg, fever, rebound, guarding, or rigid abdomen) and evidence of
perforation on diagnostic imaging (eg, ultrasound, computed tomography [CT], or magnetic resonance
imaging [MRI]) can frequently establish the presence of advanced appendicitis prior to surgical removal
[1]. However, in some patients, perforation is only discovered intraoperatively.

●Children with an appendiceal mass (phlegmon) or abscess have a delayed presentation (at least five to
seven days), and evidence of a periappendiceal mass or abscess on physical examination and diagnostic
imaging [2].

EARLY APPENDICITIS — Early appendicitis is defined as appendicitis without evidence of perforation.

Appendectomy — We suggest that patients with early appendicitis have the appendix removed. Timely
removal of an inflamed appendix prevents progression to rupture with peritonitis in some children and is
curative [3-5]. Timely appendectomy has been the standard approach since the 1890s [6]. Appendectomy
also permits direct pathologic examination of the appendix and diagnosis of rare but important coexisting
conditions such as a carcinoid tumor or alternative diagnoses such as terminal ileitis or ovarian torsion that
change subsequent management [7].

It is a safe procedure with children experiencing less morbidity than adults [8]. Wound infection and
paralytic ileus are the primary early complications of appendectomy and occur in up to 9 percent and 2
percent of patients, respectively [3]. Since the advent of antibiotics for preoperative treatment and an
emphasis on early removal, mortality following appendectomy is very rare [6]. The major life-threatening
complication consists of late small bowel obstruction due to adhesions and occurs in <1 percent of patients.
(See 'Post-appendectomy complications' below.)

However, preliminary evidence suggests that nonoperative management in selected patients can be
successful. (See 'Nonoperative management' below.)

Preoperative care — Key aspects of preoperative care for children with early appendicitis include antibiotic
prophylaxis, fluid therapy, and analgesia as follows:

Antibiotic prophylaxis – We recommend that children with nonperforated appendicitis receive a single
prophylactic dose of a broad spectrum antibiotic before operation rather than no treatment.

Acceptable antibiotic choices include:

●Cefoxitin

●Ceftriaxone and metronidazole

●Cefotetan

●Gentamicin and either clindamycin or metronidazole in patients allergic to penicillins and cephalosporins

●Piperacillin and tazobactam

Antibiotics should be administered as soon as the diagnosis of appendicitis is established and at least 30 to
60 minutes before the incision is made [9].

The inclusion of piperacillin and tazobactam for prophylaxis of uncomplicated appendicitis in children
differs from joint guidelines for prophylaxis for simple appendectomy proposed by the Infectious Diseases
Society of America, the Surgical Infection Society, The American Society of Health-System Pharmacists,
and the Society for Healthcare Epidemiology of America [10] but is consistent with guidelines proposed by
the American Pediatric Surgical Association [11]. The use of piperacillin and tazobactam for such patients
is based upon the frequent difficulty in identifying whether the appendix is perforated in children prior to
operation. However, in an observational study of almost 18,000 children with uncomplicated appendicitis
of whom one-third received extended spectrum antibiotics (primarily piperacillin and tazobactam),
treatment failure, defined as readmission within 30 days related to a complication of appendicitis, occurred
in approximately 1 percent of all patients and was not reduced in the patients receiving extended spectrum
antibiotics (adjusted odds ratio [aOR] 1.32; 95% CI 0.9-2.0) [12].

Patients with simple appendicitis do not require further doses of antibiotics after appendectomy. By contrast,
antibiotics should be continued postoperatively in children with perforated appendicitis. (See 'Antibiotics'
below.)

The effectiveness of prophylactic antibiotics in patients with early appendicitis is supported by a meta-
analysis of 45 trials that noted a significant reduction in wound infections (5 versus 11 percent, odds ratio
[OR] 0.37) and intraabdominal abscesses (0.6 versus 1.4 percent, OR 0.46) among adults and children
undergoing appendectomy who received antibiotic prophylaxis [13]. Whether any additional doses of
antibiotics are beneficial in these patients was not addressed by this meta-analysis. However, a systematic
review by the American Pediatric Surgical Association concluded that evidence is lacking to support
postoperative antibiotics in children with nonperforated appendicitis and most experts agree that additional
doses of antibiotics in these patients are unnecessary [11].

Fluid therapy and analgesia – Intravenous (IV) hydration and analgesia should be provided. Any identified
electrolyte abnormalities should be corrected before surgery. Rehydration can be accomplished by giving
20 mL/kg boluses of isotonic crystalloid until the signs of dehydration have resolved and the patient has
voided. Once euvolemia has been established the child should receive half normal saline with 10 to 20
mEq/L of potassium chloride at 1 to 1.5 maintenance and additional fluid losses (eg, vomiting) should be
replaced. (See "Treatment of hypovolemia (dehydration) in children".)

Pain control is also an important component of preoperative care of children with acute appendicitis, both
before and after the diagnosis is made. Pain management should be guided by the patient's self-assessment
of pain severity whenever possible. IV opioids (eg, morphine) are typically the best choice. Ketorolac is an
excellent choice for postoperative pain medication, and does not significantly increase the patient's bleeding
risk. (See "Evaluation and management of pain in children", section on 'Assessment of pain severity' and
"Evaluation and management of pain in children", section on 'Opioids'.)

Timing of operation — In the past, appendicitis has been considered a surgical emergency that requires
prompt appendectomy to avoid perforation and other complications. However, evidence from observational
studies suggests that adverse outcomes (eg, perforation, complications, or operating time) are not increased
for children who receive timely administration of antibiotics and undergo appendectomy less than 24 hours
after diagnosis [14-17]. For example, in a multicenter, prospective, observational study of almost 1000
children 3 to 18 years of age with appendicitis, duration of time ≤24 hours between emergency department
evaluation and operation was not associated with a significant increase in appendiceal perforation on
adjusted analysis, including children without perforation on computed tomography (CT) of the abdomen
during initial evaluation [15]. A retrospective observational study of over 2400 children undergoing
appendectomy at 23 children's hospitals also found no association between time to appendectomy ≤24 hours
and complicated appendicitis or postoperative complications [16]. On the other hand, operative delay
beyond 48 hours after admission has been associated with increased risk for surgical site infections and 30-
day complications [14].

Of note, limiting the total time of symptoms prior to appendectomy rather than the time from diagnosis to
surgery appears to be of greatest importance in preventing perforation and other adverse outcomes [18,19].
As an example, in a prospective observational study that evaluated 230 children who underwent
appendectomy, patients with symptoms greater than 48 hours had a significantly higher rate of perforation
when compared with patients with symptoms ≤48 hours (46 versus 12 to 18 percent) [18]. When evaluated
according to time from diagnosis, the perforation rate, length of stay, and operating time were not
significantly different. By contrast, in another more recent study that had found an increased risk of
perforation based upon time from emergency department diagnosis to surgery, the duration of symptoms
was not considered [20].

Laparoscopic or open approach — We recommend that children with early appendicitis undergo
appendectomy with a laparoscopic approach rather than an open approach.

Evidence supporting this recommendation for laparoscopic appendectomy includes the following:

●Two meta-analyses that compared laparoscopic to open surgery for acute appendicitis in children noted
that laparoscopic procedures were associated with a significantly decreased hospital length of stay (mean
difference 0.5 to 0.6 days) and risk of wound infection (1 to 2 versus 5 to 6 percent, odds ratio [OR] 0.20 to
0.45) [21,22]. The mean difference in operative time was 7 to 11 minutes longer for laparoscopy, which is
of marginal clinical significance. Intraabdominal abscess was more common after laparoscopy in one meta-
analysis that included observational studies and randomized trials [21] but was of low frequency and could
not be analyzed in the other meta-analysis of seven trials [22].

Good evidence to support decreased postoperative pain and earlier return to normal activities after
laparoscopic appendectomy in children is lacking. However, the decrease in hospital length of stay provides
indirect evidence for these benefits of the laparoscopic approach and is consistent with our experience.

●In a systematic review of almost 75,000 children undergoing appendectomy for uncomplicated
appendicitis, laparoscopic appendectomy was associated with a reduced length of hospital stay and no
significant difference in postoperative complications such as wound infection or intraabdominal abscess
when compared with open appendectomy [23].

Laparoscopic appendectomy may be performed using a three port (three incisions) or single incision
technique [24,25]. In a prospective observational study of 186 children with early appendicitis, 96 percent
successfully completed the procedure using single incision laparoscopic surgery.

Intraoperative considerations — Important intraoperative considerations arise based upon the appearance of
the appendix or discovery of a carcinoid tumor as follows:

●Abnormal but intact appendix – The following surgical principles should be followed [26]:

•A segment of omentum that is firmly attached to the appendix should be divided a few centimeters away
and removed with the appendix.

•The base of the appendix should be ligated close to the cecum. There is no proven benefit to inversion of
the stump.

•All purulent fluid should be aspirated.

•All incisions and trocar sites that are larger than 5 mm should be closed primarily.

●Perforated appendix – In some patients thought to have early appendicitis based upon preoperative
clinical findings, a perforated appendix will be encountered. Intraoperative considerations for patients with
advanced (perforated) appendicitis are discussed separately. (See 'Intraoperative considerations' below.)
●Normal appendix – When an apparently normal appendix is found, it should be removed. Removal of an
appendix that appears grossly normal is generally recommended because microscopic inflammation may be
noted on pathologic examination [27]. Removal of the appendix will also significantly diminish concern for
the diagnosis of appendicitis if the patient develops another episode of abdominal pain, although stump
appendicitis remains possible. (See 'Small bowel obstruction' below.)

Evidence for other possible causes of abdominal pain, including Meckel's diverticulitis, terminal ileitis,
mesenteric adenitis, omental torsion, renal mass or obstruction, cholecystitis, or tubal or ovarian pathology
should be sought if the appendix appears to be normal.

●Carcinoid tumor – Rarely, a carcinoid tumor will be seen or palpated in the appendix at the time of
appendectomy [28]. Simple appendectomy is sufficient treatment for most cases of appendiceal carcinoid.
On the other hand, a right hemicolectomy is indicated if the tumor is greater than 2 cm in diameter, if the
tumor invades through the wall of the appendix, or if the adjacent mesenteric nodes are involved. (See
"Staging, treatment, and posttreatment surveillance of nonmetastatic, well-differentiated gastrointestinal
tract neuroendocrine (carcinoid) tumors", section on 'Appendix'.)

Postoperative care — The principle management issues after appendectomy in children with early
appendicitis include adequate pain control and resumption of oral intake as follows:

●Analgesia – Evidence is lacking to guide optimal postappendectomy pain management, and practice varies
widely [29]. Postoperative pain has traditionally been managed with parenteral opioids (eg, morphine with
repeated doses every four to six hours based upon additional pain assessment) supplemented by parenteral
ketorolac or acetaminophen with conversion to oral agents (eg, ibuprofen, acetaminophen, or hydrocodone)
once the child is drinking well. If opioids are needed to control pain, the goal is to use the lowest effective
dose and duration of these medications.

However, in our experience, adequate pain control is frequently achieved by wound blocks at the time of
surgery and postoperative parenteral or oral nonsteroidal antiinflammatory drugs (NSAIDs). This approach
is especially appropriate for patients undergoing minimally invasive surgery with same-day discharge and
avoids side effects such as drowsiness and constipation. Close attention to pain assessment and resolution
of pain is essential, regardless of the regimen chosen. (See "Evaluation and management of pain in children",
section on 'Assessment of pain severity'.)

In the past, use of NSAIDs was discouraged because of the theoretical risk of bleeding. However, in studies
of their use after other operations where hemorrhage is more likely to occur (eg, tonsillectomy), NSAIDs
have not been associated with increased bleeding [30]. In one observational study of 186 children
undergoing appendectomy for early appendicitis using a single incisional laparoscopic technique, pain
control with oral NSAIDs was adequate for most patients [24].

●Oral intake and diet – Oral fluids can be introduced as soon as the child is awake. Diet may be advanced
to solid food as tolerated. If admitted, most children are able to go home within 24 to 48 hours. Some centers
now discharge patients on the day of surgery once adequate pain control and ability to tolerate liquids and
solids are confirmed. Longer lengths of stay to permit continued treatment with antibiotics is necessary if
the appendix was gangrenous or perforated. (See 'Antibiotics' below.)

Same-day discharge — Evidence suggests that selected children with early appendicitis may be discharged
on the same day of surgery with high caregiver satisfaction and without an increase in complications, urgent
revisits, or readmissions when compared to overnight hospitalization [24,31,32].

Nonoperative management — Although appendectomy for early appendicitis remains the treatment of
choice, nonoperative treatment (NOT) of early appendicitis has been proposed and may be an option in
selected children with early, uncomplicated appendicitis depending upon caregiver preference. Specifically,
it may be safe and effective for older children who can better describe their symptoms (over six years of
age) and have features of early appendicitis as follows [33]:

●Abdominal pain for <48 hours

●White blood cell (WBC) count ≤18,000/microL

●Normal C-reactive protein

●No appendicolith present on imaging

●Appendix diameter ≤1.1 cm on imaging

●No preoperative concern for rupture based upon clinical findings

NOT may be especially appropriate in children who meet the above criteria and who have comorbidities
that raise the risk of appendectomy. NOT should only be performed by a surgeon with pediatric expertise.

Antibiotic protocols vary widely but typically include 1 to 2 days of inpatient broad spectrum IV therapy
(eg, piperacillin-tazobactam, ceftriaxone and metronidazole, or ciprofloxacin and metronidazole) until
resolution of symptoms and normalization of WBC count occur followed by oral antibiotics (eg,
amoxicillin-clavulanic acid or ciprofloxacin and metronidazole) as an outpatient [34].

Initial findings from small prospective observational studies, nonrandomized trials, and one randomized
trial indicate potential benefits for selected children who undergo NOT of acute, uncomplicated
appendicitis. However, more evidence, preferably from large randomized trials, is needed to provide
guidance as to which patients should undergo NOT or appendectomy [35]:

●In a systematic review of 10 studies that provided outcomes for 413 children undergoing NOT, initial
treatment was effective in 88 to 99 percent of patients and was associated with no appendectomy at reported
follow-up (ranging from 8 weeks to 4 years) in 62 to 92 percent of patients and recurrent appendicitis
documented in 2 to 29 percent of patients [34]. There was a suggestion that longer periods of follow-up
from initial presentation were associated with a greater risk of recurrence. Complications (described in five
studies) and total length of hospital stay (reported in two studies) appeared similar during follow-up
regardless of initial treatment. In one study that was included in this review, perforation occurred during the
initial hospitalization for NOT [36]. Pooled estimates were performed by the investigators but, given the
underlying variation in methodology of the included studies, may be misleading.

●In a meta-analysis that was confined to five prospective trials: one randomized trial included in the first
meta-analysis and four prospective controlled trials where NOT was performed based upon parent
preference (one trial not included in the first meta-analysis); successful initial management without
appendectomy in the first month after presentation (168 patients) was 91 percent [37]. By one year, 73
percent of patients had not undergone appendectomy (including patients who failed NOT within the first
month of presentation) and recurrent appendicitis was documented in 22 percent of all patients undergoing
NOT. Subgroup analysis identified a significantly higher risk for failure of NOT in children with an
appendicolith.

More recent observational studies suggest that patient selection strongly influences outcomes and that NOT
using more rigorous initial criteria for inclusion is associated with the best balance of risks and benefits. For
example, in a prospective observational study of 197 children with a Pediatric Appendicitis Score ≥7, acute
symptoms (average duration 20 to 24 hours), and a pelvic ultrasound demonstrating signs of acute
appendicitis without perforation and no appendicolith, NOT was successful in 87 percent of patients at up
to 18 months of follow-up [38]. Intraluminal fluid on ultrasonography was significantly associated with
failure of NOT. In another prospective, observational study in which only children with evidence of
complicated appendicitis (signs of perforation or sepsis at presentation) had surgery within 12 hours, of the
197 children with uncomplicated appendicitis who first received IV antibiotics and observation for 24 to 48
hours, 58 percent improved and avoided appendectomy during initial hospitalization [39]. Subsequently, 2
percent of those managed without appendectomy required operation after discharge. In a retrospective study
of an insurance database that documented initial NOT in over 4,000 children, 46 percent subsequently
underwent appendectomy and 14 percent had perforated appendicitis. During one year of follow-up, NOT
was associated with significantly more advanced imaging and hospitalizations [40].

The nonoperative management of early appendicitis in adults is discussed separately. (See "Management of
acute appendicitis in adults", section on 'Evidence for nonoperative management'.)

ADVANCED APPENDICITIS — Appendicitis is considered advanced when perforation or gangrene has

developed. When possible, advanced appendicitis in infants and young children should be managed by a
pediatric surgeon [41].

Appendectomy — We recommend that children with advanced appendicitis and without an appendiceal
mass or abscess, undergo urgent appendectomy rather than delayed appendectomy. Timely appendectomy
for patients with advanced appendicitis has been the standard approach since the 1890s [6]. Appendectomy
may prevent progression to sepsis and septic shock and also permits aspiration of pus and irrigation of the
abdominal cavity. It is a safe procedure with children experiencing less morbidity than adults [8]. Wound
infection, intraabdominal abscess, and paralytic ileus are the primary early complications of appendectomy
and occur in up to 9 percent, 5 percent, and 2 percent of patients, respectively [3]. Since the advent of
antibiotics for preoperative treatment and an emphasis on early removal, mortality following appendectomy
for advanced appendicitis is very rare [6]. The major life-threatening complication consists of late small
bowel obstruction due to adhesions and occurs in <1 percent of patients. (See 'Post-appendectomy
complications' below.)

Initial nonoperative management followed by interval appendectomy may result in better outcomes than
early appendectomy for children with a delayed presentation of appendicitis associated with an appendiceal
mass (phlegmon) or abscess. However, the presence of an appendicolith at initial evaluation is associated
with failure of nonoperative management [42]. (See 'Appendiceal mass or abscess' below.)

Preoperative care — Adequate preoperative preparation is of paramount importance in patients with

complicated appendicitis and includes the following measures:

●Replacement and maintenance fluid therapy should be provided and adjusted for serum sodium and
potassium. (See "Treatment of hypovolemia (dehydration) in children" and "Maintenance intravenous fluid
therapy in children".)

●A nasogastric tube should be inserted if the child has persistent vomiting. All measured gastric drainage
should be replaced with 10 to 20 mEq/L of potassium chloride in isotonic or half normal saline. Routine use
of nasogastric tube drainage does not appear to improve the postoperative course [43].

●A urethral catheter should be inserted to monitor urine production when the child is severely dehydrated.
An hourly urine output of 1 to 2 mL/kg is a sign that the intravascular volume has been restored and the
patient is fit for surgery.
●All patients should receive preoperative antibiotics. We generally use piperacillin and tazobactam when
gangrene or perforation is suspected pre-operatively as recommended by the American Pediatric Surgical
Association guidelines [11].

The optimal prophylactic regimen is not clear and acceptable alternatives to piperacillin and tazobactam
include:

•Cefoxitin

•Ceftriaxone and metronidazole

•Cefotetan

•Gentamicin and either clindamycin or metronidazole in patients allergic to penicillins and cephalosporins

The initial dose or doses of antibiotics should be completed as soon as possible and ideally at least 30 to 60
minutes before the operation. (See 'Preoperative care' above.)

In an observational study of over 7000 children with advanced appendicitis of whom two-thirds received
extended spectrum antibiotics (primarily piperacillin and tazobactam), treatment failure, defined as
readmission within 30 days related to a complication of appendicitis, occurred in approximately 6 percent
of all patients with advanced appendicitis and was increased in patients who received extended spectrum
antibiotics (adjusted odds ratio [aOR] 1.4; 95% CI 1.1-1.9) [12].

Clinical trials are needed to determine the best empiric antibiotic regimen for these patients.

Laparoscopic or open approach — We suggest that children with appendiceal perforation undergo
appendectomy by a laparoscopic approach when surgeons who are well trained in this technique are
available. Open laparotomy for neonatal appendicitis is suggested for newborn infants with abdominal
distension and sepsis who show no signs of necrotizing enterocolitis on imaging or who display perforation
or obstruction on plain abdominal radiographs [44]. (See "Acute appendicitis in children: Clinical
manifestations and diagnosis", section on 'Neonates (0 to 30 days)' and "Neonatal necrotizing enterocolitis:
Clinical features and diagnosis".)

Evidence supporting laparoscopic appendectomy in patients with advanced appendicitis includes the
following:

●In a meta-analysis of 16 comparative studies and 3 trials published since 2000 (34,474 children with
complicated appendicitis of whom 10,965 underwent laparoscopic appendectomy), laparoscopic
appendectomy when compared with open appendectomy was associated with significantly reduced hospital
length of stay (mean reduction 0.7 days), lower risk of wound infection (3.3 versus 4.1 percent), lower risk
of bowel obstruction (1.2 versus 1.5 percent), longer operative time (range of mean excess time 2 to 50
minutes), and a higher risk for intraabdominal abscess (3.7 versus 2.6 percent) [23]. However, there was
significant heterogeneity for most pooled results.

●In an unblinded randomized trial not included in the above meta-analysis, of 131 children younger than 18
years of age with a clinical diagnosis of perforated appendicitis and no mass or phlegmon, early
appendectomy was associated with a significantly shorter time to return to normal activities (mean number
of days: 14 versus 19) and reduced adverse events (eg, abscess, small bowel obstruction, or unplanned
readmission, 30 versus 55 percent) than interval appendectomy six to eight weeks later [45]. In addition,
hospital charges and costs were significantly lower for children who had an early appendectomy [46].
●In an observational study not included in the above meta-analysis and that utilized a national database, 660
children undergoing laparoscopic appendectomy had an overall complication rate of 12 percent [47]. This
rate was not significantly different for the 169 obese children undergoing the procedure.

Taken together, these studies suggest that laparoscopic appendectomy in children with advanced
appendicitis is associated with overall lower postoperative morbidity than open appendectomy with a slight
increase in the risk of intraabdominal abscess but a shorter length of hospital stay.

Intraoperative considerations — Variation exists among pediatric surgeons regarding the intraoperative
management of advanced appendicitis in children [48]. We, along with most others, follow these general
principles [26]:

●A search should be made for an appendicolith in the pelvis or periappendiceal area when the appendix is
grossly perforated, especially if one was noted on the preoperative imaging.

●We do not routinely culture the stump, free pus, or peritoneal fluid because the results almost never alter
treatment.

●As in simple appendicitis, the base of the appendix should be ligated close to the cecum.

●A drain should be inserted if there is a well-formed abscess cavity or if the stump closure is tenuous.

●Although one observational study found no increase in adverse outcomes (wound infection or dehiscence,
intraabdominal abscess, prolonged ileus, or small bowel obstruction) when irrigation and drainage was not
performed [49], we and the majority of surgeons irrigate the peritoneal cavity, including the pelvis, with an
isotonic crystalloid solution until the returns are clear.

●The wound(s) should be irrigated generously and closed primarily.

●A peripherally placed central venous line (PICC) may be inserted at the time of surgery to facilitate
outpatient management of intravenous (IV) antibiotics, obtaining blood for laboratory studies, and, if
required, parenteral nutrition.

Postoperative care

Antibiotics — We recommend that children receive IV antibiotics after appendectomy for advanced
appendicitis until they are tolerating a regular diet and are afebrile. Children who are still febrile, have a
white blood cell (WBC) count ≥12,000/mm3, and/or are unable to tolerate a regular diet five to seven days
after surgery warrant diagnostic imaging studies to search for an abdominal or pelvic abscess [50].

●Immediate postoperative period – Based upon a meta-analysis of 45 studies, initial treatment with IV
antibiotics significantly reduces wound infection and intraabdominal abscess formation for patients with
gangrenous or perforated appendicitis compared to no treatment although data in children are limited [13].
We use piperacillin/tazobactam as recommended for perforated appendicitis by the American Pediatric
Surgical Association guidelines [11]. In retrospective series, therapy with a single antibiotic (such as
piperacillin/tazobactam, cefoxitin, or ceftriaxone) appears to be as effective as multiple antibiotic therapy
(such as ampicillin, gentamicin, and metronidazole) for preventing complications of perforated appendicitis,
as measured by length of hospital stay and readmission rates and is more cost effective [11,51,52].

In a prospective randomized controlled trial of 98 children with perforated appendicitis, metronidazole (30
mg/kg as a single daily dose) and ceftriaxone (50 mg/kg as a single daily dose) was as effective as standard
multiple daily doses of ampicillin, gentamicin, and clindamycin in preventing abscess or wound infection
and is a reasonable alternative to piperacillin/tazobactam [53]. In a separate retrospective observational
study, metronidazole and ceftriaxone once daily was equivalent to ertapenem alone or combined with
cefoxitin in terms of abscess or other postoperative complications but was markedly less costly [54]. Length
of hospitalization was similar between groups. However, patients who received the simplified regimen
incurred significantly lower antibiotic charges.

In a separate observational study of over 7000 children with complicated appendicitis, treatment failure,
defined as readmission within 30 days related to a complication of appendicitis, occurred in approximately
6 percent of all patients with complicated appendicitis and was increased in patients who received extended
spectrum antibiotics [12].

Thus, the benefits of extended-spectrum antibiotics are not clear. Clinical trials are needed to determine the
optimal antibiotic regimen.

●Duration of antibiotics and use of oral antibiotics – Our approach is to continue IV antibiotics in
children with advanced appendicitis until they are afebrile, well controlled on oral analgesics and tolerating
a regular diet. When they meet these criteria, we check their WBC count, and, if it is normal, we discharge
them on no antibiotic. If the WBC count is still elevated, we keep them in hospital on IV antibiotics.

This approach is supported by the following observational studies:

•In a retrospective observational study of 304 children with ruptured appendicitis that compared IV
antibiotic duration determined by clinical response and oral antibiotic therapy at discharge determined by
WBC to antibiotic duration of at least four days (152 patients) with no oral antibiotics at discharge, patients
whose duration of antibiotics was determined by clinical response went home, on average 39 hours sooner
than patients who received at least four days of IV antibiotics regardless of clinical findings (mean length
of stay 95 versus 134 hours, respectively) with significant cost savings [55]. There was no difference in
abdominal abscesses, reoperations, interventional radiology drainage of abscess, or inpatient readmission
between the groups.

•In a prospective observational study of 540 children before and after antibiotic regimen change in a single
institution, the over 150 patients who met discharge criteria prior to completion of five days of IV antibiotics
and who were discharged without oral antibiotics had similar rates of postoperative abscess after discharge
when compared with patients who received oral antibiotics to complete a seven day course (8 versus 6
percent, respectively) [56].

•In a prospective trial of 100 children with perforated appendicitis, 42 percent underwent discharge on oral
antibiotics (amoxicillin and clavulanate potassium, Augmentin) to complete a seven day course of
antibiotics prior to postoperative day five without an increased risk of postoperative abscesses [57].

Many pediatric surgeons use resolution of pain, return of bowel function, normalization of WBC, and
absence of fever as indications to discontinue IV antibiotics, and this approach is endorsed by the American
Pediatric Surgical Association [11,58]. In some of these patients, fever on the third postoperative day may
be a predictor of intraperitoneal infection [59]. A systematic review of postoperative antibiotic duration for
children with advanced appendicitis noted that children treated with IV antibiotics for three days did not
have an increased number of infectious complications compared with those treated for longer periods [60].

We discharge patients with advanced appendicitis when they meet our discharge criteria even if they have
been treated for fewer than five days. Although a minimum of five days of IV antibiotics is recommended
by the American Pediatric Surgical Association (APSA), [11,58], as noted above, several studies have
reported good outcomes with durations of IV antibiotics less than five days in these patients since the
publication of the APSA guidelines.
Pain control — Postoperative pain should be initially controlled with parenteral opioid analgesics (eg,
morphine). Patient-controlled analgesia is preferable, when possible. Opioid analgesia may be supplemented
with parenteral ketorolac or acetaminophen. Dosing for these agents is discussed in more detail separately.
(See "Evaluation and management of pain in children", section on 'Opioids' and "Evaluation and
management of pain in children", section on 'Nonopioid analgesics'.)

Administration of IV acetaminophen has been associated with tenfold dosing errors and toxicity that occur
when the dose in mg is administered as the volume in mL. When ordering IV acetaminophen in children,
both the dose in mg and volume in mL should be specified along with the other recommended parameters
for drug order safety (ie, mg/kg, the child’s weight in kg, and the maximum accumulated amount for 24
hours). (See "Evaluation and management of pain in children", section on 'Acetaminophen' and "Clinical
manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents",
section on 'Iatrogenic IV overdose' and "Management of acetaminophen (paracetamol) poisoning in children
and adolescents", section on 'Iatrogenic intravenous overdose'.)

Oral analgesics (eg, ibuprofen, acetaminophen, hydrocodone, or oxycodone) can be substituted once the
child is drinking well.

Intestinal dysfunction — Many patients with advanced appendicitis have a paralytic ileus or a mechanical
intestinal obstruction from fibrinous adhesions. Nasogastric drainage should be instituted for patients with
persistent vomiting or abdominal distension and not routinely.

Once intraperitoneal inflammation and infection have improved and the ileus has resolved, oral fluids can
be introduced. The diet may then be advanced to solid food as tolerated. Many pediatric surgeons will start
patients on a regular diet immediately following laparoscopic appendectomy for both simple and perforated
appendicitis.

Nutrition — Parenteral nutrition support is usually not needed in children with advanced appendicitis.
However, it is indicated in previously healthy children who are unable to eat after one week [61]. Those
who are already malnourished should begin parenteral nutrition within 48 to 72 hours following surgery.
(See "Parenteral nutrition in infants and children".)

APPENDICEAL MASS OR ABSCESS — The approach to patients with an appendiceal mass or abscess
depends upon their clinical appearance.

Ill-appearing — Ill-appearing patients with evidence of an appendiceal mass or abscess warrant early
appendectomy as for advanced appendicitis. (See 'Appendectomy' above.)

Well-appearing — Patients who present late (more than five to seven days from the onset of the illness)
with a well-localized abscess or inflammatory mass (phlegmon) may initially be treated nonoperatively
[2,62-64]. However, some experts still prefer to perform early appendectomy in these patients. Current
evidence is insufficient to determine which approach is better. For example, a small trial of 40 children with
a well-defined abdominal abscess on computed tomography (CT) found no difference in total length of
hospitalization, recurrent abscess rates, or overall charges between patients who received initial laparoscopic
appendectomy or those treated with initial nonoperative therapy (percutaneous drainage, antibiotic
administration) followed by interval appendectomy approximately 10 to 12 weeks later [65]. However, in a
separate, retrospective study of over 200 children with advanced appendicitis of whom over two-thirds had
an intraabdominal abscess at presentation, medical management was associated with significantly greater
post-admission complications (eg, bowel obstruction and recurrent appendicitis), total length of
hospitalization, and greater utilization of health care resources (eg, more imaging, longer duration of total
parenteral nutrition, and more unscheduled repeat hospitalizations) [66].
If nonoperative treatment (ie, intravenous [IV] antibiotics with or without percutaneous drainage) is chosen,
the surgeon must carefully monitor the patient’s clinical progress. There should be steady improvement in
abdominal pain, fever, appetite and intestinal function. If not, conversion to operative treatment may be
warranted.

The ideal patient for initial nonoperative management is not ill appearing and has a well localized, tender
mass in the right lower quadrant without signs of generalized peritonitis. The rationale for initial
nonoperative treatment was illustrated in a meta-analysis of 61 observational and small randomized trials
that included 55,593 adult and pediatric patients with acute appendicitis, 4 percent of whom had appendiceal
abscess or phlegmon [2]. Thirty-six percent of 886 patients with abscess or phlegmon who underwent
immediate surgery had morbidity, including postoperative infection, intestinal fistula, small bowel
obstruction, and recurrence. This frequency of complications was significantly higher than for the 14 percent
of 895 patients who initially were managed nonoperatively (odds ratio [OR] 3.4; 95% CI 2.0-5.6).

Nonoperative treatment includes the following:

●IV fluids should be administered. Oral intake may be resumed as tolerated.

●Parenteral nutrition is indicated if the child is unable to eat after one week or earlier if the child is already
malnourished.

●Antibiotics should be prescribed (as for advanced appendicitis) and continued until the child is afebrile,
tolerating a regular diet, and has a normal WBC. (See 'Advanced appendicitis' below.)

●Appropriate pain management.

A CT scan should be obtained upon admission in all cases selected for nonoperative management to identify
candidates for image-guided percutaneous drainage. Significant abscesses (>3 to 4 cm in diameter) should
be drained under image guidance (ultrasound or CT) by aspiration or placement of an indwelling catheter.
Even multiple intraabdominal abscesses may be managed in this fashion [67]. Smaller abscesses and those
not amenable to percutaneous drainage can be treated with antibiotics, at least initially.

Percutaneous drainage or laparotomy may be indicated in patients initially selected for nonoperative
management. Indications for intervention include lack of clinical improvement within 24 to 48 hours,
continued fever, worsening of localized tenderness, or increased abdominal mass size.

Although continued nonoperative management is advocated by some experts, we suggest interval

appendectomy 10 to 12 weeks following resolution of the initial episode, particularly for children with an
appendicolith. An interval appendectomy is often performed 8 to 12 weeks following resolution of the initial
episode of appendicitis in patients with appendiceal mass/phlegmon. The purpose of delay is to avoid the
morbidity of immediate appendectomy in these patients while definitively treating the underlying
appendicitis.

Evidence regarding the benefit of interval appendectomy is limited and conflicting:

●In a multicenter trial of 102 children randomized to observation after evaluation for appendiceal mass for
patients without an appendicolith or interval appendectomy, 77 percent of patients did not have recurrent
appendicitis within one year of enrollment [68]. Significant complications (eg, wound infection, intestinal
perforation, abscess formation, postoperative small bowel obstruction, or prolonged ileus) occurred in 6
percent of patients undergoing interval appendectomy. No patient underwent early appendectomy in this
study.
●In one systematic review the frequency of morbidity (eg, postoperative infection, intestinal fistula, small
bowel obstruction) associated with interval appendectomy was not substantially different than the risk of
recurrence in patients who did not undergo interval appendectomy (11 versus 7 percent, respectively) [2].
Most recurrences developed within six months of hospital discharge. Of those patients not undergoing
interval appendectomy, 20 percent required percutaneous abscess drainage. Nonoperative treatment delayed
the diagnosis of Crohn disease and cancer in approximately 2 percent of patients; delayed diagnosis was
more common in adult patients.

●Another systematic review of 127 cases reported in three retrospective observational studies found that the
pooled risk of recurrent appendicitis among children not undergoing interval appendectomy after an
appendiceal mass was 21 percent. However, there was significant heterogeneity among the studies for the
risk of recurrent appendicitis (range 0 to 42 percent) [69]. The incidence of complications after interval
appendectomy in 1247 children was 3.4 percent. Among the 955 children for whom histopathologic findings
were reported, 0.9 percent had a carcinoid tumor. In one study included in this analysis, the recurrence of
appendicitis was not influenced by age, sex, type of appendicitis, or abscess drainage [70]. In another study
included in this review, the rate of recurrence in children with an appendicolith was significantly higher
than in those without an appendicolith (76 versus 26 percent, respectively) [42].

Thus, the need for interval appendectomy after initial nonoperative management of appendiceal
abscess/phlegmon is unclear. Many surgeons still recommend interval appendectomy. A strategy of interval
appendectomy or observation should be considered on a case by case basis after discussing the risks and
benefits of each approach.

DISCHARGE CRITERIA (ALL PATIENTS) — In general and for all different "types" of appendicitis
(simple, advanced, or perforated with local abscess or phlegmon), timing of discharge is based on the clinical
condition of the patient. Children who are afebrile, tolerating a regular diet, and free of pain or well
controlled on non-narcotic analgesics are ready for discharge. This typically requires a longer stay for
advanced cases, but the criteria are similar.

Patients who meet these criteria appear to be at lower risk for post-appendectomy complications. For
example, in a case-control study comparing children with perforated appendicitis who developed
intraabdominal abscesses with those who did not, none of the patients who were afebrile and eating on the
third postoperative day developed intraabdominal abscesses [71].

POST-APPENDECTOMY COMPLICATIONS — Children with simple appendicitis have a risk of wound

infection or abscess of approximately 1 to 5 percent depending upon the surgical approach [21,22]. Up to
55 percent of children with advanced appendicitis have a complication, such as infection, bowel obstruction,
or unplanned hospital admission [45]. The most common complications are infectious. Risk factors for
postoperative abscess formation include [72,73]:

●Older age

●High body mass index

●History of diarrhea at presentation

●Fever on or after the third postoperative day

●Leukocytosis on or after the fifth postoperative day

Early
Infections — Infections that occur after appendectomy include wound abscesses, intra-abdominal
abscesses, and pelvic abscesses. Subphrenic abscesses, which were very common before we had effective
anti-microbials, are now extremely rare. Infectious complications are more likely after operation for
advanced appendicitis. With good surgical technique and appropriate use of antibiotics, wound abscesses
occur in approximately 2 to 9 percent of cases, even when the appendix is gangrenous or perforated [74,75].
Intraabdominal and pelvic abscesses occur in about 5 percent of patients with appendicitis [60,76].

The typical symptoms of postoperative infection are fever, anorexia, inability to tolerate a normal diet more
than three to five days after operation, continued weight loss, and pain in and around the incision site(s) or
in the abdomen and pelvis. Patients with these symptoms should be seen promptly, preferably in consultation
with the surgeon or surgical service who performed the appendectomy. If there is no obvious wound
infection on physical examination, an abdominal and pelvic ultrasound should be obtained. Once the
presence of an abscess is identified, a computed tomography (CT) scan of the abdomen and pelvis is often
indicated to precisely define the problem (because there may be more than one purulent collection) and to
serve as a guide to the feasibility of image-guided drainage.

Wound abscesses are treated by opening the wound to permit drainage and healing by secondary intention.

Most abdominal and pelvic abscesses can be treated by percutaneous drainage under ultrasound or CT
guidance. Pelvic abscesses, which point into the rectum, may be treated by transrectal drainage.

Intestinal dysfunction — Intestinal dysfunction is the second most common complication of appendicitis
[26]. Causes include paralytic ileus, constipation, mechanical obstruction, and rarely, intussusception. In the
first few days after appendectomy, intestinal dysfunction is usually caused by a combination of paralytic
ileus from peritonitis and mechanical obstruction from fibrinous adhesions. Most of these early bowel
"obstructions" resolve with gut rest including nasogastric suction and intravenous (IV) fluids. Antibiotics
may also be helpful. Parenteral nutrition support is indicated if the patient is unable to eat for more than five
to seven days [61]. (See 'Postoperative care' above.)

Constipation typically occurs later than paralytic ileus, often after discharge. Multiple factors may
contribute, including reduced appetite, changes in diet, reduced physical activity, and narcotic drugs. A
presumptive diagnosis of constipation can be established by phone conversation, and treatment can be
initiated on an outpatient basis, but if intake is poor, especially if accompanied by vomiting, the child should
be seen promptly for a thorough clinical assessment.

Plain abdominal radiographs are very useful in distinguishing paralytic ileus from constipation. In paralytic
ileus, radiographs show diffuse bowel dilation. With constipation, excess stool and gas can be seen in the
colon with little small bowel dilation.

In rare cases, a large bowel to large bowel or ceco-colic intussusception starting from the inverted
appendiceal stump may also occur, causing early mechanical obstruction [77]. This is often preceded by a
brief period where the gastrointestinal tract seems to be "open." The diagnosis can be established with
ultrasonography. Reoperation is usually required. (See "Intussusception in children".)

Late

Small bowel obstruction — Mechanical small bowel obstruction from postoperative and postinflammatory
adhesions occurs in less than 1 percent of children [78]. Most patients who present to the hospital with a
complete bowel obstruction more than a month after an appendectomy will require a laparotomy and
enterolysis.
Stump appendicitis — Stump appendicitis refers to the inflammation of residual appendiceal tissue months
to years after an appendectomy [79-81]. This rare condition has been attributed to incomplete appendectomy
that leaves an excessively long stump after open or laparoscopic surgery. Clinical findings are similar to
acute appendicitis, and the diagnosis should be considered in any patient with right lower quadrant pain
despite the prior history of appendectomy.

A retrospective observational report found three patients out of 2185 developed stump appendicitis
following primary appendectomy [81]. Ultrasound or CT of the abdomen with contrast assists in
establishing the diagnosis. A review of 36 case reports found that the median time to presentation is one
year after initial operation with a range of four months to 50 years [80]. Perforation occurred in 70 percent
of patients.

Mortality — Fatal complications of appendicitis are exceedingly rare (less than 0.1 percent). Most deaths
occur in very young children and in those with complicated perforating appendicitis who undergo surgery
before they are adequately resuscitated or who develop uncontrolled postoperative sepsis [82].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected
countries and regions around the world are provided separately. (See "Society guideline links: Appendicitis
in children".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The
Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who prefer short, easy-
to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: Appendicitis in adults (The Basics)" and "Patient education:
Appendicitis in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

Early appendicitis

●We suggest that children with early appendicitis undergo appendectomy within 24 hours of diagnosis
(Grade 2B). Preoperative management includes intravenous (IV) rehydration, correction of electrolyte
abnormalities, and timely administration of prophylactic antibiotics. Nonoperative management may be
appropriate in selected patients with early appendicitis and according to caregiver preference. (See
'Preoperative care' above and 'Nonoperative management' above.)

●We recommend that children with nonperforated appendicitis receive a prophylactic dose of a broad
spectrum antibiotic (eg, cefoxitin, piperacillin and tazobactam, or ceftriaxone and metronidazole) 30 to 60
minutes before operation rather than no treatment (Grade 1A). (See 'Preoperative care' above.)

●We recommend that children with early appendicitis undergo laparoscopic appendectomy rather than open
appendectomy (Grade 1B). (See 'Laparoscopic or open approach' above.)
●When an apparently normal appendix is found, it should be removed. A careful search for other causes of
abdominal pain including tubo-ovarian pathology in girls should be performed. (See 'Intraoperative
considerations' above.)

●Following surgery, oral fluids may be offered as soon as the child is awake. Analgesia may be given orally
as well. Most children are able to go home within 24 to 48 hours. (See 'Postoperative care' above.)

Advanced appendicitis

●We recommend that children with perforated or gangrenous appendicitis, that do not have an appendiceal
mass or abscess, undergo urgent appendectomy rather than delayed appendectomy (Grade 1B).

●Preoperative management of children with advanced appendicitis includes replacement and maintenance
fluid therapy and IV antibiotics. In addition, the clinician should place a nasogastric tube in vomiting
children and a urinary catheter to monitor urine output in children with severe dehydration. (See
'Preoperative care' above.)

●We suggest that children with appendiceal perforation undergo laparoscopic appendectomy rather than an
open technique when surgeons who are well trained in laparoscopy are available (Grade 2B). (See
'Laparoscopic or open approach' above.)

●We recommend that children receive IV antibiotics after appendectomy for advanced appendicitis until
they are tolerating a regular diet and are afebrile (Grade 1B). Children who are still febrile and/or unable to
tolerate a regular diet 7 to 10 days after surgery may have an abdominal or pelvic abscess and should have
diagnostic imaging studies. Other issues that must be addressed in the postoperative period include pain
control, nutrition, and management of intestinal dysfunction. (See 'Postoperative care' above.)

Appendiceal mass/phlegmon

●Ill-appearing patients with an appendiceal mass or phlegmon warrant early appendectomy. Patients who
present more than five to seven days from the onset of the illness with a well-localized abscess or
inflammatory mass (phlegmon), but are otherwise well-appearing, may initially be treated nonoperatively.
(See 'Appendiceal mass or abscess' above.)

●Although continued nonoperative management is advocated by some experts, we suggest interval

appendectomy 10 to 12 weeks following resolution of the initial episode, particularly for children with an
appendicolith (Grade 2C). In children without an appendicolith, clinicians and parents may want to weigh
the risk of morbidity versus recurrence when making the decision. (See 'Appendiceal mass or abscess'
above.)

Post-appendectomy complications

●Post-appendectomy complications include wound infection, intraabdominal or pelvic abscess,

constipation, paralytic ileus, intussusception, small bowel obstruction, and stump appendicitis. Mortality is
rare. (See 'Post-appendectomy complications' above.)

●Signs of complications include fever, anorexia, vomiting, inability to tolerate a normal diet more than three
to five days after operation, continued weight loss, or pain in and around the incision site(s) or in the
abdomen and pelvis. Patients with any one of these symptoms warrant prompt evaluation for the underlying
cause. (See 'Post-appendectomy complications' above.)

Discharge criteria
●Children who are afebrile, tolerating a regular diet, and free of pain or well controlled on non-narcotic
analgesics are ready for discharge. (See 'Discharge criteria (all patients)' above.)
Use of UpToDate is subject to the Subscription and License Agreement.

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