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Appendicitis in children A review of the current literature Richard Wood Paediatric Surgery Registrar Red Cross Children’s Hospital
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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.
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Natural 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.
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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
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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.
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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.
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Alvarado 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]
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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.
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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.
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Antibiotic 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 conversion to an oral regimen. Am J Surg 2008; 195:141-143.
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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 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.
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Surgical ManagementPerforated 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.
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Surgical ManagementPerforated Appendicitis Causes of failure of nonoperative management Band count >15% at presentation[24] Appendicolith present on imaging[25] 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.
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Surgical ManagementAbscess 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
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Surgical ManagementAbscess 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.
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Radiological imaging
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Laparoscopic 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
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Laparoscopic 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.
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AppendicitisKey anatomical points
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AppendicitisKey anatomical points
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Laparoscopic Appendicectomy
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Laparoscopic Appendicectomy
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Laparoscopic Appendicectomy
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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.
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Open Appendicectomy Transverse incision Protect wound Swab out pelvis Muscle cutting laparotomy in presence of peritonitis