Journal of Pediatric Surgery 52 (2017) 444448

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Acute appendicitis in children: not only surgical treatment

Anna Maria Caruso , Alessandro Pane, Roberto Garau, Pietro Atzori, Marcello Podda,
Alessandra Casuccio, Luigi Mascia
Pediatric Surgical Unit, SS Trinit Hospital, Cagliari, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: An accurate diagnosis of acute appendicitis is important to avoid severe outcome or unnecessary surgery
Received 7 May 2016 but management is controversial. The aim of study was to evaluate, in younger and older children, the efcacy of
Received in revised form 28 July 2016 conservative management for uncomplicated appendicitis and the outcome of complicated forms underwent
Accepted 13 August 2016 early surgery.
Methods: Children with acute appendicitis were investigated by clinical, laboratory variables and abdominal
Key words:
ultrasound and divided in two groups: complicated and uncomplicated. Complicated appendicitis underwent
Acute appendicitis
Early appendectomy
early surgery; uncomplicated appendicitis started conservative treatment with antibiotic. If in the next 2448
Appendicular mass h it was worsening, the conservative approach failed and patients underwent late surgery.
Abdominal ultrasound Results: A total of 362 pediatric patients were included. One hundred sixty-ve underwent early appendectomy;
Conservative treatment 197 patients were at rst treated conservatively: of these, 82 were operated within 2448 h for failure. The total
Surgery complications percentage of operated patients was 68.2%. An elevated association was found between surgery and ultrasound.
Conclusions: Conservative treatment for uncomplicated appendicitis had high percentage of success (58%).
Complications in operated patients were infrequent. Our protocol was effective in order to decide which patients
treat early surgically and which conservatively; specic red ags (age and onset) can identied patients at most
risk of complications or conservative failure. Type of study: treatment study.
Level of evidence: II.
2017 Elsevier Inc. All rights reserved.

The incidence of acute abdominal pain in children visiting pediatric conservative management for early and uncomplicated appendicitis,
and emergency departments is about 5% and, among all acute causes, and the outcome of complicated forms treated with early surgery.
appendicitis has an incidence of 12.7% [1], representing the most
common reason for abdominal surgery. Morbidity in children is high,
1. Material and methods
with an overall frequency of appendix perforation of 12.530% [2].
An accurate and early diagnosis of acute appendicitis is important to
1.1. Patients
avoid both severe outcome and unnecessary surgery. However, to
date, the diagnosis remains challenging because clinical signs, symp-
A prospective analysis was conducted in our center from
toms and instrumental data can be nonspecic and unreliable especially
January 2013 to December 2015; pediatric patients (up to 14 years
in younger children [3,4]. In the recent years, even in children, acute
old) hospitalized with diagnosis of acute appendicitis were included
appendicitis was no longer considered an invariably irreversible
in the study. We therefore excluded patients with other causes of
progressive disease and for this reason a conservative approach was
abdominal pain as gastroenteritis, constipation, mesenteric lymphade-
considered safe and effective for uncomplicated and unperforated
nitis or other causes of acute abdomen.
cases [58]. Conversely, the management of complicated cases, with
early or interval appendectomy, is still a matter of debate because of
high incidence of complications for both approaches [1021]. 1.2. Clinical and instrumental evaluation
There are no studies of acute appendicitis that analyze both therapeutic
possibilities in different age groups. The aim of this study was to On admission, a careful clinical history and proper physical
evaluate, in different ages (younger and older children) the efcacy of examination were performed with the assignment of a rating using
the Pediatric Appendicitis Score (PAS) [2224]. All patients were investigated
by laboratory variables as total leucocytes count (TLC) with neutrophils
Corresponding author at: Division of Pediatric Surgery, SS Trinit Hospital, Via Is
(N%), C-reactive protein (CRP) and abdominal ultrasound (US).
Mirrionis, Cagliari, Italy. Tel.: +39 3204070522; fax: +39 070 6095757. The age of patients (b or N6 years old) and the onset of symptoms
E-mail address: annacaruso2@libero.it (A.M. Caruso). (b or N48 h) were evaluated. A PAS score N 4, TLC N12.000 cells/mm 3,

http://dx.doi.org/10.1016/j.jpedsurg.2016.08.007
0022-3468/ 2017 Elsevier Inc. All rights reserved.
 A.M. Caruso et al. / Journal of Pediatric Surgery 52 (2017) 444448
N N 75%, CRP N3 mg/dL [2528] were considered diagnostic of
acute appendicitis.
As for ultrasound (US), we considered as diagnostic parameters of
appendicitis: maximum diameter of appendix N 6 mm, wall thickness
N3 mm, hyperemia of appendiceal wall, free uid or abscess in the
periappendiceal region, increased echogenicity of the adjacent
periappendiceal fat and enlarged mesenteric lymph nodes [29,30]. US
was considered negative only if a normal appendix was visualized (pa-
tients excluded from study); patients with non-visualized appendix
(non diagnostic ultrasound) were nonetheless included in this study
in order to evaluate the outcome.
Based on clinical and radiologic variables and surgery (if performed), all
cases were considered as uncomplicated and complicated appendicitis:
Uncomplicated appendicitis was dened as: unwell but not generally
ill, localized tenderness in the right iliac region with no diffuse
guarding, no palpable mass; ultrasonography criteria included: no
signs of perforation, abscess, copious disseminated peritoneal uid
or extra luminal gas; no perforation on surgery.
Complicated appendicitis was dened as peritonitis or sepsis,
complex mass (perforation or abscess) on ultrasound and surgery; the
age and the onset of symptoms more than 48 h were not considered
as absolute complicating factor.
All patients with complicated appendicitis underwent surgery within
12 h of assessment (EA, early appendectomy).
All patients with uncomplicated appendicitis started the following
nonoperative management (CT, conservative treatment):
- After the rst clinical, laboratory and ultrasound evaluation all pa-
tients received intravenous antibiotics (cefotaxime 50100 mg/kg
3 times daily); no oral intake was permitted for the following 12 h
and intravenously uids were given. After 6 and 12 h clinical
revaluation was performed and after 2448 h ultrasonography and
laboratory were repeated. In the absence of ultrasonographic
and laboratory worsening and if clinical conditions were favorable
(less pain, fever b 38C, patient able to mobilize, uid oral intake
tolerated), a normal diet was permitted, the intravenous antibiotic
maintained at least for 72 h and patients were discharged with
oral antibiotics for others 5 days and clinical control after 1 week
(NO, not operated patients);
- If in the next 2448 h clinical conditions were not improved and/or
laboratory and ultrasonographic data worsened, the conservative
approach was considered failed and patients underwent surgery
(LA, late appendectomy) using either open or laparoscopic approach,
according to surgeon's preference.
For patients with non-diagnostic ultrasound at rst evaluation
we adopted the same protocol, but the decision to perform early
appendectomy or conservative treatment was based on clinical and
laboratory data; non-operated patients repeated an ultrasonography
after 24 h and, if the ultrasound was again non-diagnostic or diagnostic
for simple appendicitis, patients remained in the group of conservative
treatment.
At admission in the hospital a written consensus from parents was
obtained for all patients, for early surgery in complicated appendicitis
and for conservative treatment in uncomplicated appendicitis specify-
ing the possibility of late surgery within 2448 h in case of no response.
The endpoints were:
- evaluation of differences among three groups: EA, LA and NO
- correlation between ultrasound and outcome
- evaluation of risk factors as age and onset of symptoms among
surgical patients
- analysis of complications as infections of surgical site, abscesses,
intestinal occlusion, reoperations and others
- number of not operated patients with readmission in hospital or late
surgery after discharge
445
1.3. Statistical analysis
Statistical analysis of quantitative and qualitative data, including de-
scriptive statistics, was performed for all items. Continuous data are
expressed as mean SD. The intergroup differences were assessed by
the chi-square test or Fisher exact test, as needed for categorical vari-
ables; the univariate analysis of variance (ANOVA) was performed for
parametric variables, and post hoc analysis with the Tukey's test was
used to determine whether there were pairwise differences. Data
were analyzed by the Epi Info software (version 6.0, Centers for Disease
Control and Prevention, Atlanta, GA, USA) and by IBM SPSS Software 22
version (IBM Corp., Armonk, NY, USA). All p-values were two-sided and
p 0.05 was considered statistically signicant.
2. Results
A total of 362 pediatric patients were included in the study.
At admission 165 patients were dened as complicated appendicitis
and underwent early appendectomy whereas 197 patients were de-
ned as uncomplicated and at rst treated with CT: of these, 82 were
operated within 2448 h for failure of conservative treatment (LA).
The total percentage of operated patients was 68.2%.
Demographic characteristics for different groups of NO, EA and LA
are reported in Table 1.
Median age of all patients was 112.2 months with differences
in three groups: patients treated early were younger than patients
treated later and not treated (p = 0.001 and p = 0.030 respectively).
Age b6 years was correlated to complicated surgery (Table 2).
As for sex, 215 were males and more males were treated early (p =
0.043 vs not operated patients).
Regarding onset, in 203 patients symptoms lasted less than 48 h and
a duration of symptoms longer than 48 h was correlated to complicated
surgery (Table 2).
Median PAS at admission was 8.6 with statistical differences among
groups: it was higher in EA group.
Laboratory analysis at admission showed statistical differences
between three groups: all parameters were more altered in early
treated patients.
In the conservative group:
- 115 patients (58%) were treated successfully with complete regres-
sion of symptoms at discharge; at 2448 h mean PAS was 1.9, labo-
ratory data showed an average TLC 8.2 cell/mm 3, neutrophils 63%
and CRP 14 mg/dL and the discharge home after an average of
4.9 days; 22 patients (19%) had further admissions after discharge
but only 10 (8.6%) needed antibiotic therapy for AA and 2 (1.7%)
were operated later (after 8 and 16 months respectively);
- 82 patients (42%) were non responsive to conservative treatment
and were treated with LA; of these patients, only 2 (2.5%) showed
perforation at surgery (Table 2);
Only 25% of EA patients were uncomplicated (misdiagnosis). 30% of
all operated patients (EA and LA) were younger than 6 years and of
these, 75.6% had complicated surgery (Table 2).
The overall percentage of complications was 7.7%, 95% of which in
EA patients; 37% of patients with complications were younger than
6 years and 16% had an onset lower than 48 h (Table 4).
Only 1 case of negative appendicitis at surgery was recorded, in a pa-
tient treated with late appendectomy.
The ultrasound was positive for appendicitis in 264 patients (73%):
159 (60%) diagnosed as uncomplicated and 105(40%) as complicated.
The ultrasound showed a sensitivity and a specicity of 85.5% and
99.2% respectively for diagnosis of complicated appendicitis with a pos-
itive predictive value of 98.1% and a negative predictive value of 93.1%.
The correlation between ultrasound and outcome was reported in
Table 3. Regarding non-diagnostic ultrasound (27%), after 2448 h the
ultrasound became diagnostic for uncomplicated appendicitis in 10%
446 A.M. Caruso et al. / Journal of Pediatric Surgery 52 (2017) 444448

Table 1
Demographic data of patients: general evaluation and differences in surgical and conservative groups.

All patients Not operated (*) Early appendectomy () Late appendectomy (^) p

Number 362 115 165 82

Age, months (mean SD) 112.2 35.1 115.6 34.2 105.0 35.7 122.1 32.4 0.398 * vs ^ 0.030 * vs 0.001 vs ^
b6 years 90 16 56 18 0.160
N6 years 272 99 109 64
Sex (M/F) 215/147 59/56 109/56 47/35 0.043 * vs
PAS (mean SD) 8.6 1.4 7.3 1.3 9.4 0.9 8.8 1.1 b 0.005 * vs ^ b 0.005 vs ^
TLC (mean SD) 16.2 4.6 13.9 3.7 17.8 5.1 16.2 3.5 0.000 * vs 0.001 * vs ^ 0.024 vs ^
N% (mean SD) 81.4 11.3 76.1 13.3 84.4 10.1 81.8 7.5 0.000 * vs 0.001 * vs ^ 0.183 vs ^
CRP (mean SD) 50.1 54.3 20.3 24.4 73.9 64.7 43.4 37 0.000 * vs 0.004 * vs ^ 0.000 vs ^
Onset symptoms b0.005 * vs ^ NSD vs ^
b48 h 203 92 72 39
N48 h 157 21 93 43
Days of hospitalization 6.7 2.7 4.9 1.4 7.9 3.0 6.7 1.9 0.000 * vs ^ 0.001 vs^

Legend: PAS: Pediatric Appendicitis Score; TLC: Total Leucocytes Count; N: Neutrophils; CRP: C- reactive protein; SD: standard deviation; NSD: no statistical difference; h: hours; vs: versus.

of patients but none of these patients underwent surgery; in no case the management was accepted also in children but there are very few stud-
ultrasound became diagnostic for complicated appendicitis. ies. A prospective nonrandomized study [8] compared operative and
nonoperative treatment for AA showing no signicant differences re-
3. Discussion garding laboratory data and hospital stay with a percentage of recur-
rence after nonoperative treatment of 28.6%. Other studies reported a
Even if acute appendicitis (AA) is the most common surgical percentage of success in more than 75% of cases after conservative treat-
emergency in childhood, diagnosis can be particularly difcult due ment for uncomplicated appendicitis [59].
to its potential atypical clinical presentation. In older children the The aim of this study was to evaluate, in different ages, the effective-
initial misdiagnosis rate for appendicitis ranges from 28% to 57% and ness of a diagnostic protocol in order to distinguish uncomplicated and
approximately 30% of patients show perforation at diagnosis, especially complicated forms of appendicitis treated with conservative and opera-
children less of 5 years old [3,4]. Ultrasound has a good sensitivity (99%), tive approach respectively. Hence, our approach to acute appendicitis
specicity (95%) and positive predictive value (97%) in the diagnosis of differs from that reported by many other authors because we decided
appendicitis in children, which helps to distinguish between simple and to treat at rst conservatively patients with uncomplicated appendicitis
complicated forms on the basis of established parameters but it is im- and to treat with early surgery perforated and complicated patients.
portant to integrate the results of US with clinical assessment [2629]. Regarding diagnosis, our results conrmed some data already de-
The management of appendicitis is a challenging problem although scribed in literature about PAS and inammatory markers [22,23].
it is a common pathology and different diagnostic tools as clinical The ultrasound was found to be a useful method in the diagnosis of
score, laboratory data and ultrasound are available. appendicitis with elevated correlation with surgery especially in com-
When patients present late, with appendicitis complicated by a plicated cases; only 7% of ultrasound scans was a false uncomplicated
contained perforation and with an appendiceal abscess or inammatory comparing to surgery and this conrm that US is specic for diagnosis
mass, a dilemma exists whether to treat with immediate operation of complications and that, when not diagnostic, is more likely to nd
(risk of intraoperative complications) or conservatively with antibiotics an uncomplicated appendicitis [27,35,36].
(with or without interval appendectomy) because recurrence rates About patients undergoing EA, the percentage of false complicated
ranging between 6% and 30% are reported [1519] and several predictive (not perforated) cases was low and with ultrasound non diagnostic in
recurrence factors are described [12,13]. 66% of cases, which further conrms the validity of our protocol selec-
According to several authors, patients with perforated appendix tion and the utility of ultrasound in order to decide which patients
managed with early appendectomy had uncomplicated operative and have to be treated early. Complications were more common in compli-
postoperative clinical course with shorter length of hospitalization, cated appendicitis, in younger children and with late onset as reported
duration of antibiotic therapy, days of fever, number of radiographic in literature [3234].
studies, post-hospitalization complications and unscheduled repeated Regarding the outcome of conservative treatment for uncomplicated
hospitalizations after discharge [1421]. appendicitis, it was safe and effective with an high percentage of suc-
Most patients with acute appendicitis show up early and before cess (58%). Nonoperated patients showed a shorter hospitalization
developing complications and usually they are treated with appendec- compared with surgical patients (EA and LA) and this differed from
tomy. Based on the premise that perforated and unperforated appendi- what reported in other studies.
citis are different entities with very different prognosis, a nonoperative It is controversial why some patients with diagnosis of uncomplicat-
ed appendicitis do not improve within 2448 h despite antibiotic ther-
Table 2
apy and therefore are operated late; those surgically complicated (1.6%)
Evaluation of complicated and uncomplicated outcome related to age and onset
symptoms. Table 3
Correlation between ultrasound, and outcome.
Uncomplicated Complicated Total
Uncomplicated Complicated Total
NO EA LA EA LA
NO EA LA EA LA
115 42 80 123 2 362
Age b6 yrs 16 / 18 56 / 90 115 42 80 123 2 362
Age N6 yrs 99 42 62 67 2 272 Not diagnostic ultrasound 35 28 22 13 / 98
Onset b48 h 92 19 39 53 / 203 Positive ultrasound 80 14 58 110 2 264
Onset N48 h 21 23 41 70 2 157 Uncomplicated 79 13 58 9 / 159
p b0.005 b0.005 b0.005 b0.005 b0.005 Complicated 1 1 / 101 2 105
p b0.005 b0.005 b0.005 b0.005 b0.005
Legend: NO: not operated, EA: early appendectomy, LA: late appendectomy, yrs.: years,
h: hours. Legend: NO: not operated, EA early appendectomy, LA late appendectomy.
 A.M. Caruso et al. / Journal of Pediatric Surgery 52 (2017) 444448
Table 4
Complications of surgery.
Total SSI Abdominal Reoperations Functional Others*
Abscess for occlusion paralytic
ileus
N (%) 19 (7.7%) 11 (58%) 1 (5.2%) 3 (15.7%) 2 (10.5%)
EA 18 11 / 3 2 2
b 6 years 6 (33%) 4 / 1 1
N 6 years 12 (67%) 7 / 2 1
LA 1 / 1 / / /
b 6 years / / / / / /
N 6 years 1 (100%) / 1 / /
Legend: N: number; EA, early appendectomy; LA, late appendectomy; SSI: surgical site
infection; * 1 pneumonia, 1 pancreatitis.
could be identied as missing complicated at admission even if, espe-
cially in younger children, it is possible a rapid development in compli-
cated forms. Uncomplicated patients undergoing LA (uncomplicated at
rst diagnosis and unperforated at late surgery) have been an unexpect-
ed and controversial result (22%); they may represent a group of pa-
tients most at risk of clinical worsening in which antibiotic therapy
has little benet,
Although the major differences were found between not operated
and EA patients, several parameters were different also with LA as age,
laboratory data and PAS and so these could be used as alarm factors
for failure of conservative treatment: however, these difference do not
justify a surgical approach for all patients renouncing a high possibility
of success (58%) even in younger children.
The major advantage of antibiotic treatment [37,38] is the avoidance
of surgery and its complications; the potential disadvantage is the fact
that, not removing inamed appendix, parents will be concerned
about recurrent appendicitis every time a child develops abdominal
pain in the future. In our study only 19% of patients had further access
to the hospital and only 1,7% was operated later: none of these patients
had a perforated appendicitis. We think that when sufcient informa-
tion is given to parents regarding so-called alarm symptoms, the rate
of readmission can be comparable with operated patients.
This study has several advantages: we included a large number of
patients all evaluated and treated in the same center, we included all
ages unlike in many studies younger patients are excluded, and we
evaluated the effectiveness of both conservative and surgical treatment.
Based on our results we think that a conservative approach should
be absolutely tried for uncomplicated appendicitis (that unlike in
many centers are treated early surgically) regardless of age and onset
of symptoms: an high level of suspicion identifying specic red ags
(age and onset) can increase diagnostic skills avoiding failures or com-
plications. The low percentage of complications occurred in complicated
appendicitis makes us lean towards a surgery instead of conservative
approach with interval appendectomy that exposes patients to a high
risk of complications as abscess and late return to normal activities for
the child and his family.
Our study has important limits: it is not a randomized trial, more
valid to evaluate signicantly the effectiveness of conservative versus
surgical treatment for uncomplicated and complicated appendicitis;
there is a relatively short time of evaluation (3 years); besides, the %
of non-diagnostic ultrasound is a signicant bias because penalizes the
results of sensitivity and specicity of ultrasonography.
In conclusion, we believe that it is important to identify patients that
may have benet from conservative treatment avoiding an unnecessary
or negative appendectomy, considering the very low risk of recurrence
after simple appendicitis [30,31]. This is an important shift from the tra-
ditional approach: appendectomy following a non-operative manage-
ment should not be considered as a complication or failure but as
another step in the management algorithm of acute appendicitis. For
complicated appendicitis our early surgical approach was safe and effec-
tive resolving the high risk of recurrence; in addition, especially for chil-
dren, since the illness is managed with a single admission the benets
447
are more evident. Further large-scale prospective trials are needed to
validate our conclusions.
Acknowledgement
2 (10.5%) We thank Elisa Romano for the computer support and database and
Maria Rita Di Pace (M.D.) and Mrs. D'Albora Rosalie for English revision
/
2 of manuscript.
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