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Acute appendicitis in children: Management

David E Wesson, MD
Section Editor
Jonathan I Singer, MD
Deputy Editor
James F Wiley, II, MD, MPH


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".)


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".)

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Literature review current through: Nov 2017. | This topic last updated: Nov 14, 2017.
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  1. Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum. Surg Clin North Am 2012; 92:505.
  2. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg 2007; 246:741.
  3. Dunn JCY. Appendicitis. In: Pediatric Surgery, Coran AG, Adzick NS, Krummel TM, et al (Eds), Elsevier, Philadelphia 2012. p.1255.
  4. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006; 202:401.
  5. Nomura O, Ishiguro A, Maekawa T, et al. Antibiotic administration can be an independent risk factor for therapeutic delay of pediatric acute appendicitis. Pediatr Emerg Care 2012; 28:792.
  6. McLANAHAN S. Further reductions in the mortality in acute appendicitis in children. Ann Surg 1950; 131:853.
  7. Gorter RR, van Amstel P, van der Lee JH, et al. Unexpected findings after surgery for suspected appendicitis rarely change treatment in pediatric patients; Results from a cohort study. J Pediatr Surg 2017; 52:1269.
  8. Lee SL, Ho HS. Acute appendicitis: is there a difference between children and adults? Am Surg 2006; 72:409.
  9. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
  10. Lee SL, Islam S, Cassidy LD, et al. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2010; 45:2181.
  11. Kronman MP, Oron AP, Ross RK, et al. Extended- Versus Narrower-Spectrum Antibiotics for Appendicitis. Pediatrics 2016; 138.
  12. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev 2005; :CD001439.
  13. United Kingdom National Surgical Research Collaborative, Bhangu A. Safety of short, in-hospital delays before surgery for acute appendicitis: multicentre cohort study, systematic review, and meta-analysis. Ann Surg 2014; 259:894.
  14. Stevenson MD, Dayan PS, Dudley NC, et al. Time From Emergency Department Evaluation to Operation and Appendiceal Perforation. Pediatrics 2017; 139.
  15. Serres SK, Cameron DB, Glass CC, et al. Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children. JAMA Pediatr 2017; 171:740.
  16. Mandeville K, Monuteaux M, Pottker T, Bulloch B. Effects of Timing to Diagnosis and Appendectomy in Pediatric Appendicitis. Pediatr Emerg Care 2015; 31:753.
  17. Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 2006; 243:17.
  18. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010; :CD001546.
  19. Markar SR, Blackburn S, Cobb R, et al. Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children. J Gastrointest Surg 2012; 16:1993.
  20. Alkhoury F, Malvezzi L, Knight CG, et al. Routine same-day discharge after acute or interval appendectomy in children: a prospective study. Arch Surg 2012; 147:443.
  21. St Peter SD, Adibe OO, Juang D, et al. Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial. Ann Surg 2011; 254:586.
  22. St. Peter, SD. Appendicitis. In: Ashcraft's Pediatric Surgery, 5th edition, Holcomb III GW, Murphy JP (Eds), Saunders Elsevier, Philadelphia, PA 2010. p.549.
  23. Greason KL, Rappold JF, Liberman MA. Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain. Its time has come. Surg Endosc 1998; 12:223.
  24. Dall'Igna P, Ferrari A, Luzzatto C, et al. Carcinoid tumor of the appendix in childhood: the experience of two Italian institutions. J Pediatr Gastroenterol Nutr 2005; 40:216.
  25. Cardwell M, Siviter G, Smith A. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev 2005; :CD003591.
  26. Minneci PC, Mahida JB, Lodwick DL, et al. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. JAMA Surg 2016; 151:408.
  27. Georgiou R, Eaton S, Stanton MP, et al. Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis. Pediatrics 2017; 139.
  28. Lopez ME, Wesson DE. Medical Treatment of Pediatric Appendicitis: Are We There Yet? JAMA Pediatr 2017; 171:419.
  29. Tanaka Y, Uchida H, Kawashima H, et al. Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis. J Pediatr Surg 2015; 50:1893.
  30. Huang L, Yin Y, Yang L, et al. Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis. JAMA Pediatr 2017; 171:426.
  31. Steiner Z, Buklan G, Stackievicz R, et al. Conservative treatment in uncomplicated acute appendicitis: reassessment of practice safety. Eur J Pediatr 2017; 176:521.
  32. Caruso AM, Pane A, Garau R, et al. Acute appendicitis in children: not only surgical treatment. J Pediatr Surg 2017; 52:444.
  33. Bachur RG, Lipsett SC, Monuteaux MC. Outcomes of nonoperative management of uncomplicated appendicitis. Pediatrics 2017; 140.
  34. Surgical Advisory Panel. American Academy of Pediatrics. Guidelines for referral to pediatric surgical specialists. Pediatrics 2002; 110:187.
  35. Ein SH, Langer JC, Daneman A. Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis. J Pediatr Surg 2005; 40:1612.
  36. St Peter SD, Valusek PA, Little DC, et al. Does routine nasogastric tube placement after an operation for perforated appendicitis make a difference? J Surg Res 2007; 143:66.
  37. Schwartz KL, Gilad E, Sigalet D, et al. Neonatal acute appendicitis: a proposed algorithm for timely diagnosis. J Pediatr Surg 2011; 46:2060.
  38. Blakely ML, Williams R, Dassinger MS, et al. Early vs interval appendectomy for children with perforated appendicitis. Arch Surg 2011; 146:660.
  39. Myers AL, Williams RF, Giles K, et al. Hospital cost analysis of a prospective, randomized trial of early vs interval appendectomy for perforated appendicitis in children. J Am Coll Surg 2012; 214:427.
  40. Michailidou M, Sacco Casamassima MG, Goldstein SD, et al. The impact of obesity on laparoscopic appendectomy: Results from the ACS National Surgical Quality Improvement Program pediatric database. J Pediatr Surg 2015; 50:1880.
  41. Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: a survey of North American Pediatric Surgeons. J Pediatr Surg 2004; 39:875.
  42. Akkoyun I, Tuna AT. Advantages of abandoning abdominal cavity irrigation and drainage in operations performed on children with perforated appendicitis. J Pediatr Surg 2012; 47:1886.
  43. Nadler EP, Reblock KK, Ford HR, Gaines BA. Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children. Surg Infect (Larchmt) 2003; 4:327.
  44. Goldin AB, Sawin RS, Garrison MM, et al. Aminoglycoside-based triple-antibiotic therapy versus monotherapy for children with ruptured appendicitis. Pediatrics 2007; 119:905.
  45. St Peter SD, Tsao K, Spilde TL, 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.
  46. Hurst AL, Olson D, Somme S, et al. Once-Daily Ceftriaxone Plus Metronidazole Versus Ertapenem and/or Cefoxitin for Pediatric Appendicitis. J Pediatric Infect Dis Soc 2017; 6:57.
  47. Skarda DE, Schall K, Rollins M, et al. Response-based therapy for ruptured appendicitis reduces resource utilization. J Pediatr Surg 2014; 49:1726.
  48. Desai AA, Alemayehu H, Holcomb GW 3rd, St Peter SD. Safety of a new protocol decreasing antibiotic utilization after laparoscopic appendectomy for perforated appendicitis in children: A prospective observational study. J Pediatr Surg 2015; 50:912.
  49. Fraser JD, Aguayo P, Leys CM, et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg 2010; 45:1198.
  50. 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.
  51. Lose G, Holm B, Bauer T, et al. The predictive value of the third day temperature in the decision whether to continue or terminate antibiotic treatment in perforated appendicitis. Ann Chir Gynaecol 1987; 76:201.
  52. Snelling CM, Poenaru D, Drover JW. Minimum postoperative antibiotic duration in advanced appendicitis in children: a review. Pediatr Surg Int 2004; 20:838.
  53. Teitelbaum DH, Coran AG. Nutritional Support. In: Pediatric Surgery, 6th edition, O'Neill JA, Coran AG, Fonkalsrud E, Grosfeld JL (Eds), Mosby, Maryland Heights, MO 2006. Vol 1, p.199.
  54. Bufo AJ, Shah RS, Li MH, et al. Interval appendectomy for perforated appendicitis in children. J Laparoendosc Adv Surg Tech A 1998; 8:209.
  55. Nadler EP, Reblock KK, Vaughan KG, et al. Predictors of outcome for children with perforated appendicitis initially treated with non-operative management. Surg Infect (Larchmt) 2004; 5:349.
  56. Weber TR, Keller MA, Bower RJ, et al. Is delayed operative treatment worth the trouble with perforated appendicitis is children? Am J Surg 2003; 186:685.
  57. St Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg 2010; 45:236.
  58. Bonadio W, Rebillot K, Ukwuoma O, et al. Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management. Pediatr Infect Dis J 2017; 36:937.
  59. McCann JW, Maroo S, Wales P, et al. Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy. Pediatr Radiol 2008; 38:661.
  60. Hall NJ, Eaton S, Stanton MP, et al. Active observation versus interval appendicectomy after successful non-operative treatment of an appendix mass in children (CHINA study): an open-label, randomised controlled trial. Lancet Gastroenterol Hepatol 2017; 2:253.
  61. Hall NJ, Jones CE, Eaton S, et al. Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J Pediatr Surg 2011; 46:767.
  62. Puapong D, Lee SL, Haigh PI, et al. Routine interval appendectomy in children is not indicated. J Pediatr Surg 2007; 42:1500.
  63. Fraser JD, Aguayo P, Sharp SW, et al. Physiologic predictors of postoperative abscess in children with perforated appendicitis: subset analysis from a prospective randomized trial. Surgery 2010; 147:729.
  64. Garey CL, Laituri CA, Little DC, et al. Outcomes of perforated appendicitis in obese and nonobese children. J Pediatr Surg 2011; 46:2346.
  65. Lee SL, Yaghoubian A, Kaji A. Laparoscopic vs open appendectomy in children: outcomes comparison based on age, sex, and perforation status. Arch Surg 2011; 146:1118.
  66. Lee SL, Yaghoubian A, de Virgilio C. A multi-institutional comparison of pediatric appendicitis outcomes between teaching and nonteaching hospitals. J Surg Educ 2011; 68:6.
  67. Emil S, Laberge JM, Mikhail P, et al. Appendicitis in children: a ten-year update of therapeutic recommendations. J Pediatr Surg 2003; 38:236.
  68. Henry MC, Walker A, Silverman BL, et al. Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: a multicenter case-control study. Arch Surg 2007; 142:236.
  69. Hamada Y, Fukunaga S, Takada K, et al. Postoperative intussusception after incidental appendicectomy. Pediatr Surg Int 2002; 18:284.
  70. Pledger G, Stringer MD. Childhood deaths from acute appendicitis in England and Wales 1963-97: observational population based study. BMJ 2001; 323:430.
  71. Tsao KJ, St Peter SD, Valusek PA, et al. Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach. J Pediatr Surg 2007; 42:939.
  72. Waseem M, Devas G. A child with appendicitis after appendectomy. J Emerg Med 2008; 34:59.
  73. Liang MK, Lo HG, Marks JL. Stump appendicitis: a comprehensive review of literature. Am Surg 2006; 72:162.
  74. Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000; 66:739.