Evidence-based Practice in Pediatric Appendicitis


  • Patomphon Ekkarat Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
  • Surasak Sangkhathat Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand


pediatric appendicitis, appendectomy


Management of acute appendicitis is one of the most challenging topics in pediatric surgery. Recent researches have focused on systematic approaches in diagnosis and minimally invasive surgical techniques. In order to avoid morbidity caused by delayed management, clinical scoring systems and imaging modalities have been undergoing continuing modifications with an attempt to find the optimal diagnostic algorithm. Although an appendectomy is the mainstay treatment, some recent studies have reported successes with initial non-operative management in selected cases of uncomplicated appendicitis. In cases with an appendiceal mass, evidences have suggested that conservative management is preferable in the pediatric age group. Interval appendectomy for a subsided appendiceal mass is no longer mandatory. As minimally invasive surgery has gained its popularity among pediatric surgeons, laparoscopic appendectomy is an attractive procedure with proven advantage in enhancing recovery and reducing post-operative
wound complications, especially in complicated appendicitis.


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1. Wang LT, Prentiss KA, Simon JZ, et al. The use of white blood cell
count and left shift in the diagnosis of appendicitis in children.
Pediatr Emerg Care 2007;23:69.

2. Tseng YC, Lee MS, Chang YJ, Wu HP. Acute abdomen in
pediatric patients admitted to the pediatric emergency
department. Pediatr Neonatol 2008;49:126-34.

3. Chaiprasit P. Childhood appendicitis in regional hospital.
Thai J Surg 2011;32:73-76.

4. Ademuyiwa AO, Bode CO, Adesanya OA, Elebute OA. Nontrauma
related paediatric abdominal surgical emergencies
in Lagos, Nigeria: Epidemiology and indicators of survival.
Niger Med J 2012;53:76-9.

5. Aarabi S, Sidhwa F, Riehle KJ, et al. Pediatric appendicitis
inNew England: epidemiology and outcomes. J Pediatr Surg

6. Chatbanchai W, Hedley AJ, Ebrahim SB, et al. Acute abdominal
pain and appendicitis in north east Thailand. Paediatr
Perinat Epidemiol 1989;3:448-59.

7. Andersen SB, Paerregaard A, Larsen K. Changes in the
epidemiology of acuteappendicitis and appendectomy in
Danish children 1996-2004. Eur J Pediatr Surg 2009; 19:286-9.

8. Kwok MY, Kim MK, Gorelick MH. Evidence-based approach
to the diagnosis of appendicitis in children. Pediatr Emerg
Care 2004; 20:690.

9. Sakellaris G, Tilemis S, Charissis G. Acute appendicitis in
preschool-age children. Eur J Pediatr 2005; 164:80.

10. Bundy DG, Byerley JS, Liles EA, et al. Does this child have
appendicitis? JAMA 2007; 298:438.

11. Kulik DM, Uleryk EM, Maguire JL. Does this child have
appendicitis? A systematic review of clinical prediction rules
for children with acute abdominal pain. J Clin Epidemiol 2013;

12. Schwartz KL, Gilad E, Sigalet D, et al. Neonatal acute
appendicitis: a proposed algorithm for timely diagnosis. J
Pediatr Surg 2011;46:2060.

13. Schorlemmer GR, Herbst CA Jr. Perforated neonatal
appendicitis. South Med J 1983;76:536-7.

14. Amyand C.Of an inguinal rupture, with a pin in the appendix
caeci, incrusted with stone; and some observations on
wounds in the guts. Philosophical Transactions of the Royal
Society of London 1736;39:329-36.

15. Hutchinson R. Parasympathomimetic decompression of
acute colonic pseudo-obstruction. Lancet 1993;342:1562.

16. Esposito C, Iaquinto M, Escolino M, Settimi A. Laparoscopic
management of a newborn with a right Amyand’s hernia and
a left incarcerated inguinal hernia. Afr J Paediatr Surg 2013;

17. Colvin JM, Bachur R, Kharbanda A. The presentation of
appendicitis in preadolescent children. Pediatr Emerg Care

18. Dickson AP, MacKinlay GA. Rectal examination and acute
appendicitis. Arch Dis Child 1985; 60:666-7.

19. Dunning PG, Goldman MD. The incidence and value of rectal
examination in children with suspected appendicitis. Ann R
Coll Surg Engl 1991;73:233-4.

20. Kessler C, Bauer SJ. Utility of the digital rectal examination in
the emergency department: a review. J Emerg Med 2012;

21. Rothrock SG, Pagane J. Acute appendicitis in children:
emergency departmentdiagnosis and management. Ann
Emerg Med 2000;36:39-51.

22. Becker T, Kharbanda A, Bachur R. Atypical clinical features of
pediatric appendicitis. Acad Emerg Med 2007;14:124.

23. Bates MF, Khander A, Steigman SA, et al. Use of white bloodcell
count and negative appendectomy rate. Pediatrics

24. Yu CW, Juan LI, Wu MH, et al. Systematic review and metaanalysis
of the diagnostic accuracy of procalcitonin, Creactive
protein and white blood cell count for suspected
acute appendicitis. Br J Surg 2013; 322-9.

25. McGowan DR, Sims HM, Zia K, et al. The value of biochemical
markers in predicting a perforation in acute appendicitis. ANZ
J Surg 2013;79-83.

26. D’Souza N, Karim D, Sunthareswaran R. Bilirubin; a diagnostic
marker for appendicitis. Int J Surg 2013;11:1114-7

27. Feng S, Wu P, Chen X. Hyperfibrinogenemia in appendicitis:
a new predictor of perforation in children. Pediatr Surg Int

28. Emmanuel A, Murchan P, Wilson I, Balfe P. The value of
hyperbilirubinaemia in the diagnosis of acute appendicitis.
Ann R Coll Surg Engl 2011;93:213-7.

29. Lintula H, Kokki H, Kettunen R, Eskelinen M. Appendicitis score
for children with suspected appendicitis. A randomized clinical
trial. Langenbecks Arch Surg 2009;394:999-1004.

30. Kharbanda AB. Appendicitis: do clinical scores matter? Ann
Emerg Med 2014; 64:373-5.

31. Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002;

32. Kharbanda AB, Taylor GA, Fishman SJ, Bachur RG. A clinical
decision rule to identify children at low risk for appendicitis.
Pediatrics 2005;116:709-16.

33. van den Broek WT, van der Ende ED, Bijnen AB, et al. Which
children could benefit from additional diagnostic tools in
case of suspectedappendicitis? J Pediatr Surg 2004;39:

34. Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis
scoring systems using a prospective pediatric cohort. Ann
Emerg Med 2007;49.

35. Alvarado A. A practical score for the early diagnosis of acute
appendicitis. Ann Emerg Med 1986;15:557-64.

36. Ebell MH, Shinholser J. What Are the Most Clinically Useful
Cutoffs for the Alvarado and Pediatric Appendicitis Scores?
A Systematic Review. Ann Emerg Med 2014;192-9.

37. Wu HP, Yang WC, Wu KH, et al. Diagnosing appendicitis at
different time points in children with right lower quadrant pain:
comparison between Pediatric Appendicitis Score and the
Alvarado score. World J Surg 2012;216-21.

38. National Guideline Clearinghouse, Agency for Healthcare
Research and Quality, US Department of Health and Human
Services. ACR Appropriateness Criteria(r) right lower quadrant
pain-suspected appendicitis. The American College of
Radiology 2012.

39. National Guideline Clearinghouse, Agency for Healthcare
Research and Quality, US Department of Health and Human
Services. Clinical policy: critical issues in the evaluation and
management of emergency department patients with
suspected appendicitis. The American College of Radiology
40. Srinivasan A, Servaes S, Peña A, Darge K. Utility of CT after
sonography for suspected appendicitis in children: integration
of a clinical scoring system with a staged imaging protocol.
Emerg Radiol 2014.

41. Ross MJ, Liu H, Netherton SJ, et al. Outcomes of children with
suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 2014;21:538-42.

42. Toprak H, Kilincaslan H, Ahmad IC, et al. Integration of ultrasound
findings with Alvarado score in children with suspected
appendicitis. PediatrInt 2014;56:95-9.

43. Wagner PL, Eachempati SR, Soe K, et al. Defining the current
negative appendectomy rate: for whom is preoperative
computed tomography making an impact? Surgery

44. Sivit CJ. Imaging the child with right lower quadrant pain and
suspected appendicitis: current concepts. Pediatr Radiol

45. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from
CT scans in childhood and subsequent risk of leukaemia and
brain tumours: a retrospective cohort study. Lancet 2012;

46. Aspelund G, Fingeret A, Gross E, et al. Ultrasonography/MRI
versus CT for diagnosing appendicitis. Pediatrics 2014;133:586-

47. Martin AE, Vollman D, Adler B, Caniano DA. CT scans may not
reduce the negative appendectomy rate in children. J Pediatr
Surg 2004;39:886-90.

48. Bachur RG, Hennelly K, Callahan MJ, et al. Diagnostic imaging
and negative appendectomy rates in children: effects of age
and gender. Pediatrics 2012;129:877-84.

49. Yardeni D, Hirschl RB, Drongowski RA, et al. Delayed versus
immediate surgery in acute appendicitis: do we need to
operate during the night? J Pediatr Surg 2004;39:464-9.

50. Armstrong J, Merritt N, Jones S, et al. Non-operative
management of early, acute appendicitis in children: is it safe
and effective? J Pediatr Surg 2014;49:782-5.

51. Abes M, Petik B, Kazil S. Nonoperative treatment of acute
appendicitis in children. J Pediatr Surg 2007;42:1439-44.

52. Burjonrappa S, Rachel D. Pediatric appendectomy: optimal
surgical timing andrisk assessment. Am Surg 2014;80:496-9.

53. Svensson JF, Patkova B, Almström M, et al. Nonoperative
treatment with antibiotics versus surgery for acute nonperforated
appendicitis in children: A pilot randomized
controlled trial. Ann Surg 2014.

54. Svensson JF, Hall NJ, Eaton S, et al. A review of conservativetreatment
of acute appendicitis. Eur J Pediatr Surg

55. Lee SL, Islam S, Cassidy LD, et al; 2010 American Pediatric
Surgical Association Outcomes and Clinical Trials Committee.
Antibiotics and appendicitis in the pediatric population: an
American Pediatric Surgical Association Outcomes and
Clinical Trials Committee systematic review. J PediatrSurg

56. Blakely ML, Williams R, Dassinger MS, et al. Early vs interval
appendectomy for children with perforated appendicitis.
Arch Surg 2011;146:660-5.

57. Williams RF, Interiano RB, Paton E, et al. Impact of a randomized
clinical trial on children with perforated appendicitis. Surgery

58. Andersson RE, Petzold MG. Nonsurgical treatment of
appendiceal abscess or phlegmon: a systematic review and
meta-analysis. Ann Surg 2007;246:741-8.

59. Zhang HL, Bai YZ, Zhou X, Wang WL. Nonoperative
management of appendiceal phlegmon or abscess with an
appendicolith in children. J Gastrointest Surg 2013;17:766-70.

60. Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus
open appendectomy in children: a meta-analysis. Ann Surg

61. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic
versus open surgery for suspected appendicitis. Cochrane
Database Syst Rev 2010;CD001546.

62. Nataraja RM, Loukogeorgakis SP, Sherwood WJ, et al. The
incidence of intraabdominal abscess formation following
laparoscopic appendicectomy in children: a systematic
review and meta-analysis. J Laparoendosc Adv Surg Tech A

63. Markar SR, Karthikesalingam A, Di Franco F, Harris AM.
Systematic review and meta-analysis of single-incision versus
conventional multiport appendicectomy. Br J Surg 2013;

64. Wang X, Zhang W, Yang X, et al. Complicated appendicitis in
children: is laparoscopic appendectomy appropriate?
Acomparative study with the open appendectomy–our
experience. J Pediatr Surg 2009;44:1924-7.

65. St Peter SD, Adibe OO, Iqbal CW, et al. Irrigation versus suction
alone during laparoscopic appendectomy for perforated
appendicitis: a prospective randomized trial. Ann Surg 2012;

66. Cai YL, Xiong XZ, Wu SJ, et al. Single-incision laparoscopic
appendectomy vs conventional laparoscopic appendectomy:
systematic review and meta-analysis. World J
Gastroenterol 2013;19:5165-73.

67. Clerveus M, Morandeira-Rivas A, Moreno-Sanz C, Herrero-
Bogajo ML, Picazo-Yeste JS, Tadeo-Ruiz G. Systematic review
and meta-analysis of randomized controlled trials comparing
single incision versus conventional laparoscopic appendectomy.
World J Surg 2014;38:1937-46.

68. Gasior AC, Knott EM, Holcomb GW 3rd, et al. Patient and
parental scar assessment after single incision versus standard
3-port laparoscopic appendectomy: long-term follow-up from
a prospective randomizedtrial. J Pediatr Surg 2014;49:120-2.

69. Xu AM, Huang L, Li TJ. Single-incision versus three-port
laparoscopic appendectomy for acute appendicitis:
systematic review and meta-analysis ofrandomized controlled
trials. Surg Endosc 2015;29:822-43.

70. Ponsky TA, Krpata DM. Single-port laparoscopy: Considerations
in children. J Minim Access Surg 2011;7:96-8.

71. Narci A, Karaman I, Karaman A, et al. Isperitoneal drainage
necessary in childhood perforated appendicitis?-
acomparative study. J Pediatr Surg 2007;42:1864-8.

72. Akkoyun I, Tuna AT. Advantages of abandoning abdominal
cavity irrigation and drainage in operations performed on
children with perforated appendicitis. J Pediatr Surg 2012;

73. Hartwich JE, Carter RF, Wolfe L, Goretsky M, Heath K, St Peter
SD, Lanning DA. The effects of irrigation on outcomes in cases
of perforated appendicitis in children. J Surg Res 2013;180:

74. Phillips AW, Jones AE, Sargen K. Should the macroscopically
normal appendix be removed during laparoscopy for acute
right iliac fossa pain when no other explanatory pathology is
found? Surg Laparosc Endosc Percutan Tech 2009;19:392-4.

75. Fawkner-Corbett D, Jawaid WB, McPartland J, Losty PD. Interval
appendectomy in children clinical outcomes, financial costs
and patient benefits. Pediatr Surg Int 2014;30:743-6.

76. 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-




How to Cite

Ekkarat P, Sangkhathat S. Evidence-based Practice in Pediatric Appendicitis. Thai J Surg [Internet]. 2015 Mar. 30 [cited 2023 Feb. 1];36(1). Available from: https://he02.tci-thaijo.org/index.php/ThaiJSurg/article/view/226265



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