Perforated Appendicitis: management options Darren Bowe

Case: 7yom with R-side abd pain Abdominal pain starting 4 days prior to arrival. Improved 1 day prior to arrival; now worse than before Emesis x2, poor appetite, decreased UOP, fever T 40.1ºC, tachycardic, normotensive Physical Exam Appropriately developed 7yo boy in moderate discomfort lying in bed Oropharyx- dry Lungs- CTAB Abd- minimal bowel sounds, flat, rigid, R-side abdominal pain worst in RLQ, +rovsing’s sign, minimal RLQ pain with R-straight leg raise, no palpable masses

Case: 7yom with R-side abd pain UA- no WBC, no RBC Abd US- mildly enlarged appendix to 0.77cm; max wall thickness 0.2cm; fecalith measuring 0.85cm within the appendix - relation to origin undetermined; small amount of adjacent free fluid; no focal fluid collection. IMPRESSION: appendicitis with fecalith and high suspicion for perforation 134 101 5.1 24 8.2 107 34.4 -Polys 68% -Bands 23 (H)

Case: 7yom with R-side abd pain Hospital Course Started on Zosyn in ED and was continued throughout hospitalization To the OR for lap appy on evening of admission; found to have a retrocecal appendix that was highly inflamed/gangrenous w/o obvious perforation Discharged on POD#3 with 1-week course of augmentin; CBC on day of discharge showed WBC 6.1 with no bands. Pathology Findings- Acute inflammatory cells involving full-thickness of the tip and mid-portion of the appendix. One area of essentially full-thickness necrosis w/neutrophils extending out of tissue Diagnosis- Appendix with fecalith and a microscopic perforation

?

Conclusions Dilemma - when to initiate and when to abandon non-operative therapy? The overall complication rate is lower in non-operative groups compared to immediate operation for perf’d appendix. The complication rate is higher for folks who fail non-operative therapy when compared to folks who have immediate operation.

Conclusions Resuscitation and early surgery: Nonoperative Protocol: Age <5yrs Immunocompromise Widely disseminated disease Intestinal obstruction Septic shock Other medical conditions Nonoperative Protocol: All other medically stable patients Evaluate for treatment response at 24hrs Consider bandemia level

References Abes M, Petik B, Kazil S. Nonoperative treatment of acute appendicitis in children. J Pediatr Surg 2007; 42:1439-1442. Aprahamian CJ, Barnhart DC, Bledsoe SE, Vaid Y, Harmon CM. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences 2007; 42:934-938. Janik JS, Ein SH, Shandling B, et al. Nonsurgical management of appendiceal mass in late presenting children. J Pediatr Surg 1980; 15(4):574 -6. Whyte C, Levin T, Harris BH. Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management. J Pediatr Surg 2008; 43:1459-1463.