1. Perforated Appendicitis: management options
Darren Bowe

2. 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

3. 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)

4. 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

5. ?

8. 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.

9. 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

10. References
Abes M, Petik B, Kazil S. Nonoperative treatment of acute appendicitis in children. J Pediatr Surg 2007; 42:
Aprahamian CJ, Barnhart DC, Bledsoe SE, Vaid Y, Harmon CM. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences 2007; 42:
Janik JS, Ein SH, Shandling B, et al. Nonsurgical management of appendiceal mass in late presenting children. J Pediatr Surg 1980; 15(4):
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: