Appendicitis is a common diagnosis in ED, and once it is confirmed clinically or on ultrasound, the patient usually goes pretty quickly to theatre for an appendectomy. But is a course of antibiotics just as effective as taking these kids to theatre?
A recent article accepted for publication in the Journal of the American College of Surgeons (Feb 2014) investigated this question in a prospective, non-randomised trial comparing urgent appendectomy with antibiotic management of acute appendicitis in children.
Minneci PC, Sulkowski JP, Nacion KM, Mahida JB, Cooper JN, Moss RL, Deans KJ, Feasibility of a Nonoperative Management Strategy for Uncomplicated Acute Appendicitis in Children, Journal of the American College of Surgeons (2014), DOI: 10.1016/j.jamcollsurg.2014.02.031.
Who were the patients?
Eligible children who presented to the author’s hospital (in the USA) were:
- 7-17 years old
- Less than 48 hours of abdominal pain
- WCC < 18 000
- US or CT confirming non-ruptured appendicitis (appendix <1.1cm, no phlegmon, abscess or faecolith)
- Surgical review confirming clinical appendicitis
Exclusion criteria:
- Diffuse peritonitis
- Positive pregnancy test
- Chronic abdominal pain
There were 77 patients in the study.
What was the intervention?
Enrolled patients could opt for surgical management or non-operative management. Of the 77 patients: 47 chose surgery and 30 chose non-operative management.
The surgical group went straight for an appendectomy, with antibiotics prior to surgery (these were discontinued post-op).
The non-operative group had:
- Minimum 24 hours of piperacillin/tazobactam
- Minimum of 12 hours nil by mouth and then could start a diet if the pain was improving
- Pain relief PRN
- Switched to oral amoxicillin once tolerating oral diet and once discharged should have completed a total of 10 days of antibiotics
Doesn’t this seem a bit dangerous?
Patients were removed from the non-operative group if they did not show clinical improvement within 24 hours of antibiotics; or if they returned with abdominal pain after discharge.
What was the follow-up?
Patients were followed up for 30 days to look at outcomes which included: non-operative management; length of hospital stay; disability days; quality of life.
So what happened?
After 30 days, 27 out of the 30 patients had successful non-operative management. Of the three that failed:
- One had an appendectomy within the first 24 hours due to failure to improve and had acute appendicitis
- One had an appendectomy within the first 24 hours due to failure to improve and had appendicitis secondary to a tumour
- One had an appendectomy after representation one-day post-discharge and the appendix was normal
In the non-operative group, there was a longer hospital stay, but a shorter time to return to normal activity. Quality of life scores were higher at 30 days in the non-operative group.
Previously most studies on the conservative management of appendicitis have been on adults, and this study in children provides some promising preliminary results (although it is on quite a small sample). The main risk from missed appendicitis would be from a perforated appendix, and none of the patients in this study went on to have a perforated appendix within 30 days.
However, longer-term issues would be recurrent abdominal pain which could have a significant impact on the lives of these families; and also the eventual outcome of appendectomy as this would negate the benefit of the delay. The authors are aiming to follow up in 1 year so we should keep an eye out for the next article from this group of authors.
