Patient selection: pediatric appendicitis
Indications for immediate surgery - any of the following:
(1) hemodynamic instability
(2) diffuse peritonitis
(3) symptoms for less than 5 to 7 days (early presentation)
Indications for non-operative management - all of the following:
(1) hemodynamically stable
(2) without diffuse peritonitis
(3) duration > 7 days
(4) reliable home environment for follow-up and return to hospital if problems arise
Predictors of failure in non-operative management include:
(1) appendicolith
(2) WBC count > 15,000 per microliter
(3) bandemia
(4) CT evidence of abscess, evidence of disease beyond the right lower quadrant, or free peritoneal fluid
(5) bowel obstruction
(6) fever > 24 hours after the start of nonoperative treatment
(7) failure to improve with conservative management
Non-operative management includes:
(1) requires careful selection of patients
(2) requires careful follow-up
(3) requires antibiotic therapy
(4) may involve elective appendectomy after inflammation subsides (interval appendectomy)
Antibiotic therapy for nonoperative management:
(1) intravenous antibiotics until all of the following:
(1a) afebrile for 24 hours
(1b) tolerating a diet
(1c) pain well-controlled
(2) subsequent discharge with switch to oral antibiotics for up to 7 days as an outpatient
