Original article
Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis

https://doi.org/10.1016/j.jpedsurg.2005.06.001Get rights and content

Abstract

Aim of Study

The aim of this study was to determine if the presence of an appendicolith is associated with an increased risk for recurrent appendicitis after nonoperative treatment of pediatric ruptured appendix with inflammatory mass or abscess.

Methods

Ninety-six pediatric patients (52 girls, 44 boys), aged 16 months to 17 years (average, 7 years), were managed between 1980 and 2003. All were treated nonoperatively with intravenous triple antibiotics for 5 to 21 days. All children had at least a 2-year follow-up. This study was approved by the hospital research ethics board.

Main Results

Six children (6%) who became worse and 41 (46%) who had an interval appendectomy were eliminated from the study. The other 49 patients comprised the study group and received no further treatment. Twenty-eight (57%) had no recurrence, and 21 (43%) had a recurrence within 1 month to 2 years (average, 3 months). In the study group, 31 (63%) children had no appendicolith on radiological imaging and 18 (37%) had. Presence of an appendicolith was associated with a 72% rate of recurrent appendicitis compared with a recurrence rate of 26% in those with no appendicolith (χ2 test, P < .004).

Conclusion

We conclude that the patients with appendicolith should have an interval appendectomy.

Section snippets

Materials and methods

Ninety-six pediatric patients (52 girls, 44 boys), aged 16 months to 17 years (average, 7 years), were managed at the Hospital for Sick Children (HSC), Toronto, Canada, between January 1980 and January 2003 (Fig. 1) for ruptured appendicitis with an inflammatory mass or abscess proven by history, examination, plain abdominal radiographs, barium enema, ultrasonography (US), and/or computed tomography. The decision to treat the patient nonoperatively was made by the staff surgeon. None of these

Results

Six children (all with an appendicolith) became worse (4 increasing symptoms and signs, 1 appendiceal fistula, and 1 small bowel obstruction) within 1 month of treatment. Five were operated on immediately, and 1 had another large inflammatory mass, was treated with triple antibiotics again, improved, was discharged home, and had an interval appendectomy. They were eliminated from the study group.

Of the remaining 90 patients, 41 (46%) had an elective interval appendectomy within 1 to 11 months

Discussion

At HSC, there are about 270 cases of appendicitis per year [9], of which 20% are ruptured. One half of the ruptured appendices present with an inflammatory mass or abscess [10]. In 1980 [11], we reported our experience with “37 late presenting children with appendiceal mass…treated between 1965 and 1975…(with no antibiotics) and there was one recurrence before all the others had a successful interval appendectomy.” Sixteen years later (1996) [8], we reported a smaller 10-year (1980-1989)

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