Nonoperative management of Appendicitis

Appendectomy for  an appendicitis presenting early remains the treatment of choice in majority of the cases but a minority of children can be considered for a Non Operative Management(NOM) if the treating surgeon considers and parents/patient consent to same.

The NOM may be safe and effective for older children who can better describe their symptoms (over six years of age) and meet all of the following criteria:

  • Abdominal pain for <48 hours
  • White blood cell (WBC) count ≤18,000/microL
  • Normal C-reactive protein 
  • No appendicolith present on imaging (CT scan preferred)
  • Appendix diameter ≤1.1 cm on imaging
  • No preoperative concern for rupture based upon clinical findings

NOM should only be under in-patient care of a surgeon with pediatric expertise. During in-patient care, IV fluids and broad-spectrum antibiotics are used for 1 to 2 days(eg, piperacillin- tazobactam, ceftriaxone and metronidazole, or ciprofloxacin and metronidazole) until resolution of symptoms and normalization of WBC count. Followed by oral antibiotics (eg, amoxicillin-clavulanic acid or ciprofloxacin and metronidazole) as an outpatient.

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