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Innovations in the evaluation and management of appendicitis could lead to better patient care and improved outcomes.
Appendicitis is the most common cause of acute surgical abdomen in the pediatric population, and even though appendicitis is a well-known disease process, there is ongoing interest in identifying innovations that could lead to better patient care and improved outcomes.
As discussed by Catherine J Hunter, MD, FAAP, at the American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition in a session on September 18, some of these efforts have led to “Controversies in pediatric appendicitis,” as her presentation was titled.
“It is important that pediatricians be aware of new developments in pediatric appendicitis evaluation and management and also be familiar with the current status of active areas of research,” said Hunter, associate professor of Surgery (Pediatric Surgery) and Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Discussing diagnosis, Hunter said that a “good old-fashioned” clinical examination remains the mainstay for identifying a child who is suffering from acute appendicitis. Evaluation with imaging is not necessary, but there are good data demonstrating the accuracy of ultrasound for diagnosing acute appendicitis when it is performed by a skilled ultrasonographer.
In addition, accumulating experience at Lurie Children’s Hospital and some other pediatric centers indicate that magnetic resonance imaging (MRI) has good diagnostic performance. However, Hunter cautioned against evaluation with computed tomography (CT) scan, which may be particularly used if a child presents in the emergency department at a community hospital.
“I would really advocate that CT scan be avoided in children given the known risks of radiation exposure. Although MRI avoids radiation and appears useful, cost analyses are still needed to determine its role in the diagnostic evaluation,” she said.
Timing of surgery for acute appendicitis is another area of controversy with the idea that it should be handled as an emergency being replaced by recognition that definitive intervention can be safely delayed for a reasonable period if the child receives appropriate supportive care in the interim.
“Data from a few studies show that compared with more immediate operative management, there is no increased risk for postoperative complications or readmission if the child is started on intravenous fluids and antibiotics and is operated on within 8 hours,” Hunter said.
There is also growing interest in nonoperative management of acute appendicitis. Whereas surgical appendectomy has been the long-standing gold standard, data from studies in adults support management with antibiotics alone. Clinical trials in the pediatric population are ongoing to see if medical management is a feasible and safe therapeutic alternative to surgery, and early results are promising.
“The findings are intriguing, but more information is needed. In the meantime, it is important to counsel families that recurrence of acute appendicitis is a possibility with nonoperative management,” Hunter said.
In addition, she cautioned that children with neutropenia should likely be excluded from nonoperative management. “I would recommend these children be taken to the OR because they are likely to have a higher relapse risk if managed with medical management alone. Furthermore, I would recommend considering a broader spectrum antibiotic in addition to surgery,” Hunter said.
Acute appendicitis is the most common urgent surgical condition seen in the pediatric population, and despite efforts to standardize practice guidelines and make approaches to diagnosis and management evidence based, there continues to be significant variation in practice patterns for the evaluation and care of children with acute appendicitis. With those issues in mind, and because of the current emphasis on providing value-based surgical care, it is critical for pediatricians to be aware of “Controversies in appendicitis.”
In a session on this topic at the AAP’s 2017 National Conference, Dr Catherine Hunter discussed a number of important issues. An update on nonoperative management of acute appendicitis in children may be particularly valuable for pediatricians considering that more and more, and parents seem to be asking about this option and wondering whether their child really needs surgery based on what they have read online.
Although there is a lot of evidence to support nonoperative management of acute appendicitis for adults, trials evaluating this approach in children are still ongoing and more information is needed before it should be offered outside the context of enrollment in an institutional review board-approved clinical trial protocol. Pediatricians asked about nonoperative management should counsel parents that there are studies under way and early data are encouraging, but the safety of this approach needs to be established before it can be routinely considered.
Certainly, as Hunter points out, children with neutropenia should be excluded from nonoperative management for acute appendicitis, but there is also emerging information to show that even in children who are healthy and deemed to have simple, uncomplicated appendicitis, there are certain risk factors that portend a higher failure rate of this treatment strategy. Until more is known about what children can potentially do well with nonoperative management and who should be ineligible, surgical intervention should remain the standard of care.
-Monica E. Lopez, MD, MS, is associate professor of Surgery and Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas.