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Perforation risk in pediatric appendicitis: assessment and management

Authors Howell EC, Dubina ED, Lee SL

Received 11 June 2018

Accepted for publication 17 August 2018

Published 26 October 2018 Volume 2018:9 Pages 135—145


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Professor Roosy Aulakh

Erin C Howell,1 Emily D Dubina,1 Steven L Lee1,2

1Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA; 2Division of Pediatric Surgery, UCLA Mattel Children’s Hospital, Los Angeles, CA, USA

Abstract: Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.

Keywords: pediatric, perforated appendicitis, diagnosis, management, interval appendectomy

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