Perforation risk in pediatric appendicitis: assessment and management

Erin C Howell, Emily D Dubina, Steven L Lee, Erin C Howell, Emily D Dubina, Steven L Lee

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: diagnosis; interval appendectomy; management; pediatric; perforated appendicitis.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

References

    1. Curran TJ, Muenchow SK. The treatment of complicated appendicitis in children using peritoneal drainage: Results from a public hospital. J Pediatr Surg. 1993;28(2):204–208.
    1. Sivit CJ, Siegel MJ, Applegate KE, Newman KD. When Appendicitis Is Suspected in Children. Radiographics. 2001;21(1):247–262. questionnaire 288–294.
    1. Guthery SL, Hutchings C, Michael Dean J, Hoff C. National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids’ inpatient database. J Pediatr. 2004;144(5):589–594.
    1. Morrow SE, Newman KD. Current management of appendicitis. Semin Pediatr Surg. 2007;16(1):34–40.
    1. Gosain A, Williams RF, Blakely ML. Distinguishing acute from ruptured appendicitis preoperatively in the pediatric patient. Adv Surg. 2010;44(1):73–85.
    1. Blakely ML, Williams R, Dassinger MS, et al. Early vs interval appendectomy for children with perforated appendicitis. Arch Surg. 2011;146(6):660–665.
    1. Svensson J, Hall N, Eaton S, Pierro A, Wester T. A review of conservative treatment of acute appendicitis. European Journal of Pediatric Surgery. 2012;22(03):185–194.
    1. Svensson JF, Patkova B, Almström M, et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg. 2015;261(1):67–71.
    1. Ashcraft KW, Holcomb GW, Murphy JP, Ostlie DJ, editors. Ashcraft’s Pediatric Surgery. 6th ed. London; New York: Saunders/Elsevier; 2014.
    1. Pham X-BD, Sullins VF, Kim DY, et al. Factors predictive of complicated appendicitis in children. J Surg Res. 2016;206(1):62–66.
    1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910–925.
    1. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, editors. Schwartz’s Principles of Surgery. 10th ed. New York: McGraw-Hill Education; 2014.
    1. Abes¸ M, Petik B, Kazil S. Nonoperative treatment of acute appendicitis in children. J Pediatr Surg. 2007;42(8):1439–1442.
    1. Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg. 2007;31(1):86–92.
    1. Holcomb G, St. Peter S. Current management of complicated appendicitis in children. European Journal of Pediatric Surgery. 2012;22(03):207–212.
    1. Ponsky TA, Hafi M, Heiss K, Dinsmore J, Newman KD, Gilbert J. Interobserver variation in the assessment of appendiceal perforation. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2009;19(s1):s15–s18.
    1. St. Peter SD, Sharp SW, Holcomb GW, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg. 2008;43(12):2242–2245.
    1. Newman K, Ponsky T, Kittle K, et al. Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg. 2003;38(3):372–379.
    1. Ponsky TA, et al. Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children. JAMA. 2004;292(16):1977–1982.
    1. Brender JD, Marcuse EK, Koepsell TD, Hatch EI. Childhood appendicitis: factors associated with perforation. Pediatrics. 1985;76(2):301–306.
    1. Williams RF, Blakely ML, Fischer PE, et al. Diagnosing ruptured appendicitis preoperatively in pediatric patients. J Am Coll Surg. 2009;208(5):819–825.
    1. Bonadio W, Rebillot K, Ukwuoma O, Saracino C, Iskhakov A. Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management. Pediatr Infect Dis J. 2017;36(10):937–941.
    1. Church JT, Klein EJ, Carr BD, Bruch SW. Early appendectomy reduces costs in children with perforated appendicitis. J Surg Res. 2017;220:119–124.
    1. Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: A continuing diagnostic challenge. Pediatr Emerg Care. 2000;16(3):160–162.
    1. Peng Y-S, Lee H-C, Yeung C-Y, Sheu J-C, Wang N-L, Tsai Y-H. Clinical criteria for diagnosing perforated appendix in pediatric patients. Pediatr Emerg Care. 2006;22(7):475–479.
    1. Nelson DS, Bateman B, Bolte RG. Appendiceal perforation in children diagnosed in a pediatric emergency department. Pediatr Emerg Care. 2000;16(4):233–237.
    1. Barrett ML, Hines AL, Andrews RM. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. [Accessed May 27, 2018]. Trends in Rates of Perforated Appendix, 2001–2010: Statistical Brief #159.
    1. Sarda S, Short HL, Hockenberry JM, Mccarthy I, Raval MV. Regional variation in rates of pediatric perforated appendicitis. J Pediatr Surg. 2017;52(9):1488–1491.
    1. Bickell NA, Aufses AH, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg. 2006;202(3):401–406.
    1. Siddique K, Baruah P, Bhandari S, Mirza S, Harinath G. Diagnostic accuracy of white cell count and C-reactive protein for assessing the severity of paediatric appendicitis. JRSM Short Rep. 2011;2(7):59–6.
    1. Stringel G. Appendicitis in children: A systematic approach for a low incidence of complications. The American Journal of Surgery. 1987;154(6):631–635.
    1. Willis ZI, Duggan EM, Bucher BT, et al. Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis. JAMA Surg. 2016;151(5):e160194.
    1. Minneci PC, Sulkowski JP, Nacion KM, et al. Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. J Am Coll Surg. 2014;219(2):272–279.
    1. Rothrock SG, Skeoch G, Rush JJ, Johnson NE. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med. 1991;20(1):45–50.
    1. Chang Y-J, Chao H-C, Kong M-S, Hsia S-H, Yan D-C. Misdiagnosed acute appendicitis in children in the emergency department. Chang Gung Med J. 2010;33(5):551–557.
    1. Kosloske AM, Love CL, Rohrer JE, Goldthorn JF, Lacey SR. The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation. Pediatrics. 2004;113(1):29–34.
    1. Lin C-J, Chen J-D, Tiu C-M, et al. Can ruptured appendicitis be detected preoperatively in the ED? Am J Emerg Med. 2005;23(1):60–66.
    1. Beltrán MA, Almonacid J, Vicencio A, Gutiérrez J, Cruces KS, Cumsille MA. Predictive value of white blood cell count and C-reactive protein in children with appendicitis. J Pediatr Surg. 2007;42(7):1208–1214.
    1. Kim DY, Nassiri N, de Virgilio C, et al. Association Between Hyponatremia and Complicated Appendicitis. JAMA Surg. 2015;150(9):911–912.
    1. Käser SA, Furler R, Evequoz DC, Maurer CA. Hyponatremia is a specific marker of perforation in sigmoid diverticulitis or appendicitis in patients older than 50 years. Gastroenterol Res Pract. 2013;2013(11):462891.
    1. Yaghoubian A, de Virgilio C, Dauphine C, Lewis RJ, Lin M. Use of admission serum lactate and sodium levels to predict mortality in necrotizing soft-tissue infections. Arch Surg. 2007;142(9):840–846.
    1. Wall DB, de Virgilio C, Black S, Klein SR. Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. The American Journal of Surgery. 2000;179(1):17–20.
    1. Wong C-H, Khin L-W, Heng K-S, Tan K-C, Low C-O. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections*. Crit Care Med. 2004;32(7):1535–1541.
    1. Falor AE, Zobel M, Kaji A, Neville A, de Virgilio C. Admission variables predictive of gangrenous cholecystitis. Am Surg. 2012;78(10):1075–1078.
    1. O’Leary MP, Neville AL, Keeley JA, Kim DY, de Virgilio C, Plurad DS. Predictors of Ischemic Bowel in Patients with Small Bowel Obstruction. Am Surg. 2016;82(10):992–994.
    1. Russell WS, Schuh AM, Hill JG, et al. Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care. 2013;29(5):568–573.
    1. Garcia Peña BM, Cook EF, Mandl KD. Selective Imaging Strategies for the Diagnosis of Appendicitis in Children. Pediatrics. 2004;113(1):24–28.
    1. Garcia Pena BM, Taylor GA, Fishman SJ, Mandl KD. Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children. Pediatrics. 2000;106(4):672–676.
    1. Hansen LW, Dolgin SE. Trends in the Diagnosis and Management of Pediatric Appendicitis. Pediatr Rev. 2016;37(2):52–58.
    1. Peña BMG, Taylor GA, Lund DP, Mandl KD. Effect of computed tomography on patient management and costs in children with suspected appendicitis. Pediatrics. 1999;104(3):440–446.
    1. Fraser JD, Aguayo P, Sharp SW, et al. Accuracy of computed tomography in predicting appendiceal perforation. J Pediatr Surg. 2010;45(1):231–235.
    1. Rosenbaum DG, Askin G, Beneck DM, Kovanlikaya A. Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging. Pediatr Radiol. 2017;47(11):1483–1490.
    1. Martin JF, Mathison DJ, Mullan PC, Otero HJ. Secondary imaging for suspected appendicitis after equivocal ultrasound: time to disposition of MRI compared to CT. Emerg Radiol. 2018;25(2):161–168.
    1. Dibble EH, Swenson DW, Cartagena C, Baird GL, Herliczek TW. Effectiveness of a Staged US and Unenhanced MR Imaging Algorithm in the Diagnosis of Pediatric Appendicitis. Radiology. 2018;286(3):1022–1029.
    1. Kim JR, Suh CH, Yoon HM, et al. Performance of MRI for suspected appendicitis in pediatric patients and negative appendectomy rate: A systematic review and meta-analysis. Journal of Magnetic Resonance Imaging. 2018;47(3):767–778.
    1. Schulz T, Bennek J, Schneider JP, et al. MRI-guided pediatric interventions. Rofo. 2003;175(12):1673–1681.
    1. Schulz T, Tröbs RB, Schneider JP, et al. Pediatric MR-guided interventions. Eur J Radiol. 2005;53(1):57–66.
    1. Leeuwenburgh MM, Wiezer MJ, Wiarda BM, et al. OPTIMAP study group Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg. 2014;101(1):e147–e155.
    1. Janik JS, Ein SH, Shandling B, Simpson JS, Stephens CA. Nonsurgical management of appendiceal mass in late presenting children. J Pediatr Surg. 1980;15(4):574–576.
    1. Chen C, Botelho C, Cooper A, Hibberd P, Parsons SK. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg. 2003;196(2):212–221.
    1. López JJ, Deans KJ, Minneci PC. Nonoperative management of appendicitis in children. Curr Opin Pediatr. 2017;29(3):358–362.
    1. Robinson JR, Avritscher EBC, Gay JC, et al. Measuring the Value of a Clinical Practice Guideline for Children With Perforated Appendicitis. Ann Surg. 2017;266(1):195–200.
    1. Knott EM, Gasior AC, Ostlie DJ, Holcomb GW, St Peter SD. Decreased resource utilization since initiation of institutional clinical pathway for care of children with perforated appendicitis. J Pediatr Surg. 2013;48(6):1395–1398.
    1. Slusher J, Bates CA, Johnson C, Williams C, Dasgupta R, von Allmen D. Standardization and improvement of care for pediatric patients with perforated appendicitis. J Pediatr Surg. 2014;49(6):1020–1025.
    1. Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee Systematic Review. J Pediatr Surg. 2010;45(11):2181–2185.
    1. Fishman SJ, Pelosi L, Klavon SL, O’Rourke EJ. Perforated appendicitis: Prospective outcome analysis for 150 children. J Pediatr Surg. 2000;35(6):923–926.
    1. Rodriguez JC, Buckner D, Schoenike S, Gomez-Marin O, Oiticica C, Thompson WR. Comparison of two antibiotic regimens in the treatment of perforated appendicitis in pediatric patients. IntJournal of Clinical Pharmacology and Therapeutics. 2000;38(10):492–499.
    1. St. Peter SD, Little DC, Calkins CM, et al. A simple and more cost-effective antibiotic regimen for perforated appendicitis. J Pediatr Surg. 2006;41(5):1020–1024.
    1. Powers RJ, Andrassy RJ, Brennan LP, Weitzman JJ. Alternate approach to the management of acute perforating appendicitis in children. Surg Gynecol Obstet. 1981;152(4):473–475.
    1. Vane DW, Fernandez N. Role of Interval Appendectomy in the Management of Complicated Appendicitis in Children. World J Surg. 2006;30(1):51–54.
    1. Rentea RM, St. Peter SD. Pediatric Appendicitis. Surg Clin North Am. 2017;97(1):93–112.
    1. Hurst AL, Olson D, Somme S, et al. Once-Daily Ceftriaxone Plus Metronidazole Versus Ertapenem and/or Cefoxitin for Pediatric Appendicitis. J Pediatric Infect Dis Soc. 2017;6(1):57–64.
    1. Guillet-Caruba C, Cheikhelard A, Guillet M, et al. Bacteriologic epidemiology and empirical treatment of pediatric complicated appendicitis. Diagn Microbiol Infect Dis. 2011;69(4):376–381.
    1. Ochsner AJ. The cause of diffuse peritonitis complicating appendicitis and its prevention: Chairman’s address, delivered before the section on surgery and anatomy, at the fifty-second annual meeting of the A. M. A., at St. Paul, Minn., June 4–7, 1901. J Am Med Assoc. 1901;XXXVI(25):1747–1754.
    1. Skoubo-Kristensen E, Hvid I. The appendiceal mass: results of conservative management. Ann Surg. 1982;196(5):584–587.
    1. Bagi P, Dueholm S. Nonoperative management of the ultrasonically evaluated appendiceal mass. Surgery. 1987;101(5):602–605.
    1. Hoffmann J, Rolff M, Lomborg V, Franzmann M. Ultraconservative management of appendiceal abscess. J R Coll Surg Edinb. 1991;36(1):18–20.
    1. Gillick J, Velayudham M, Puri P. Conservative management of appendix mass in children. Br J Surg. 2001;88(11):1539–1542.
    1. Guida E, Pederiva F, Grazia MD, et al. Perforated appendix with abscess: Immediate or interval appendectomy? Some examples to explain our choice. Int J Surg Case Rep. 2015;12:15–18.
    1. Erdoğan D, Ibrahim Karaman, Narcı A, et al. Comparison of two methods for the management of appendicular mass in children. Pediatr Surg Int. 2005;21(2):81–83.
    1. Roach JP, Partrick DA, Bruny JL, Allshouse MJ, Karrer FM, Ziegler MM. Complicated appendicitis in children: a clear role for drainage and delayed appendectomy. Am J Surg. 2007;194(6):769–773.
    1. Emil S, Duong S. Antibiotic therapy and interval appendectomy for perforated appendicitis in children: a selective approach. Am Surg. 2007;73(9):917–922.
    1. Zhang H-L, Bai Y-Z, Zhou X, Wang W-L. Nonoperative Management of Appendiceal Phlegmon or Abscess with an Appendicolith in Children. Journal of Gastrointestinal Surgery. 2013;17(4):766–770.
    1. Fawkner-Corbett D, Jawaid WB, Mcpartland J, Losty PD. Interval appendectomy in children clinical outcomes, financial costs and patient benefits. Pediatr Surg Int. 2014;30(7):743–746.
    1. Owen A, Moore O, Marven S, Roberts J. Interval Laparoscopic Appendectomy in Children. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2006;16(3):308–311.
    1. Furuya T, Inoue M, Sugito K, et al. Effectiveness of Interval Appendectomy After Conservative Treatment of Pediatric Ruptured Appendicitis with Abscess. Indian J Surg. 2015;77(S3):1041–1044.
    1. Luo C-C, Cheng K-F, Huang C-S, et al. Therapeutic effectiveness of percutaneous drainage and factors for performing an interval appendectomy in pediatric appendiceal abscess. BMC Surg. 2016;16(1):72.
    1. Keckler SJ, Tsao K, Sharp SW, Ostlie DJ, Holcomb GW, St. Peter SD. Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis with abscess. J Pediatr Surg. 2008;43(6):977–980.
    1. Bufo AJ, Shah RS, Li MH, et al. Interval appendectomy for perforated appendicitis in children. J Laparoendosc Adv Surg Tech A. 1998;8(4):209–214.
    1. Henry MC, Gollin G, Islam S, et al. Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis. J Pediatr Surg. 2007;42(1):19–24.
    1. Iqbal CW, Knott EM, Mortellaro VE, Fitzgerald KM, Sharp SW, St. Peter SD. Interval appendectomy after perforated appendicitis: what are the operative risks and luminal patency rates? J Surg Res. 2012;177(1):127–130.
    1. Nazarey PP, Stylianos S, Velis E, et al. Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy. J Pediatr Surg. 2014;49(3):447–450.
    1. Talishinskiy T, Limberg J, Ginsburg H, Kuenzler K, Fisher J, Tomita S. Factors associated with failure of nonoperative treatment of complicated appendicitis in children. J Pediatr Surg. 2016;51(7):1174–1176.
    1. Mcneeley MF, Vo NJ, Prabhu SJ, Vergnani J, Shaw DW. Percutaneous drainage of intra-abdominal abscess in children with perforated appendicitis. Pediatr Radiol. 2012;42(7):805–812.
    1. St. Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg. 2010;45(1):236–240.
    1. Weber TR, Keller MA, Bower RJ, Spinner G, Vierling K. Is delayed operative treatment worth the trouble with perforated appendicitis is children? Am J Surg. 2003;186(6):685–689.
    1. Gasior AC, Marty Knott E, Ostlie DJ, St. Peter SD. To drain or not to drain: an analysis of abscess drains in the treatment of appendicitis with abscess. Pediatr Surg Int. 2013;29(5):455–458.
    1. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon) Surgery. 2010;147(6):818–829.
    1. Fawley J, Gollin G. Expanded utilization of nonoperative management for complicated appendicitis in children. Langenbecks Arch Surg. 2013;398(3):463–466.
    1. St. Peter SD, Snyder CL. Operative management of appendicitis. Semin Pediatr Surg. 2016;25(4):208–211.
    1. Hall NJ, Jones CE, Eaton S, Stanton MP, Burge DM. Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J Pediatr Surg. 2011;46(4):767–771.
    1. Darwazeh G, Cunningham SC, Kowdley GC. A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See? Am Surg. 2016;82(1):11–15.
    1. Gonzalez DO, Deans KJ, Minneci PC. Role of non-operative management in pediatric appendicitis. Semin Pediatr Surg. 2016;25(4):204–207.
    1. Puapong D, Lee SL, Haigh PI, Kaminski A, Liu IL, Applebaum H. Routine interval appendectomy in children is not indicated. J Pediatr Surg. 2007;42(9):1500–1503.
    1. Raval MV, Lautz T, Reynolds M, Browne M. Dollars and sense of interval appendectomy in children: a cost analysis. J Pediatr Surg. 2010;45(9):1817–1825.
    1. Tanaka Y, Uchida H, Kawashima H, et al. More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary? J Pediatr Surg. 2016;51(12):1957–1961.
    1. Kogut KA, Blakely ML, Schropp KP, et al. The association of elevated percent bands on admission with failure and complications of interval appendectomy. J Pediatr Surg. 2001;36(1):165–168.
    1. Liu ZF, Yu JC, Hsieh HF, Lin CH. Perforated appendicitis: urgency or interval surgery? Zentralbl Chir. 2007;132(6):539–541.
    1. Mazziotti MV, Marley EF, Winthrop AL, Fitzgerald PG, Walton M, Langer JC. Histopathologic analysis of interval appendectomy specimens: support for the role of interval appendectomy. J Pediatr Surg. 1997;32(6):806–809.
    1. Ein SH, Langer JC, Daneman A. Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis. J Pediatr Surg. 2005;40(10):1612–1615.
    1. Gahukamble DB, Gahukamble LD. Surgical and pathological basis for interval appendicectomy after resolution of appendicular mass in children. J Pediatr Surg. 2000;35(3):424–427.
    1. Myers AL, Williams RF, Giles K, et al. Hospital cost analysis of a prospective, randomized trial of early vs interval appendectomy for perforated appendicitis in children. J Am Coll Surg. 2012;214(4):427–434.
    1. Levin T, Whyte C, Borzykowski R, Han B, Blitman N, Harris B. Nonoperative management of perforated appendicitis in children: can CT predict outcome? Pediatr Radiol. 2007;37(3):251–255.
    1. Nadler EP, Reblock KK, Vaughan KG, Meza MP, Ford HR, Gaines BA. Predictors of outcome for children with perforated appendicitis initially treated with non-operative management. Surg Infect. 2004;5(4):349–356.
    1. Aprahamian CJ, Barnhart DC, Bledsoe SE, Vaid Y, Harmon CM. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences. J Pediatr Surg. 2007;42(6):934–938.
    1. Whyte C, Levin T, Harris BH. Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management. J Pediatr Surg. 2008;43(8):1459–1463.
    1. Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpable mass. Ann Surg. 1981;193(2):227–229.
    1. Duggan EM, Marshall AP, Weaver KL, et al. A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis. Pediatr Surg Int. 2016;32(7):649–655.
    1. Dennett KV, Tracy S, Fisher S, et al. Treatment of perforated appendicitis in children: what is the cost? J Pediatr Surg. 2012;47(6):1177–1184.
    1. Schurman JV, Cushing CC, Garey CL, Laituri CA, St Peter SD. Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial. J Pediatr Surg. 2011;46(6):1121–1125.
    1. Liu JJ, Bellamy GR, Mccormick M. Patient bypass behavior and critical access hospitals: implications for patient retention. J Rural Health. 2007;23(1):17–24.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren