Introduction
Pediatric appendicitis remains a considerable healthcare concern and is associated with substantial cost and resource utilization. There have been ongoing research efforts surrounding the diagnosis and management of pediatric appendicitis, which have led to advancement in practices, development of standardized evidence-based treatment algorithms, and promotion of patient-centered approaches to management. This chapter will provide a review of the pathophysiology, presentation, workup, existing evidence, and controversies related to the management of acute appendicitis in children.
Epidemiology
As one of the most common surgical conditions in children, appendicitis has an estimated annual incidence of 83 per 100,000. , In the United States, it ranks as the fifth most common reason for hospitalization in children, accounting for approximately 40,000 hospital stays with aggregate costs totaling $492 million in 2018. , Globally, the peak incidence occurs in the 15- to 19-year-old age group. Interestingly, there has been an overall steady increase in incidence and concurrent decrease in mortality rate over the last two decades. It is estimated that the overall lifetime risk of appendicitis is approximately 8%.
Pathophysiology
The most frequently cited pathophysiology for appendicitis originates with luminal obstruction due to stool, lymphoid hyperplasia, or in rare cases, an appendiceal neoplasm. This was initially described in an experimental model 80 years ago. The result of luminal obstruction is an increase in intraluminal pressure that causes vascular compromise, mucosal ischemia, and subsequent bacterial invasion of the appendiceal wall. , There are several bacterial, viral, fungal and parasitic organisms that infect the appendix, which results in a wide range of specific and nonspecific histopathologic findings. These organisms include Yersinia, Salmonella, Shigella, mumps, Coxsackie B, and adenovirus. , However, the exact pathogenesis of inflammation and mechanism of bacterial invasion into the appendiceal wall remains unknown. In addition, prior evidence suggests an association with a wide variety of environmental and genetic risk factors including a three-fold greater relative risk in those with a positive family history. , ,
It is usually assumed that the natural history of untreated appendicitis is a progression to perforation and abscess development. This theory is supported by the fact that delays in diagnosis and presentation are associated with perforation or complicated appendicitis. Despite this, there are multiple cases of ongoing uncomplicated appendicitis for multiple days without progression to complicated appendicitis. There have been studies demonstrating resolution of appendicitis without treatment or progression to relapsing disease and chronic appendicitis. The age distribution of rates of complicated appendicitis has also been described. Complicated appendicitis rates are significantly higher in children younger than 5 and approach 90% in children less than 1 year of age. The reasons for this are multifactorial. Some explain this pattern as a result of younger children having a more challenging time describing or articulating their symptomatology, so the disease has progressed further before it becomes apparent to the caregivers or providers. Also, due to the lower frequency of appendicitis in younger children, clinician suspicion is decreased, also contributing to delays in diagnosis.
Diagnosis
Clinical Presentation
The classical presentation of acute appendicitis is periumbilical abdominal pain with migration to the right lower quadrant, typically within 24 hours of the onset of symptoms. Early inflammation causes luminal distension activating visceral pain fibers contributing to periumbilical, generalized pain. As the appendix becomes more inflamed, it contacts the parietal peritoneum, triggering somatic pain fibers in the right lower quadrant, typically in McBurney’s point (located on the right side of the abdomen one-third of the distance from the anterior iliac spine to the umbilicus). In addition, children may also present with fever, anorexia, nausea, and vomiting. Other clinical signs of appendicitis include localized or generalized peritonitis with involuntary guarding, rebound tenderness, a Rovsing sign (palpation of the left lower quadrant elicits right lower quadrant pain), obturator sign (flexion and internal rotation of the right hip elicits pain), and iliopsoas sign (right hip extension elicits pain). Interestingly, previous studies have evaluated the accuracy of these signs and have found that the Rovsing, obturator, and iliopsoas signs have low sensitivity (16%–44%) and high specificity (86%–98%) in diagnosing appendicitis. Overall, focal pain in the right lower quadrant is the most reliable predictor of appendicitis. A systematic review of 21 studies including 8605 pediatric patients found that migration of pain to the right lower quadrant and presence of pain with coughing or hopping were the findings most strongly associated with appendicitis with a positive likelihood ratio of 4.81 and 7.64, respectively. There is also some variability regarding presenting symptoms and age. The likelihood of appendicitis in those with a history of focal right lower quadrant pain, history of migration of pain, and diarrhea is greater for younger patients (3- to 6-year-old age group).
Laboratory Tests
There is no known biomarker that is specific for appendicitis. Serum studies are generally not sensitive or specific for the diagnosis. Nonetheless, laboratory values, including white blood cell count (WBC), absolute neutrophil count (ANC), and c-reactive protein (CRP), are frequently used for diagnostic purposes. However, their ability to discriminate between appendicitis and other inflammatory conditions is limited. Despite their variability, they have been shown to be useful in improving diagnostic accuracy when used in combination with radiographic imaging. For example, a recent retrospective study investigating children with suspected appendicitis demonstrated that among children with a nondiagnostic ultrasound, the combination of having >72 hours of symptoms and a normal WBC had a negative predictive value (NPV) of 100%. Laboratory test accuracy is also heavily influenced by timing. A prospective cohort study demonstrated that the WBC peaked at <24 hours, CRP peaked at 24–48 hours of pain for nonperforated appendicitis, WBC peaked at 24–48 hours, and the CRP peaked at >48 hours of pain for perforated appendicitis.
Radiographic Imaging Studies
Ultrasound
Alongside clinical evaluation and physical examination, imaging plays a significant role in the diagnosis of appendicitis. When available, ultrasound is often the initial diagnostic imaging modality of choice in children due to its low cost, lack of need for sedation, and avoidance of radiation , ( Fig. 40.1 ). Diagnostic accuracy of ultrasound is operator dependent.
These ultrasound studies from two different patients depict evidence of appendicitis. On the axial view (A) , an appendicolith measuring 6.3 mm in diameter is depicted. The appendix is also greater than 6 mm in diameter, which meets criteria for appendicitis. On the right (B) , in this longitudinal ultrasound view, the enlarged appendix measures 11 mm in diameter.
Previous studies have shown lower accuracy in children with obesity and improved accuracy with specialized pediatric sonographers. Reported sensitivity ranges from 72.5% to 94.8%, and specificity ranges from 95% to 99%. , , , In a systematic review and meta-analysis, pooled sensitivity and specificity were 89% and 97%, respectively, when performed by emergency medicine physicians and 96% and 97%, respectively, when performed by nonemergency medicine physicians. Standardized reporting systems and templates for radiologists have also been associated with improvement in diagnostic accuracy, with one study reporting an increase in sensitivity from 66.7% to 92.2%
There have been attempts at standardizing imaging characteristics to improve accuracy and decrease the need for additional unnecessary imaging. One such model is the Appy-Score, where 1 is a normal and completely visualized appendix, 2 is a normal but only partially visualized appendix, 3 is a nonvisualized appendix, 4 is equivocal, 5a is nonperforated appendicitis, and 5b is perforated appendicitis. Their study suggested that while there was no significant improvement in diagnostic accuracy, the rate of computed tomography (CT) imaging after implementation decreased by 31%. Another study assessing the implementation of a standardized reporting system for ultrasound findings similarly found a decrease in the rate of CT imaging from 44.3% to 9.6% and annual cost reduction of $300,527. Furthermore, implementation of diagnostic algorithms (discussed below) for appendicitis have also been associated with decreased rates of CT imaging. ,
Computed Tomography
CT scans continue to be one of the most commonly performed imaging modalities for suspected appendicitis. Although ultrasound is the first-line diagnostic imaging tool of choice for pediatric appendicitis, CT is still performed in more than half of children, with most CT scans being performed at nonpediatric hospitals. A previous meta-analysis comparing ultrasound and CT demonstrated a pooled sensitivity and specificity of ultrasound of 88% and 94%, respectively, and 94% and 95% for CT. Interestingly, despite CT having greater diagnostic accuracy and studies demonstrating that dedicated CT imaging can be performed with reduced doses of radiation, there is no evidence that CT is associated with lower rates of negative appendectomy, and overall sensitivity and specificity for detecting appendiceal perforation in the absence of a well-formed abscess is reported to be only 62% and 81%, respectively. CT can be a useful adjunct in the setting of indeterminate findings or nonvisualized appendix on ultrasound. , Figs. 40.2 and 40.3 show representative findings.
These three CT scans show differing presentations for appendicitis. (A) The appendix ( arrow ) is enlarged and has a thickened wall. There are no inflammatory changes such as periappendiceal fat stranding. (B) The appendix ( arrow ) is enlarged, and there are free fluid and inflammatory changes medially indicating likely perforation. (C) The patient presented with a 1-week history of pain and the appendix has perforated with the development of two abscesses (∗). In addition, a fecalith is seen medially ( dotted arrow ). The patient was initially managed nonoperatively with drainage of the abscesses and intravenous antibiotics. She underwent laparoscopic interval appendectomy 10 weeks following the initial admission.
This sagittal CT image depicts three appendicoliths ( arrow ) and an enlarged appendix.
Magnetic Resonance Imaging
Due to the issues surrounding CT scanning, magnetic resonance imaging (MRI) has been suggested as the preferred cross-sectional imaging modality. MRI can also be a useful adjunct in the setting of a nonvisualized appendix on ultrasound, with similar sensitivity and specificity to CT. , The overall sensitivity and specificity are 97% with a negative appendectomy rate of 3.1%. Some of the challenges to this modality are higher costs, slower acquisition time, potential need for sedation, and limited availability. There are institutions that protocolize MRI characteristics specifically for appendicitis and have demonstrated success. Of note, in most children’s hospitals with MRI availability, ultrasound remains the first-line diagnostic imaging modality of choice and MRI is only used when results are indeterminate.
Pediatric Appendicitis Risk Scores
Given the limitations and variability of the diagnostic testing modalities and potential consequences of missed or delayed diagnosis, several composite risk scores have been developed to help improve the diagnostic accuracy of pediatric appendicitis. Some of the most studied scores include the Pediatric Appendicitis Score (PAS), Alvarado score, Appendicitis Inflammatory Response (AIR) score, and the pediatric Appendicitis Risk Calculator (pARC).
The PAS is a scoring system ranging from 0 to 10 based on history, physical exam, and laboratory testing. The factors include migration of pain, anorexia, nausea/vomiting, fever >38°C, cough/percussion/hopping tenderness, right lower quadrant tenderness, leukocytosis >10,000 cells/mm 3 , and polymorphonuclear neutrophilia >7500 cells/mm 3 . In the initial experience with the scoring system, the authors reported that a score ≥6 was highly associated with appendicitis. The PAS has been externally validated and found to be useful in ruling out appendicitis with a score ≤2 and diagnosing appendicitis with a score ≥7.
The Alvarado score, also known as MANTRELS (Migration, Anorexia-acetone, Nausea-vomiting, Tenderness in right lower quadrant, Rebound pain, Elevation of temperature, Leukocytosis, Shift to the left), is a 10-point scoring system based on clinical signs and symptoms in patients presenting with abdominal pain. The scores are combined with recommendations regarding patient disposition, including discharge (score 1–4), observation (score 5–6), or surgical intervention (score 7–10). This scoring system has been studied and validated in several different populations including adults and children. In a systematic review and meta-analysis, at the cutoff point of 5 for differentiating between discharge and admission for observation, the Alvarado score had a sensitivity of 0.99 and specificity of 0.57 in children. A meta-analysis demonstrated that in children with pretest probabilities ≤60%, a score <4 is associated with a 3% probability of appendicitis, thus making appendicitis highly unlikely.
The AIR score is an 8-point scoring system developed using weighted ordered logistic regression analysis involving patient history, physical exam, and laboratory testing. The factors include vomiting, right lower quadrant tenderness, rebound tenderness, fever ≥38.5°C, proportion of polymorphonuclear leukocytes, WBC, and CRP. The AIR was recently validated in a large prospective study involving 3878 children and adult patients presenting with <5 days of abdominal pain. The authors concluded that the AIR scoring system was more accurate in detecting appendicitis in patients <15 years of age, with a receiver operating curve (ROC) area of 0.87. The AIR was also found to be even better at detecting complicated appendicitis, with an ROC area of 0.93.
Finally, the pARC includes age, sex, temperature, nausea/vomiting, pain duration, pain location, pain with walking, pain migration, guarding, WBC, and ANC. This comprehensive score ranges from 0% to 100% and stratifies patients across seven clinically actionable risk categories (<5%, 5%–14%, 15%–24%, 25%–49%, 50%–74%, 75%–84%, and ≥85%), with corresponding negative appendectomy rates of 8.8%, 7.7%, 6.8%, 5.2%, 5.5%, 2.6%, and 1.2%, respectively. In this study, the pARC had an AUC of 0.85, outperforming the PAS, which had an AUC of 0.77. The pARC was externally validated across 11 community emergency departments in patients 5–20.9 years of age who presented with abdominal pain. In this patient population, the pARC similarly outperformed the PAS with an ROC curve of 0.89 versus 0.80. These systems are illustrated in Table 40.1 .
Table 40.1
Pediatric Appendicitis Score, Alvarado Score, and Appendicitis Inflammatory Response Score for Diagnosing Appendicitis in Children
| Pediatric Appendicitis Score (Points) | Alvarado Score (Points) | Appendicitis Inflammatory Response Score (Points) | Pediatric Appendicitis Risk Calculator (Percent) |
|---|---|---|---|
| Cough/percussion/hopping tenderness in the right lower quadrant (2) | Rebound pain (1) | Vomit (1) | Age |
| Anorexia (1) | Anorexia (1) | Pain right fossa (1) | Sex |
| Fever (1) | Fever (>37.3) (1) | Tenderness: Light (1), medium (2), strong (3) | Temp |
| Nausea/emesis (1) | Nausea/emesis (1) | Fever (38.5) (1) | Nausea/emesis |
| Right lower quadrant tenderness (2) | Right lower quadrant tenderness (2) | Polymorphonuclear neutrophilia: 70%–84% (1), >85% | Pain duration |
| Migration of pain (1) | Migration of pain (1) | Leukocytosis: 10.0–14.9K(1),>15K (2) | Pain location |
| Leukocytosis (WBCs 210,000) (1) | Leukocytosis (WBCs >10,000) (2) | CRP: 1–4.9 mg/L(1), >5 (2) | Pain with ambulation |
| Polymorphonuclear neutrophilia (1) | Left shift (neutrophils >75%) (1) | Sum of 9 suggests appendicitis | Pain migration |
| Sum of 6 suggests appendicitis | Sum of 7 suggests appendicitis |
Guarding
Leukocytosis ANC The pARC requires use of an online or electronic health record (EHR)-integrated calculator. |
There have been a great deal of comparative studies evaluating the differences in diagnostic accuracy of the various pediatric appendicitis risk scores. In summary, there does not seem to be one score that can reliably determine the diagnosis of appendicitis without imaging. The scores can be valuable tools in clinical algorithms for triaging patients with a higher likelihood of appendicitis that will require imaging to determine if appendicitis is the cause of the patient’s symptoms.
Management of Pediatric Appendicitis
Management of Uncomplicated Appendicitis
Surgical Management
Uncomplicated acute appendicitis in children can be managed nonoperatively with antibiotics (NOM) alone, or operatively with appendectomy, with laparoscopy being the preferred approach. Historically, the management for uncomplicated appendicitis has been an appendectomy. While previously performed open, the laparoscopic appendectomy is now the current standard of care with an average length of stay of 1 day. , Moreover, some institutions have moved toward same-day discharge in many patients. A recent study demonstrated no differences in rates of readmission or complications between those undergoing same-day discharge and those discharged on postoperative day 1 or 2 in pediatric patients with uncomplicated appendicitis. There are multiple techniques for laparoscopic appendectomy, but the most commonly described is a three-port appendectomy with one port for the camera and two additional working ports. The positioning of the ports remains variable and surgeon dependent. Some surgeons choose to perform these procedures as a single-incision procedure. Several randomized trials have compared these two techniques. In a pediatric study of 360 patients, there was no difference in surgical site infections, dose of analgesics, length of stay, or time of convalescence. The main benefit is purported to be cosmetic; however, long-term studies have failed to demonstrate a significant cosmetic advantage. ,
Operative management of uncomplicated appendicitis is associated with minor complication rates ranging from 5% to 15% and major complication rates of 1%–5%. These include intraabdominal abscesses, superficial and organ space surgical site infections, small bowel obstruction, and ileus. , Historically, there was concern regarding the time-dependent pathophysiology of acute appendicitis with an increasing risk of appendiceal perforation if intervention was delayed. This continues to be a topic of controversy due to the successful use of antibiotics for uncomplicated appendicitis. A study that included 2429 children who underwent appendectomy within 24 hours of presentation across 29 hospitals in the National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) database demonstrated that there was no evidence of a significant association between timing of operative intervention and postoperative complications. Interestingly, there was a study of 18,927 children who underwent appendectomy within 24 hours of presentation that found that patients who underwent appendectomy 16–24 hours after presentation were more likely to have operative findings of complicated appendicitis, higher rates of postoperative percutaneous drain placement, increased use of postoperative TPN, and increased length of stay compared to those who underwent appendectomy within 16 hours of presentation. Within these groups, there were no significant differences in rates of organ space surgical site infections or readmission rates. Conversely, a large multiinstitutional study across 16 NSQIP-Pediatric hospitals demonstrated that institutions in the longest quartile of time to appendectomy had significantly longer lengths of stay and higher average total costs compared to institutions in the shortest quartile of time to appendectomy. Given these results, when patients/families decide to pursue operative management or nonoperative measures fail, while immediate/emergent appendectomy confers no benefit, appendectomy should be performed earlier to minimize complications associated with appendiceal perforation and its associated increase in healthcare resource utilization.
Nonoperative Management
In the past decade, there has been mounting evidence demonstrating that NOM is safe and effective for uncomplicated acute appendicitis in children. This management paradigm has seen a major momentum shift in the treatment of appendicitis in both the adult and pediatric populations. This strategy was initially demonstrated in adult studies, which have shown fewer complications, better pain control, and shorter sick leave. , Within pediatrics, there are now multiple meta-analyses reporting overall treatment success rates ranging from 60%–90% and no increase in treatment-associated complications with an initial NOM strategy compared to surgery. The most recent meta-analysis involving 5727 children across 21 studies demonstrated that 8% of patients had early failure and underwent appendectomy during their initial hospital stay, and 16% of patients eventually underwent appendectomy after discharge. There was no statistically significant difference in length of stay between nonoperative and operative management groups across multiple studies. Additional studies evaluated total hospital stay and hospital readmission and demonstrated no differences between groups. A multiinstitutional meta-analysis of randomized clinical trials and prospective clinical controlled trials investigated NOM of 404 cases of pediatric appendicitis and found that 168 patients underwent NOM, with a pooled analysis demonstrating that 11 (6.5%) patients had early failure of NOM. Of the 157 patients with early success, 5 (3.2%) patients had late failure (more than 1 month from symptoms), resulting in an overall treatment success rate of 90.5%. One of the key takeaways from this study was that the presence of an appendicolith was associated with increased risk of treatment failure, with a risk ratio of 10.43 (95% CI 1.36–74.26). The increased risk of failure due to the presence of an appendicolith has been replicated in additional studies, making it one of the most common exclusion criteria for consideration of NOM. Additional studies have demonstrated that factors such as rebound tenderness, muscle guarding, appendiceal diameter >9 mm, intraluminal appendiceal fluid, higher pain scores, and longer duration of pain are significantly associated with recurrence. , ,
One of the largest prospective clinical trials investigating NOM of pediatric appendicitis to date included 1068 children from 7–17 years of age across 10 tertiary children’s hospitals. Nonoperative management consisted of hospital admission with minimum of 24 hours of intravenous antibiotics and observation with home oral antibiotics for a total course of 7 days of therapy. Of the 370 patients who underwent initial NOM, 53 (14.3%) patients had early treatment failure and required appendectomy during their initial hospitalization. Of the 317 patients with early treatment success, 72 (22.7%) had late treatment failures requiring appendectomy. Once the study was adjusted for factors such as baseline patient socioeconomic status, demographics, and clinical characteristics, the overall success rate of NOM at 1 year was 67.1%. The study also found that NOM was associated with significantly fewer patient and caregiver disability days compared to surgery, both at 30 days and 1 year. Higher quality-of-life scores at 30 days were also noted in the NOM group. Given the results of this study and the previous evidence demonstrating the safety and efficacy of NOM of pediatric appendicitis, there are many that advocate for a patient/family-centered, shared decision-making approach to choosing between treatment options for uncomplicated appendicitis. Using this approach, patients and their families are empowered to make a treatment decision that is aligned with their unique priorities and values based on the different risks and benefits associated with surgery (i.e., higher disability days, postoperative pain, risk of postoperative complications) as compared to NOM (i.e., risk of early treatment failure or subsequent recurrence) with antibiotics alone.
Complicated Appendicitis
Complicated appendicitis can be defined as appendicitis with either a grossly identifiable hole in the appendix, a fecalith in the abdomen, or the presence of a well-formed abscess or frank pus in the abdomen. Complicated appendicitis is observed in about 30% of hospital admissions for appendicitis and is associated with increased morbidity and an increase in resource utilization, with a three-fold increase in length of stay and a 50% increase in total cost. Complicated appendicitis can be managed in one of three ways: antibiotics alone, antibiotics and subsequent interval appendectomy, and early appendectomy at the time of initial presentation.
The use of antibiotics alone has remained controversial due to the risk of incidental pathologic findings and the uncertain rate of recurrence. Regarding pathologic findings, a recent study investigating histopathologic findings in 149 children who underwent interval appendectomy 6–8 weeks after initial presentation found no neoplasms; however, there was persistent inflammation on histopathology. A recent pooled systematic review and meta-analysis found that the overall incidence of carcinoid tumor was 0.9%. One major question is the risk of recurrent appendicitis without interval appendectomy. The same meta-analysis cited an incidence of recurrent appendicitis from 0% to 42%, with an overall pooled risk of 20.5%. However, there is a paucity of data comparing antibiotics alone and antibiotics with interval appendectomy. Based on the available data, a shared decision-making process with the patient and their caregiver about interval appendectomy should be performed that allows them to evaluate the risks and benefits of interval appendectomy versus the approximately 20% risk of developing recurrent appendicitis.
There is currently a lack of rigorous prospective data comparing the effectiveness of antibiotics with subsequent interval appendectomy and early appendectomy at the time of initial presentation. The rationale for treating initially with antibiotics is to avoid a challenging operation during the peak inflammatory response. This remains a difficult clinical scenario for the surgeon as many factors are involved. Previous studies report heterogeneous results likely due to the wide variety of characteristics and range of disease severity in the presentation of complicated appendicitis. Overall, complicated appendicitis can be categorized into two main groups: perforation without abscess/phlegmon and perforation with abscess/phlegmon. These categories can help guide management strategies. A recent systematic review and meta-analysis investigated NOM of complicated pediatric appendicitis and specifically stratified the results by disease category (presence of abscess/phlegmon vs. no abscess or phlegmon [“free perforated”]). The study included 1288 patients across 14 studies in the analysis. The authors found that the relative risk (RR) of complications in those with abscess/phlegmon undergoing initial NOM versus early appendectomy was 0.7. Conversely, the RR of complications in those with free perforated appendicitis undergoing initial NOM versus early appendectomy was 1.56. Similarly, readmission rates were favorable to initial NOM in the abscess/phlegmon group (RR 0.35) and favorable to surgery in the free perforated appendicitis group (RR 1.49). Within this analysis, the overall pooled success rate of initial NOM was 90%. The authors also evaluated cost of nonoperative management versus surgery and did not demonstrate a statistically significant difference. They concluded that children presenting with complicated appendicitis with abscess/phlegmon have better outcomes with initial NOM and interval appendectomy whereas those presenting with free perforation without abscess/phlegmon have better outcomes with early appendectomy during initial hospitalization. Despite recommendations such as this, there are many factors involved in the decision making for upfront surgery compared to nonoperative management. Factors such as number of days of pain, size of abscesses, and specific imaging characteristics are all considered during the decision-making process.
Another important aspect to the approach to complicated appendicitis with a well-formed abscess is the decision to pursue image-guided drainage procedures ( Fig. 40.4 ). With the advancement in radiological imaging and interventional capabilities, the risk of percutaneous drainage or aspiration is now very low. Although it has become common practice to percutaneously drain well-formed abscesses, controversy exists regarding the necessity of drainage procedures compared to antibiotics alone. In one study, there was no benefit to drain placement. This is also an active area of research in the treatment of postoperative fluid collections related to complicated appendicitis.
This young child presented with an 8-day history consistent with perforated appendicitis. A CT scan was performed at an outside hospital that showed marked inflammation of the pelvis and a well-defined abscess ( asterisk ). The patient had initial percutaneous drainage followed by antibiotics. He underwent laparoscopic interval appendectomy 8 weeks later and was discharged that afternoon.
Summary
With an increased focus on patient-centered treatment options within the healthcare system, the management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms. Despite being one of the most studied disease processes in pediatric surgery, the diagnostic workup and management strategies continue to vary among providers and institutions. Current evidence can be used to develop standardized institution-specific diagnostic and treatment algorithms based on available resources with the ultimate goal of decreasing rates of missed diagnosis and promoting patient-centered care that can minimize disability, complications, and healthcare resource utilization.
References
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