Non-operative Treatment of Acute Non-perforated Appendicitis
Non-operative Treatment of Acute Non-perforated Appendicitis
Gold Standard treatment of appendicitis is appendectomy but non-operative treatment of
 non-perforated appendicitis with antibiotics is also under trial. Although appendectomy is
 curative but it is an invasive procedure done under general anesthesia with different risks
 and complications during and after operation, leading to disturbance of child daily routines
 and activities. Reported rates of perioperative complications are from 5% - 10%, with serious
 complications occurring in 1% to 7% of patients.

 Children presenting with acute (<2 days) right iliac fossa pain with pediatric appendicitis
 score >7, with none of the following on ultrasonography: abscess formation, or loss of the
 echogenic sub-mucosal layer of the appendix or presence of an appendicolith or
 periappendiceal fluid collection will be labeled as having appendicitis.

 After diagnosis we divided the patients into two groups.patients in group A will be treated
 with antibiotics and appendectomy is done for group B patients.
Acute appendicitis is one of the most common presenting conditions in pediatric emergencies.
 It has an estimated lifetime risk of about 8%. Although it commonly occurs in the second
 decade of life but 11.4% children are diagnosed with acute appendicitis in the pediatric
 emergency.

 The rationale of my study is that limited local clinical trial is available regarding the
 efficacy of non-operative treatment with antibiotics vs operative treatment of acute
 non-perforated appendicitis in children.

 All children between 5 and 15 years of age of both genders admitted in the pediatric surgery
 emergency with having pediatric appendicitis score (PAS anexure 1) >7 will be included in the
 study.

 All the patients inducted in the study will be randomly divided into two groups:
 Non-operative treatment (group A) and operative treatment (group B), using computer generated
 number. Each patient will be evaluated and relevant data according to the predesigned
 questionnaire will be collected and documented. Age, duration of symptoms, body
 temperature,C-reactive protein, white blood cell, neutrophil concentrations, Ultrasound
 findings and PAS score will be noted at the time of admission. Children in non-operative
 treatment group will be given intravenous meropenem (10 mg/kg/dose x IV x TDS) and
 metronidazole (20 mg/kg/day divided into 3 doses) for at least 48 hours. Once the child
 starts tolerating oral intake and becomes clinically improved, the treatment will be changed
 to oral ciprofloxacin (20 mg/kg/day divided into 2 divided doses) and metronidazole (20 mg/kg
 × 1 per 24 hours) for another 8 days. Supportive care will be given equally to all the
 patients as protocol of treatment with regular vital monitoring. Improvement or development
 of complications will be noted. Discharge criteria for both groups will be: afebrile for 24
 hours, with or without oral antibiotics, adequate pain relief on oral analgesia assesd by
 visual analogue scale ( VAS) scale (anexure 2), tolerating a light diet, and mobile.

 Failure of non-operative treatment will be defined if any one of the following is seen:
 abscess formation or complex peri-appendiceal fluid collection seen on ultrasonography, the
 need for surgery (due to worsening of symptoms evaulated by history, physical examination and
 repeat ultrasonography) within 48 hours, or recurrence of appendicitis within 3 months.

 Patients with recurrence of symptoms of appendicitis (right iliac fossa pain with pediatric
 appendicitis score >7) after complete resolution previously with non-operated treatment, will
 be labeled as Recurrent appendicitis.All the data will be collected on a preformed
 questionnaire. Discharge criteria for both the groups will be: afebrile for 24 hours, with or
 without oral antibiotics, adequate pain relief on oral analgesia and tolerating a light diet.
 Patient will be kept on follow-up in group-A for duration of 3 month to 6 month. Patients
 will be kept on follow-up in Outdoor patients department once in a week till 3 months in
 group B.

 ANNEXURE 1: Pediatric Appendicitis Score (PAS)

 No Symptoms Score

 1. Right iliac fossa tenderness to cough, percussion, or hopping 2

 2. Migration of pain to Right iliac fossa 1

 3. Anorexia 1

 4. Fever (Temperature ≥38.0ºC/100.4ºF) 1

 5. Nausea or vomiting 1

 6. Tenderness over right iliac fossa 2

 7. Leukocytosis (WBC >10,000 ) 1

 8. Left shift (PMN >7,500 ) 1

 Acute Appendicitis if score is >7

 Anexure 2 Visual Analogue Scale

 0 = Relaxed and comfortable 1-3 = Mild discomfort 4-6 =Moderate pain 7-10 =Severe discomfort
 or pain or both
Inclusion Criteria:

 • All children between 5 and 15 years of age of both genders admitted in the pediatric
 surgery emergency with having PAS score >7will be included in the study.

 Exclusion Criteria:

 -  Patient with suspicion of perforated appendicitis on the basis of generalized
 peritonitis and abscess formation on ultrasound.

 -  Patients with an appendicular mass, diagnosed by clinical examination and
 ultrasonography.

 -  Patient with previous non-operative treatment of acute appendicitis (recurrent
 appendicitis)

 -  Patients with C-reactive proteins > 40 mg/L.

 -  Patients with history of any previous abdominal surgery.