Appendicitis Algorithm

Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
APPENDICITIS, SUSPECTED
• Algorithm for Suspected Appendicitis
• Notes
• References
Algorithm for Suspected Appendicitis

Suspected Stabilise
appendicitis Prepare for OT
(no mass) Book, Consent
IV Cefoxitin
No ? perforation
30mg/kg
(1g max) q8h
Yes
Appendicectomy IV amoxycillin 25 mg/kg (max 1g) q8h

Open or IV Gentamicin* – once daily dose
Laparascopic IV metronidazole 7.5 mg/kg (max
(see notes) 500mg) q8h
Normal / Simple Suppurative Gangrenous / Perforated
No further antibiotics Cefoxitin 24-48 hours Triple antibiotics

3-5 days
Clinically
well & Investigate as
No
taking full per consultant
diet?
Yes
Discharge
No school 1 week
No sports 1 week (laparascopic), 2 weeks (open)
Follow-up as per consultant
Author: Dr Bhavesh Patel, Dr James Hamill Service: Paediatric Surgery

Editor: Dr Raewyn Gavin Date Issued: October 2005
Appendicitis, Suspected Page:
Gentamicin*
Given as a once daily dose - refer to current Paediatric Aminoglycoside and Vancomycin
Guidelines for further information on dosing and required monitoring of peak and trough levels
(pharmacy intranet site or www.rch.org.au/pharmacopoeia).
Notes
Laparoscopic versus open appendicectomy
The literature is still controversial, and most recent studies do not show significant differences
between the two for length of stay, pain relief, complications and return to normal activity. The
decision to be made by surgeon and patient depending on consultant, timing of operation and skill
level of surgeon. Laparoscopy would be preferable for female patients with diagnostic uncertainty
and for children who would have better access laparoscopically (i.e. obese). Internal audit (Nov 03
– Jun 04 suggests better outcome with laparoscopy in terms of length of stay and complications).
Overnight delay
Studies show no significant morbidity or complications from waiting overnight for appendicectomy.
Appendiceal Mass
Again controversial, but most papers advocate conservative management with broad spectrum
antibiotics and interval appendicectomy. Incidence of ~16-40% will fail conservative management
and require drainage or operation earlier than the booked interval appendicectomy. It is unknown
which patients will be likely to be in this group, therefore interval appendicectomy is still
recommended.
This is only a guideline – this is NOT to be used as a protocol. Procedures and

practice may change based on consultant and patient.
References
1. Emil S, Laberge JM, Mikhail P, et al: Appendicitis in children: a ten-year update of therapeutic
recommendations. J Pediatr Surg. 2003 Feb; 38(2): 236-42
2. Andersen BR, Kallehave FL, Andersen HK: Antibiotics versus placebo for prevention of postoperative
infection after appendicectomy. (Cochrane Review). In: The Cochrane Library, Issue 2, 2004.
Chichester, UK: John Wiley & Sons, Ltd.
3. Meguerditchian A, Prasil P, Cloutier R et al: Laparoscopic appendectomy in children: A favourable

alternative in simple and complicate appendicitis. J Pediatr Surg. 2002 May; 37(5): 695-698.
4. Little DC, Custer MD, May BH et al: Laparoscopic appendectomy: an unnecessary and expensive
procedure in children? J Pediatr Surg. 2002 March; 37(3): 310-317.
5. Lau WY, Fan ST, Chu KW et al: Cefoxitin versus gentamicin and metronidazole in prevention of post-
appendicectomy sepsis: a randomized, prospective trial. Journal of antimicrobial chemotherapy. 1986
Nov;18(5): 613-9.
6. Samuel M, Hosie G, Holmes K: Prospective evaluation of nonsurgical versus surgical management of

appeniceal mass. J Pediatr Surg 2002 Jun; 37(6): 882-886.
7. Gahukamble DB, Gahukamble LD: Surgical and pathological basis for interval appendicectomy after
resolution of appendicular mass in children. J Pediatr Surg 2000 Mar; 35(3): 424-427
8. Gillick J, Velayudham M, Puri P: Conservative management of appendix mass in children. Br J Surg

2001, 88: 1539-1542.
9. Elridge B, Kimber C, Wolfe R et al: Uptime as a measure of recovery in children postappendectomy. J

Pediatr Surg 2003 Dec; 38(12): 1822-1825.


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Starship Children’s Health Clinical Guideline

Algorithm for Suspected Appendicitis

Appendicectomy IV amoxycillin 25 mg/kg (max 1g) q8h

Normal / Simple Suppurative Gangrenous / Perforated

No further antibiotics Cefoxitin 24-48 hours Triple antibiotics

Author: Dr Bhavesh Patel, Dr James Hamill Service: Paediatric Surgery

This is only a guideline – this is NOT to be used as a protocol. Procedures and

3. Meguerditchian A, Prasil P, Cloutier R et al: Laparoscopic appendectomy in children: A favourable

6. Samuel M, Hosie G, Holmes K: Prospective evaluation of nonsurgical versus surgical management of

8. Gillick J, Velayudham M, Puri P: Conservative management of appendix mass in children. Br J Surg

9. Elridge B, Kimber C, Wolfe R et al: Uptime as a measure of recovery in children postappendectomy. J

Author: Dr Bhavesh Patel, Dr James Hamill Service: Paediatric Surgery

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