Acute appendicitis is one of the most common reasons for performing emergency surgery in children. However, surgery can be costly and very unsettling for young patients and their families. Now, a fresh review of published evidence finds treatment with antibiotics could be an effective and safe alternative.

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The current gold standard treatment worldwide for appendicitis is appendectomy – a surgical procedure that removes the inflamed appendix.

However, the researchers say larger, randomized trials need to confirm this finding before clinical recommendations can be made.

The study – led by the University of Southampton in the United Kingdom – is published in the journal Pediatrics.

Appendicitis is inflammation of the appendix – a finger-like tube of tissue attached to the large intestine. The condition can strike at any age but mostly occurs in children, teenagers, and young adults.

There are several causes of appendicitis, and in many cases the exact cause is not clear. The condition can result from infection in the gut or other part of the body that causes the tissue in the wall of the appendix to swell.

Other causes of appendicitis include: inflammatory bowel disease; blockage caused by stools, parasites, or growths; abdominal injury; and blockage of the opening inside the appendix.

The current gold standard treatment worldwide for appendicitis is appendectomy – a surgical procedure that removes the inflamed appendix. It is the most common emergency surgery in children.

Fast facts about appendicitis
  • Over 5 percent of people in the United States develop appendicitis at some point.
  • The condition is the most common cause of acute abdominal pain requiring surgery in the U.S.
  • If not treated, appendicitis can lead to serious complications such as peritonitis.

Learn more about appendicitis

However, the surgery is invasive and costly, “not to mention extremely daunting for the child concerned and their family,” says Nigel Hall, associate professor of pediatric surgery at Southampton and senior author of the study.

Prof. Hall and colleagues assessed published evidence from the past 10 years in studies of children receiving non-operative treatment – that is, antibiotics – as an alternative to appendectomy.

Ten studies covering a total of 413 children met the criteria for assessment. None of them reported safety concerns or specific adverse events.

The review also found that appendicitis recurred in 14 percent of cases after non-surgical treatment.

“Our review shows that antibiotics could be an alternative treatment method for children,” says Prof. Hall.

However, he and his colleagues also concluded that more robust research – in the form of large, randomized trials – is now needed to evaluate the long-term clinical outcomes and cost-effectiveness of antibiotics versus surgery for the treatment of appendicitis in children.

The team at Southampton – along with colleagues in several other U.K. hospitals – are already conducting a 1-year feasibility trial where children with appendicitis are randomly assigned to receive surgery or antibiotics.

The point of the initial trial is to see how many patients and their families are willing to take part in such a study, and how well the patients recover.

“This will give us an indication of how many children we may be able to recruit into a future larger trial and how the outcomes of non-operative treatment compare with an operation,” Prof. Hall explains.

The overall pioneering study of which the feasibility trial forms a part is called the CONservative TReatment of Appendicitis in Children a randomized controlled Trial (CONTRACT) and is funded by the National Institute for Health Research (NIHR).

When we compared the adult literature to the data in our review it suggested that antibiotic treatment of acute appendicitis is at least as effective in children as in adults. This now needs to be explored more widely.”

Prof. Nigel Hall

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