Acute appendicitis in children: Reexamining indications for conservative treatment – A large prospective analysis

Published:December 17, 2021DOI:


      • What is currently known about this topic?
      • Pediatric trials have shown that conservative antibiotic treatment for acute uncomplicated appendicitis is a viable option.
      • What new information is contained in this article?
      • Conservative antibiotic treatment in uncomplicated appendicitis in children should consider older age, larger outer appendiceal diameter and high WBC counts as risk-factors for recurrent appendicitis and subsequent appendectomy.



      Conservative antibiotic treatment (CAT) for uncomplicated acute appendicitis (AUA) in children has been proven safe and efficacious. However, as data accumulate, high rates of recurrent appendicitis and subsequent appendectomy have been reported. This prospective longitudinal study evaluated risk-factors for recurrent AUA after CAT in a large cohort, with long-term follow-up.

      Materials and methods

      Children ages 5 to 16 years admitted to the Department of Pediatric Surgery from 2014 through 2018, diagnosed with AUA were eligible for CAT. We recorded their age, appendix outer diameter, white blood cell counts, C-reactive protein and other related signs and symptoms associated with AUA. Clinical and ultrasonographic follow-up was carried out until follow-up data collection ceased according to the study design (2014–2019).


      The cohort included 646 children who were initially treated successfully with CAT. Among them, 180 (28%) were readmitted for recurrent acute appendicitis during the follow-up period and 138 (21%) eventually had appendectomy. Overall success of 79% for CAT was recorded in this cohort. A multivariable model including; age, sex, appendiceal diameter, WBC and CRP, found the factors of older age, larger outer appendiceal diameter and high WBC counts significantly related to appendectomy during the follow-up period. We offer a decision tree model to predict appendectomy probabilities for patients based on their prognostic measurements.


      CAT in AUA in children should consider older age, larger outer appendiceal diameter and high WBC counts as risk-factors for recurrent AUA and subsequent appendectomy. The proposed decision tree model may help both clinicians and parents before CAT is chosen.

      Level of evidence

      Level 2



      AUA (uncomplicated acute appendicitis), CAT (Conservative antibiotic treatment), IQR (interquartile range)
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