Nonoperative management of perforated appendicitis in children: can CT predict outcome?

Background The optimal treatment of perforated appendicitis remains controversial, but there is a trend toward nonoperative management. CT scanning might be helpful in determining which patients could benefit from this treatment option. Objective To determine the value of CT imaging in predicting clinical success or failure in children with nonoperative management of perforated appendicitis. Materials and methods Admission CT scans of 34 children with perforated appendicitis treated nonoperatively between January 2003 and June 2006 were retrospectively reviewed. All children were given intravenous antibiotics. Clinical outcome was correlated with imaging findings including the maximal area, number and complexity of collections, presence of an appendicolith or extraluminal air, and extent of intra-abdominal disease outside the right lower quadrant. Patients with an accessible simple collection were drained if their clinical condition did not improve. Results Successful nonoperative management was achieved in 20 patients; 14 patients failed nonoperative therapy. The presence of collections in three or more sectors (defined as the pelvis and four abdominal quadrants) correlated strongly with clinical failure (P<0.05), while there was no correlation found between clinical outcome and the presence of an appendicolith, extraluminal air, distant ascites, and collection size or complexity. Conclusion In the nonoperative management of children with perforated appendicitis, admission CT findings demonstrating disease beyond the right lower quadrant correlate with treatment failure.