EBM Review Series: Treatment Options for Pediatric Appendicitis
VACEP Evidence-Based Medicine for General Emergency Physicians Series
Authors: Peter Victoria, MD & Joshua Easter, MD, MSc, MHA, MBA | UVA Health
Reviewers: Enjana Bylykbashi, MD & Emily Kershner, MD | VCU Health
Editor: Winston Wu, MD | Virginia Tech Carilion School of Medicine
The VACEP Evidence-Based Medicine Review Series allows Virginia emergency medicine residents and attendings to share and analyze a recent peer-reviewed clinical study. You can also read the full article, “Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis” from the Injury Journal, Volume 180 Issue 1.
THE CASE
A 12-year-old boy presents to your ED with his parents for abdominal pain. The pain began around the umbilicus yesterday and has since migrated to the right lower quadrant. He has had a decreased appetite, low-grade fever, and one episode of non-bilious vomiting. On arrival, his vital signs are: temperature 38.2 °C, heart rate 108, blood pressure 104/68, respiratory rate 18, and oxygen saturation 99% on room air. He appears mildly uncomfortable but alert. Abdominal exam reveals focal RLQ tenderness with voluntary guarding. Ultrasound demonstrates uncomplicated appendicitis without evidence of abscess. The family prefers to avoid surgery and asks if antibiotics alone are a reasonable alternative.
Should this patient be offered nonoperative management?
BACKGROUND
Acute appendicitis remains one of the most common surgical emergencies in children and has traditionally been managed with prompt appendectomy. In recent years, nonoperative management (NOM) with antibiotics has gained attention as a potential alternative to appendectomy for acute uncomplicated appendicitis in children. Early studies suggested that NOM may be safe in the short-term and could lead to decreased recovery time and avoidance of surgery (Leite, 2022) These findings paralleled increasing acceptance of NOM of appendicitis in adults.
Despite these findings, concerns remain regarding the long-term treatment durability, risk of recurrence, and whether complications from delayed surgery may be more severe. As practice patterns shift toward shared decision making with families, an updated synthesis of the highest quality evidence is needed. The authors of this study sought to address these gaps with an updated meta-analysis incorporating newer data by evaluating randomized clinical trials (RCTs) comparing NOM with appendectomy in pediatric patients. Their goal was to determine if antibiotics alone are equivalent to appendectomy in terms of treatment success, complications, and meaningful functional outcomes in children.
Faria et al. systematically reviewed and analyzed RCTs comparing NOM to appendectomy for pediatric acute uncomplicated appendicitis (Faria, 2025). Nonrandomized or quasi-randomized studies were excluded to ensure the highest level of evidence. Data extraction followed Cochrane Handbook for Systematic Reviews of Interventions and PRISMA guidelines. The primary outcomes were treatment failure within one year, treatment success within one year, and major complications as defined by a Clavien-Dindo classification of IIIb or greater. Treatment failure in the NOM group was defined as need for intervention within 48 hours, recurrence of symptoms consistent with appendicitis, or need for appendectomy. Meanwhile, a negative appendectomy indicated failure in the operative group. Treatment success in the NOM group was defined as discharge without undergoing appendectomy, while success in the operative group was defined as absence of a negative appendectomy. Secondary outcomes included time to return to school and normal activities, length of stay, appendicitis recurrence, readmissions, mortality, and hospital expenses. Risk ratios (RRs) were used to assess treatment efficacy for categorical outcomes, while continuous variables were analyzed using mean differences.
They identified seven RCTs assessing 1,480 pediatric patients younger than 18 years old with uncomplicated appendicitis, Children managed with antibiotics alone had nearly five times the risk of treatment failure (RR 5.0; 95% CI 3.6–6.9) and significantly lower treatment success (RR 0.67; 95% CI 0.60–0.75). Major complications were rare but occurred much more frequently among NOM patients (RR 33; 95% CI 8–141). Recurrence of appendicitis after NOM was common, arising at a rate of 18.5 events per 100 patients. Despite these increased risks, NOM offered modest short-term advantages, including a faster return to school (mean difference –1.4 days; 95% CI −2.64 to −0.1) and quicker return to normal activity (–4.9 days; 95% CI −8.7 to −1.2), though these early benefits may be offset by later readmissions or delayed appendectomy.
A major strength of this meta-analysis is its inclusion of only randomized clinical trials, providing the highest-quality evidence to date on pediatric NOM of appendicitis. The sample size is also substantially larger than earlier analyses. The use of trial sequential analysis adds further rigor by assessing whether the accumulated evidence is sufficient to draw firm conclusions. Finally, the authors included some functional, patient-centered outcomes such as return to school which are highly relevant to both families and pediatric clinicians.
This review has several limitations. First, moderate heterogeneity was noted in secondary outcomes, likely driven by lack of standardized antibiotic regimens, surgical techniques, or follow-up protocols across trials. The lack of standardized antibiotic regimens also prevents practical guidance on the best antibiotic regime. While some patient-centered outcomes are reported in the meta-analysis, other outcomes such as pain and patient or parental satisfaction with each treatment strategy are not reported. The presence of an appendicolith is not studied in this meta-analysis. This is an important factor as adult studies have demonstrated that the presence of an appendicolith is associated with poorer outcomes such as accelerated recurrence in nonoperative patients (Tian, 2025).
This meta-analysis found that NOM in children and adolescents is associated with significantly higher treatment failure, lower treatment success, and substantially increased major complications within one year compared with appendectomy. While it offers slightly quicker return to school and activity, these benefits may be outweighed by the high recurrence and complication rates. Based on these findings, appendectomy remains the more reliable treatment for uncomplicated appendicitis in pediatric patients.
When discussing treatment options with your patient and his family, they again voice their concerns about surgery. However, upon hearing the increased risks associated with this approach, they agree to surgery. The patient goes to the OR with pediatric surgery and undergoes an uneventful laparoscopic appendectomy.Shock index (SI), defined as heart rate (HR) divided by systolic blood pressure (SBP), was first described in 1967 as an approximation of hemodynamic status. Currently, shock index can be used as a prediction tool and risk stratification to help determine critically ill patients from a variety of medical causes. There are now several variations of shock index including the original SI (HR/SBP), modified SI (HR/mean arterial pressure), Age SI (age x HR/SBP), and shock index pediatric adjust (SIPA) (Koch, 2019). Shock indices have been used to help guide care in the pre-hospital setting, triage, and in-hospital management of patients.
There is a significant amount of literature on using shock index as a predictive tool in trauma. Prior studies have found that an abnormal shock index is associated with increased mortality, hospital length of stay (LOS), injury severity score (ISS > 16), intensive care unit (ICU) admission rate, and incidence of blood transfusion (Cannon, 2009; Bruijns 2013; Liao, 2024). However, these studies all included patients who were frankly hypotensive (SBP < 90), and so the findings may have been influenced by the patients that were in obvious shock. The authors of our paper sought to focus on individuals potentially in hemorrhagic shock but not hypotensive, in order to determine if shock index was a useful triage tool among these patients (Lin, 2025).
STUDY SUMMARY
This study looked at the utility of SI in identifying trauma patients with compensated shock, using early transfusion as a surrogate marker for shock. The authors hypothesized that an abnormal SI (> 0.7) in non-hypotensive (SBP > 90) trauma patients would be associated with early blood transfusion (Lin 2025). This was a retrospective study, performed at a Level 1 trauma center from January 2016 - March 2023. Patient demographics, injury characteristics, vitals upon hospital arrival, blood products administered during the first hour following arrival, and hospital disposition were gathered. Exclusion criteria were individuals with a SBP < 90, age < 18, pregnancy, interfacility transfers, and individuals who died within 60 minutes of arrival. SI was calculated by arrival HR divided by arrival SBP. The SI was then stratified into thresholds of: ≤ 0.7, 0.7-0.9, > 0.9 to 1.1, > 1.1 to 1.3, and > 1.3. They used the odds of transfusion within 1 hour of arrival for each SI category with ≤ 0.7 as the referent and calculated using contingency tables from the cross-tabulation function and reported with 95% confidence intervals. P-values < 0.05 were considered statistically significant. Receiver operating characteristic curve (ROC) analysis and the Youden index criteria were used to determine a meaningful SI value to raise clinical concern for early transfusion in the “normotensive” early compensated shock trauma population.
About the EBM Review Series
This is a literature review series started by the University of Virginia’s Josh Easter, MD, MSc, a VACEP board member working to connect the academic community in Virginia. We invite each residency in Virginia (and D.C.) to create a faculty/resident team to submit and review articles. Sign up to submit one.
Goals
Provide a brief monthly synopsis of a high yield article germane to the practice of emergency medicine for distribution to all VACEP members
Provide an opportunity for a peer reviewed publication and invited presentation for faculty and trainees
Foster an academic community focused on evidenced based medicine for emergency medicine residency programs in the region
PEER REVIEW Q&A
Question: What was the average follow-up period? This can be important if they were looking at outcomes in the nonoperative group.
Author response: The follow up period for four of the included RCTs was 12 months and another two RCTs had a follow up period of 6 months. The final included RCT had a follow up period of 14 days after discharge.
Question: You make a point regarding higher treatment failure and lower treatment success. Are these the same thing?
Author response: Treatment success and failure had specific definitions in this study and were not exactly the same. Treatment failure in the NOM group was defined as need for intervention within 48 hours, recurrence of symptoms consistent with appendicitis, or need for appendectomy. Meanwhile, a negative appendectomy indicated failure in the operative group. Treatment success in the NOM group was defined as discharge without undergoing appendectomy, while success in the operative group was defined as absence of a negative appendectomy.
Question: Regarding limitations, you note that the presence of an appendicolith is an important exclusion given that adult studies demonstrated a difference in outcomes in non-operative patients. Our understanding is that these patients are at higher risk of treatment failure due to the obstruction. Is this correct?
Author response: Higher treatment failure in adult patients with an appendicolith is multifactorial but is primarily related to the mechanical obstruction created by the appendicolith. The increased intraluminal pressure created by the obstruction leads to ischemia of the appendiceal wall which decreases the tissue penetration of antibiotics. Additionally, antibiotics alone do not address the obstruction itself which further decreases their efficacy in patients with an appendicolith.
REFERENCES
1. Faria I, Cintra ACG, de Oliveira LGAM, et al. Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis: A Systematic Review and Meta-Analysis. JAMA Pediatr. 2026;180(1):26–34. doi:10.1001/jamapediatrics.2025.4091
2. de Almeida Leite RM, Seo DJ, Gomez-Eslava B, et al. Nonoperative vs Operative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-analysis. JAMA Surg. 2022;157(9):828-834. doi:10.1001/jamasurg.2022.2937
3. Tian J. Appendicolith in non-operative management of acute appendicitis: Implications for recurrence and future directions. World J Clin Cases. 2025;13(28):109664. doi:10.12998/wjcc.v13.i28.109664
