Nonoperative Management of Periappendiceal Abscess in Children: a Comparison of Antibiotics Alone Versus Antibiotics plus Percutaneous Drainage

Abstract Purpose To determine the optimal nonoperative management of periappendiceal abscess in a pediatric population, we compared the therapeutic efficacy and cost-effectiveness of antibiotics alone versus antibiotics plus percutaneous drainage (PD). Methods We conducted a 10-year retrospective chart review of pediatric patients less than 18 years of age who had acute perforated appendicitis complicated by periappendiceal abscess. Group 1 consisted of patients (N = 35) who received nonoperative management with antibiotics only. Group 2 consisted of patients (N = 11) who underwent PD and also received antibiotics. Group 1 was subdivided into groups 1A and 1B. Group 1A consisted of patients (N = 25) who responded to antibiotics treatment. Group 1B consisted of patients (N = 10) who were initially treated with antibiotics but subsequently required PD. Patients' demographics, initial clinical presentation, abscess size and location, length of hospital stay, outcome, and complications were compared among these groups. Results Median hospital stay of group 1A and group 2 was identical at 6 days. Group 1B had a significantly longer median hospital stay of 13 days. There were no deaths and no significant long-term complications in any group. One patient in group 1A returned to the emergency room (ER) for abdominal pain and was readmitted for observation. Four patients in group 1B returned to the ER shortly after discharge and required readmission. One of these 4 patients developed acute pancreatitis in addition to enlarging abscess and underwent surgical drainage. There were no documented failures or complications of treatment in group 2 prior to interval appendectomy with the exception of 1 patient lost to follow-up. The presence of small bowel obstruction at the time of admission was an independent predictor of increased length of stay. Conclusions Antibiotic therapy alone can be effective in a majority of patients and is recommended as initial management. To prevent potential complications and increased cost, PD should not be delayed if clinical symptoms persist or the abscess remains unchanged. Reimaging 6 days after initiation of antibiotic therapy with ultrasound or MRI is recommended to identify patients who would progress on antibiotics alone or who need to receive drainage without delay. Level of evidence Level III.