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Kids reporting higher levels of appendicitis pain at presentation were more likely to struggle with a non-operative approach during hospitalization, a secondary analysis of a prospective study found.

Among 370 pediatric patients with uncomplicated appendicitis, those who reported pain levels of 7 to 10 at presentation had a greater risk of non-operative treatment failure while hospitalized (RR 2.1, 95% CI 1.0-4.4), reported Peter Minneci, MD, MHSc, of the Nationwide Children's Hospital in Columbus, Ohio, and colleagues.

However, these kids with higher pain levels did not have greater risk for delayed treatment failure (RR 1.3, 95% CI 0.7-2.3) or overall failed treatment at 1 year (RR 1.50, 95% CI 0.97-2.22), according to the findings in .

Pain lasting over 24 hours at presentation was linked to a lower risk for delayed treatment failure, meaning from discharge through 1 year (RR 0.3, 95% CI 0.1-1.0), although this characteristic was not linked to treatment failure during hospitalization or at 1 year.

Previously reported showed that two-thirds of patients with uncomplicated acute appendicitis who elected non-operative management with antibiotics had success at 1 year, and these patients had fewer days lost to disability compared with those electing surgery initially. Overall, 125 of the patients experienced treatment failure at 1 year, with 14% undergoing appendectomy during initial hospitalization and 20% between discharge and 1 year. The median time to recurrence was 2 months.

Demographics, insurance, white blood cell (WBC) count, transfer status, primary language, imaging results, or symptoms at presentation were not associated with risk for treatment failure.

Patients were slightly more satisfied with their decision after experiencing successful nonoperative management compared with those whose treatment failed, at both 30 days (28.0 vs 27.0, respectively, out of 30) and 1 year (28.1 vs 27.0).

"Although the finding was not statistically significant, patients who underwent ultrasonography alone were more than twice as likely to have in-hospital treatment failure as those who underwent a computed tomography scan," noted Rebecca Rentea, MD, MS, of the Children's Mercy Hospital in Kansas City, and Shawn St. Peter, MD, of the University of Missouri-Kansas City, in an .

"Nonoperative management of appendicitis relies on good visualization of the appendix to assess treatment eligibility. Ultrasonography is operator dependent and can produce a lack of visualization even in experienced hands," added Rentea and St. Peter.

No differences in the study were seen between healthcare satisfaction and health-related quality of life at 30 days and 1 year, which were both high regardless of outcome, but the editorialists noted that this may not be all that surprising due to "choice-supportive bias, whereby a person remembers their choice as better than it was simply because it was the one to which they had committed."

Appendicitis remains the most common cause of emergency intra-abdominal surgery among children, the study authors pointed out. While trials have suggested that antibiotics are a reasonable alternative to appendectomy in certain cases, nearly 25% of acute appendicitis patients on antibiotics end up needing an appendectomy within a year.

For their new study, Minneci and colleagues examined data on 370 children (ages 7 to 17 years) who from May 2015 to October 2018 had selected non-operative management with antibiotics for their uncomplicated appendicitis. The patients came from a larger non-randomized controlled trial conducted at 10 hospitals in the Midwest Pediatric Surgery Consortium.

Overall, 62% were boys, and the median age was 12. Follow-up occurred for 1 year, with an 89% completion rate. Those who had image-confirmed appendicitis with an appendix of 1.1 cm or below, a WBC count of 5,000 cells/μL to 18,000 cells/μL, and an onset of pain within 48 hours of antibiotic initiation were included.

Rentea and St. Peter noted that limitations to the study "included prehospital factors that were associated with treatment choice. Patients choosing surgery were more likely to have been transferred from another institution, suggesting that surgical preference may have been seeded at the presenting facility."

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