The Presence but not the Location of an Appendicolith Affects the Success of Interval Appendectomy in Children with Ruptured Appendicitis

doi:10.4236/ss.2011.22009

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Surgical Science, 2011, 2, 39-44

doi:10.4236/ss.2011.22009 Published Online April 2011 (http://www.SciRP.org/journal/ss)

The Presence but not the Location of an Appendicolith

Affects the Success of Interval Appendectomy in Children

with Ruptured Appendicitis

Iyore A. James, Stephen Druhan, Donna A. Caniano, Gail E. Besner

Nationwide Children’s Hospital and The Ohio State University College of Medicine

Columbus, OH 43205, USA

E-mail: [email protected]

Received July 20, 2010; revised February 25, 2011; accepted February 28, 2011

Abstract

Purpose: To determine whether the presence and/or location of an appendicolith can predict failure of initial

non-operative management in children with ruptured appendicitis. Methods: A retrospective chart review of

pediatric patients presenting with ruptured appendicitis was performed. Patients in whom the intent to treat

was with initial non-operative management and interval appendectomy (IA) were selected (n = 117). One

patient was excluded due to the presence of both intraluminal and extraluminal appendicoliths. Children who

failed initial non-operative management were assigned to the “failure” group (n = 22). Children that im-

proved and underwent elective IA were assigned to the “success” group (n = 94). Age, gender, duration of

symptoms, presence of an appendicolith, appendicolith location (intraluminal/extraluminal), presence of a

drainable abscess, and complications were reviewed. Results: There was an overall 18.8% failure rate for IA.

Patients with an appendicolith had a 41.7% failure rate, and patients without an appendicolith had a 13%

failure rate (p = 0.003). Patients with intraluminal or extraluminal appendicoliths each had a 41.7% failure

rate. The presence or absence of a drainable intra-abdominal abscess did not affect the failure rate. Children

in the failure group presented to the hospital earlier (6.57 ± 2.59 vs. 10.02 ± 7.21 days; p = 0.030). Conclu-

sions: The presence of an appendicolith increases the likelihood of failure of initial non-operative manage-

ment of ruptured appendicitis in children; however, the location of the appendicolith is not a predictor of

failure.

Keywords: Ruptured Appendicitis, Failure Non-Operative Management, Appendicolith

1. Introduction

The management of ruptured appendicitis in a child that

presents with a relatively indolent course remains a sub-

ject of debate [1]. There is a growing consensus for

treating these patients non-operatively with intravenous

antibiotics and percutaneous drainage of abscess (if

amenable), followed by an interval appendectomy in 6-8

weeks [2-5]. However, the routine performance of inter-

val appendectomy remains controversial [6-8].

Failure rates of initial non-operative approaches for

ruptured appendicitis range from 6%-26% [9-13]. Sev-

eral studies on predictors of failure of non-operative

management have yielded inconsistent results [10-14].

Although some authors report that the presence of an

appendicolith is predictive of failure [10,11] others did

not demonstrate this finding [13,14]. The discrepancy in

these reports may be related to the location of the appen-

dicolith, however, there have been no studies of this re-

ported in the literature. The aim of the current study was

to determine whether the location of an appendicolith

could predict failure of non-operative management in

children with ruptured appendicitis.

2. Methods

The study was approved by the Nationwide Children’s

Hospital Institutional Review Board (Protocol #IRB08-

00317). A search of all pediatric patients presenting to

our institution with ruptured appendicitis between Janu-

ary 1994 and March 2009 was performed on the Nation-

wide Children’s Internal Decision Support Data System.

40 I. A. JAMES ET AL.

A retrospective chart review was conducted for patients

in whom the intent to treat was with initial non-operative

management and subsequent interval appendectomy (IA).

Initial non-operative management consisted of intrave-

nous broad spectrum antibiotic therapy (typically am-

picillin, gentamycin and clindamycin or gentamycin and

clindamycin alone), with or without percutaneous drain-

age of intra-abdominal abscess. When amenable, percu-

taneous drainage of abscess was performed under CT

scan or ultrasound guidance by interventional radiolo-

gists. Patients were typically monitored for 4-5 days to

ensure resolution of symptoms and discharged to home

with intravenous antibiotics through a peripherally in-

serted central venous catheter (PICC). Interval appen-

dectomy was usually performed 4 to 8 weeks later (me-

dian 6 weeks). Patients who had persistent or recurrent

symptoms or who developed frank peritonitis underwent

appendectomy prior to scheduled elective IA, and were

included in the “failure” group (n = 22). Children that

improved upon initiation of therapy and underwent elec-

tive IA were included in the “success” group (n = 94).

Age, gender, duration of symptoms, appendicolith loca-

tion, presence of a drainable abscess on radiographic

imaging (CT scan or ultrasonography), complications,

and pathology reports to confirm the presence of an ap-

pendicolith, were reviewed.

Statistical analysis was performed using the Student t

test and logistic regression with statistical significance

set at p ≤ 0.05.

3. Results

3.1. Patient Selection

A total of 985 patients were admitted with a primary

diagnosis of ruptured appendicitis between January 1994

and March 2009. There were 117 patients in which the

intent to treat was with initial non-operative management

and subsequent interval appendectomy (Figure 1). One

patient in the success group was excluded because both

intraluminal and extraluminal appendicoliths were seen

on CT scan, leaving 116 patients left to study.

3.2. Patient Demographics

The study group consisted of 75 boys and 41 girls with

an age range of 1 to 17 years. The most common pre-

senting symptoms were right lower quadrant pain, fever,

diarrhea, nausea and vomiting. Twenty-two out of 116

patients failed elective IA management giving an overall

failure rate of 18.8%. There was no statistical difference

in the mean age of the success vs. failure groups (10.03 ±

3.90 years vs. 8.59 ± 4.46 years; p-value 0.13). Children

in the failure group were ill (mostly abdominal pain) for

Figure 1. Methodology flowchart. (A review of 985 charts revealed 117 patients in whom the intent was to treat with initial

non-operative management and subsequent interval appendectomy (IA). One patient was excluded from the study because

both intraluminal and extraluminal appendicoliths were identified on radiographic imaging. Twenty-two patients failed con-

ervative management). s

I. A. JAMES ET AL.

a shorter period of time prior to admission compared to

children in the success group (6.57 ± 2.59 days vs. 10.02 ±

7.21 days; p-value 0.03) (Table 1).

3.3. Presence/Location of Appendicolith

All radiology studies (CT scans or ultrasonography) of

the 116 patients that met study criteria were retrospec-

tively reviewed by a single certified radiologist. The ra-

diologist identified 8 patients with intraluminal appendi-

colith and 4 patients with extraluminal appendicolith in

the “failure” group, and 12 patients with intraluminal

appendicolith and 20 patients with extraluminal appen-

dicolith in the “success” group, for a total of 44 patients

with an appendicolith identified. Upon review of the pa-

thology and operative reports of these 116 patients, there

were 5 patients with intraluminal appendicolith and 5

patients with extraluminal appendicolith in the “failure”

group, and there were 7 patients with intraluminal ap-

pendicolith and 7 patients with extraluminal appendico-

lith in the “success” group, for a total of 24 patients with

an appendicolith identified (Table 1). The overall accu-

racy rate for the radiologist identifying any appendicolith

was 79.3% (Table 2), and the overall accuracy rate for

the radiologist identifying the location of the appendico-

lith was 90.5% (Table 3).

Of the 24 patients that had an appendicolith confirmed

on pathology and/or operative reports, 10 patients failed

IA (41.7 % failure rate). Of the 92 patients without an

appendicolith on pathology/operative reports, 12 failed

(13% failure rate). Thus, the presence of an appendico-

lith increases the rate of failure of IA {p = 0.003; (1.73,

13.1 95% CI)} (Table 1). Patients with either an in-

traluminal or extraluminal appendicolith had equal fail-

ure rates of 41.7% (Figure 2).

3.4. Presence of abscess

There were a total of 66 intra-abdominal abscesses that

were amenable to percutaneous drainage by interven-

tional radiology. Of the 66 patients with a drainable in-

tra-abdominal abscess, 14 failed IA (21.2% failure rate).

Of the 50 patients without a drainable abscess present, 8

failed IA (16% failure rate). Thus, the presence or ab-

sence of a drainable intra-abdominal abscess did not af-

fect the failure rate of IA (p = 0.48).

3.5. Complications

There were 4 patients in the failure group that had com-

plications including two patients with wound infection,

one patient with Clostridium difficile colitis after initiation

of antibiotic therapy, and one patient with a sub-hepatic

abscess requiring percutaneous drainage by interven-

tional radiology. There were 3 patients with complica-

tions in the success group, including one patient with a

pelvic abscess that developed after initial percutaneous

drainage of an intra-abdominal abscess requiring a sec-

ond percutaneous drainage by interventional radiology, a

second patient with non-life threatening antibiotic allergy,

and a third patient that developed an enterocutaneous

fistula after initial placement of a percutaneous drain by

interventional radiology that resolved with conservative

management.

Table 1. Demographics of 116 patients in whom the intent

to treat was with initial non-operative management and

subsequent elective interval appendectomy (IA).

Success

94/116

(81.2%)

Failure

22/11

(18.8%)

p-value Odds

ratio

Age (years) 10.03 ± 3.90 8.59 ± 4.46 0.13

Duration of

symptoms (days)10.02 ± 7.21 6.57 ± 2.59 0.03

Appendicolith

(n = 92)

80/92

(87%)

12/92

(13%) 0.003 4.762

Any

Appendicolith

(n = 24)

14/24

(58.3%)

10/24

(41.7%) - -

Extraluminal

Appendicolith

(n = 12)

7/12

(58.3%)

5/12

(41.7%) 1 1

Intraluminal

Appendicolith

(n = 12)

7/12

(58.3%)

5/12

(41.7%) - -

Drainable

Abscess Present

(n = 66)

52/66

(78.8%)

14/66

(21.2%) 0.480 0.708

Drainable Abscess

(n = 50)

42/50

(84%)

8/50

(16%) - -

Complications

(n = 7)

3/7

(42.9%)

4/7

(57.1%) 0.018 0.148

Complications

(n = 109)

91/109

(83.5%)

18/109

(16.5%) - -

Twenty-two of the 116 patients who met eligibility criteria failed this ap-

proach, giving an overall failure rate of 18.8%. Values are reported as mean ±

standard deviation. Children in the failure group were ill for a shorter period

of time prior to admission compared to children in the success group (p =

0.03). Logistic regression was used to test whether the presence and/or the

location of an appendicolith affected the success of initial non-operative

management. Note that the presence and location of appendicoliths in this

table were defined by operative notes and pathology reports. Compared to

patients with any appendicolith, patients with no appendicolith had a sig-

nificantly lower failure rate (13%, p = 0.003). There were equal numbers of

patients with extraluminal appendicoliths (n = 12) and intraluminal appen-

dicoliths (n = 12) in the study population. The failure rate of patients with

either extraluminal or intraluminal appendicoliths was the same (41.7%, p =

1). The incidence of a complication was significantly increased in the “fail-

ure” group compared to the “success” group (p = 0.018).

42 I. A. JAMES ET AL.

Table 2. Accuracy of the radiologist’s ability to diagnose the

presence of an appendicolith.

Operative/Pathology Findings

Radiology Findings (+)

Appendicolith

(-)

Appendicolith

Number of

patients

(+) Appendicolith 22 22 44

(-) Appendicolith 2 70 72

Total 24 92 116

The radiologist’s findings regarding the presence of an appendicolith in

patients presenting with ruptured appendicitis in whom the intent was to

treat with initial non-operative management and subsequent IA have been

correlated with the operative notes/pathology reports. The accuracy of the

radiologist’s ability to diagnose the presence of an appendicolith was 79.3%;

positive predictive value equals 50%; negative predictive value equals

97.2%.

Table 3. Accuracy of the radiologist’s ability to diagnose the

location of an appendicolith.

Operative/Pathology Findings

Radiology Findings Intraluminal

Appendicolith

Extraluminal

Appendicolith

Intraluminal Appendicolith 7 1

Extraluminal Appendicolith 1 12

The radiologist’s findings regarding the location of an appendicolith have

been correlated with the operative notes/pathology reports of the 24 patients

noted to have any appendicolith by pathology/operative reports. Three

patients had intraluminal appendicoliths identified on pathology that were

not identified by the radiologist and thus not included in this table. The

accuracy of the radiologist’s diagnosis of the location of an appendicolith

was 90.5%; positive predictive value equals 87.5%; negative predictive

value equals 92.3%.

4. Discussion

In a hemodynamically stable pediatric patient with rup-

tured appendicitis and no signs of diffuse peritonitis,

conservative management with intravenous antibiotics,

percutaneous drainage of abscess (if amenable), and in-

terval appendectomy in 6-8 weeks is the current pre-

ferred treatment by many [1,15]. Several authors have

reported that the presence of an appendicolith is predic-

tive of failure of initial non-operative management with

elective IA, and that in these patients, immediate surgery

is recommended [10,11]. However, others have reported

no correlation between the presence of an appendicolith

and failure of initial non-operative management [13,14].

To clarify this discrepancy, we sought to investigate our

experience and to determine whether the location of an

appendicolith can influence the success of elective IA

management.

Approximately 26% of the 325 (average) cases of

acute appendicitis diagnosed annually at our institution

Figure 2. Success of IA based on the presence and location

of appendicolith. (There were 24 patients with an appendi-

colith and 92 patients without an appendicolith identified

on either operative or pathology reports. Of the 24 patients

with an appendicolith, 10 failed IA (41.7 % failure rate). Of

the 92 patients without an appendicolith, 12 failed (13%

failure rate). Thus, the presence of an appendicolith in-

creases the rate of failure of IA {*p = 0.003; (1.73, 13.1 95%

CI)} Patients with intraluminal or extraluminal appendico-

liths had equal failure rates of 41.7%).

present with ruptured appendicitis. During the study pe-

riod, 116 patients (~12% of patients presenting with

ruptured appendicitis) were treated with attempted IA.

Ninety-four patients were successfully treated with IA

whereas 22 patients failed conservative management,

representing a failure rate of 18.8%, which is consistent

with previous reports [9]. CT scans and ultrasonography

exhibit similar accuracy for detecting acute appendicitis

[16]. Radiology images (either CT scans or ultrasono-

graphy) of all 116 patients were retrospectively reviewed

by a certified pediatric radiologist to evaluate the pres-

ence and location of an appendicolith. Operative and

pathology reports were reviewed to evaluate the accuracy

of the radiologist’s report. The overall accuracy of the

radiologist identifying the presence and location of an

appendicolith were 79.3% and 90.5% respectively.

In our study, a significantly higher proportion of pa-

tients that failed conservative management had an ap-

pendicolith. We anticipated that the presence of an ex-

traluminal appendicolith might be predictive of failure of

IA based on the following: 1) a retained appendicolith

harbors intestinal bacteria and serves as a nidus for in-

fection, 2) studies have shown that a retained appendico-

lith after appendectomy is associated with a high rate of

intra-abdominal abscess formation [17,18], and 3) ex-

traluminal retained post-operative appendicoliths require

surgical removal to prevent recurrent infections. How-

ever, when the failure rate of IA was examined based on

the location of the appendicolith, patients with either an

I. A. JAMES ET AL.

intraluminal or extraluminal appendicolith had a similar

failure rate of 41.7%. Since only 20.7% (n = 24) of our

study population presenting with perforated appendicitis

and intent to treat with IA had an appendicolith docu-

mented on pathology or operative reports, it is possible

that the location of an appendicolith was not predictive

of failure due to small sample size. The recorded inci-

dence of appendicolith in children presenting with per-

forated appendicitis has not been definitively established.

In one study by Fraser et al., the incidence of appendico-

lith based on histopathology reports was 26.3% in chil-

dren with perforated appendicitis, and this was signifi-

cantly higher compared to children that had either “un-

complicated appendicitis,” “non-inflamed appendix,” or

“incidental appendectomy” [19].

Nadler et al. reported that the need for abscess drainage

doubles the likelihood of failure of initial non-operative

management due to inadequate source control [13]. We

did not demonstrate this finding in our study. Statistically

significant characteristics of patients that failed conser-

vative treatment were the presence of an appendicolith

and duration of symptoms. The fact that significantly

more patients in the failure group presented to the hospi-

tal earlier in the course of their illness suggests that the

severity of their symptoms may have prompted the care-

giver to bring the child to the emergency department

sooner. We have not verified this assumption in this

study because of the lack of a reliable standardized ob-

jective marker for assessing the severity of presenting

symptoms. In a matched analysis comparing clinical

characteristics of patients treated with initial non-operative

management versus immediate appendectomy for perfo-

rated appendicitis, Henry et al. observed that the only

statistically significant difference between the two groups

was duration of abdominal pain, where patients with pain

less than 5 days in duration were more likely to undergo

immediate appendectomy [2]. These investigators also

demonstrated that patients who failed nonoperative

management had a shorter duration of abdominal pain

(average 4.4 days) compared to patients that were suc-

cessfully treated with nonoperative management (aver-

age 7.3 days). Their findings are consistent with our re-

sults.

Our study demonstrates that the presence of an appen-

dicolith increases the likelihood of failure of initial

non-operative management of ruptured appendicitis in

children, but the location of the appendicolith is not a

predictor of failure of initial non-operative management

in these patients. Furthermore, it is apparent that the ra-

diologist at times identifies appendicoliths that are not

confirmed on operative/radiology reports. Thus, the

presence of an appendicolith on admission CT scan or

ultrasonography should not necessarily dissuade the

practitioner from attempting initial non-operative man-

agement with IA, whether the appendicolith is reported

to be intraluminal or extraluminal. While established

predictors for failure of non-operative management may

be essential for standardizing care of ruptured appendici-

tis in pediatric patients, careful clinical judgment contin-

ues to be imperative in the management of these patients.

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