Acute appendicitis remains one of the most frequent abdominal emergencies in children and continues to be a major contributor to morbidity across different healthcare settings [1,2]. Although older children often present with a clearer symptom pattern, the disease can appear with atypical or subtle features in younger age groups, making timely diagnosis more challenging [3,4]. Early symptoms may be vague, and younger children may have difficulty describing the character or location of pain, leading to delays in seeking medical attention and a higher risk of perforation, abscess formation, and prolonged recovery [1,4]. The clinical profile of pediatric appendicitis is also shaped by variations in awareness, healthcare access, and diagnostic practices across regions [1,2]. Ultrasonography has emerged as an essential first-line imaging tool, yet its diagnostic accuracy may vary depending on the child’s age, body habitus, and operator expertise [3,4]. Consequently, clinicians often rely on a combination of clinical judgment, laboratory indicators, and imaging findings to establish the diagnosis with confidence. Understanding how children present within a specific setting and determining the proportion who progress to complicated appendicitis is critical for improving outcomes and reducing avoidable morbidity [1,2,5]. Equally important is evaluating how they respond to current management strategies, including the increasing use of minimally invasive surgical techniques and the selective application of conservative therapy in carefully chosen cases [5,6]. With these considerations in mind, the present study sought to examine the demographic pattern, clinical features, imaging findings, and management outcomes of children diagnosed with acute appendicitis over a one-year period. By analyzing these aspects in a structured manner, the study aims to offer practical insights into disease behavior in routine pediatric surgical practice and to identify factors associated with advanced or complicated presentations.

Study Design and Setting This prospective observational study was carried out in the Department of Pediatric Surgery, Niloufer Institute of Child Health, Hyderabad. Data collection spanned one full year, from June 2024 to May 2025. Study Population and Sample Size A total of 50 children presenting with clinical features suggestive of acute appendicitis were consecutively enrolled. All children aged 1 to 12 years with a provisional clinical diagnosis were considered eligible. Inclusion and Exclusion Criteria Children with typical or suspected acute appendicitis were included. Exclusion criteria comprised cases with appendiceal masses planned for interval appendectomy, children with a history of previous abdominal surgery, and those who were ultimately diagnosed with other abdominal conditions after evaluation. Clinical Assessment Each child underwent detailed evaluation, including onset and duration of abdominal pain, presence of vomiting, fever, and migration of pain to the right iliac fossa. Physical examination focused on detecting guarding, rebound tenderness, and localized peritoneal signs. Laboratory investigations included complete blood counts, with emphasis on total leukocyte count and neutrophil percentage. Imaging Evaluation Ultrasonography of the abdomen was performed for all participants by experienced radiologists. Specific observations included appendiceal diameter, wall thickness, compressibility, peri-appendiceal fluid, and presence of appendicolith. Cases were classified as uncomplicated or complicated based on combined clinical and imaging criteria. Management Protocol Management decisions were guided by clinical severity and imaging findings. Surgical treatment consisted of either laparoscopic or open appendectomy. Children considered suitable for non-operative management received intravenous antibiotics, fluid support, and close monitoring. Indications for shifting to surgery included persistent pain, fever, or failure to improve clinically. Outcome Assessment Postoperative and post-treatment outcomes were documented prospectively. Parameters included duration of hospital stay, wound-related complications, postoperative abscess formation, and need for delayed surgical intervention. Ethical Considerations and Consent Informed consent was obtained from parents or guardians before enrollment. All relevant clinical and demographic details were recorded on a structured proforma.

A total of 50 children with acute appendicitis were enrolled during the study period. The age of the cohort ranged from early childhood to adolescence, with a mean of 9.3 ± 2.8 years. More than half of the children were between 5 and 10 years of age, and boys slightly outnumbered girls. The complete demographic pattern is shown in Table 1. Table 1. Demographic Profile of Children With Acute Appendicitis (N = 50) Variable Category n (%) / Mean ± SD Age (years) Mean ± SD 9.3 ± 2.8 Age groups < 5 years 5 (10%) 5–10 years 27 (54%) > 10 years 18 (36%) Gender Male 29 (58%) Female 21 (42%) Clinical symptoms at presentation displayed a broad but predictable distribution. Prolonged abdominal pain lasting more than 24 hours was reported in 60% of children, while vomiting and fever were noted in 74% and 68% respectively. On examination, guarding was present in 70% and rebound tenderness in 64%, indicating significant peritoneal irritation in many cases. Laboratory evaluation revealed leukocytosis in 72% and neutrophilia in 80%. These findings are summarized in Table 2. Table 2. Clinical Presentation and Laboratory Findings Parameter n (%) Pain >24 hours before presentation 30 (60%) Fever 34 (68%) Vomiting 37 (74%) Migration of pain to RIF 31 (62%) Guarding 35 (70%) Rebound tenderness 32 (64%) Leukocytosis >11,000/mm³ 36 (72%) Neutrophilia (>75%) 40 (80%) Ultrasound examination supported the clinical diagnosis for most children. A thickened, non-compressible appendix was visible in 76% of cases, while peri-appendiceal fluid collections were observed in nearly one-third. Appendicoliths were present in 18%. Based on clinical and imaging criteria, uncomplicated appendicitis constituted 68% of the study group, and the remaining 32% showed features of complicated disease. Details are presented in Table 3. Table 3. Imaging Findings and Classification of Appendicitis Variable n (%) USG: non-compressible, thickened appendix 38 (76%) USG: peri-appendiceal fluid 15 (30%) USG: appendicolith 9 (18%) Type of appendicitis Uncomplicated Complicated (perforated/gangrenous/abscess) Most children underwent operative treatment. Laparoscopic appendectomy was the preferred approach and accounted for 60% of all surgeries. Open appendectomy was performed in 12 children, mainly in those with advanced inflammation. Conservative treatment was attempted in eight children; six recovered without surgery, while two eventually required operative removal due to persistent symptoms. Intraoperative examination revealed congested appendicitis in 52%, gangrenous changes in 21%, and perforation in 19%. The overall complication rate remained low, with wound infection documented in four children and a single case of postoperative abscess. No mortality occurred. The detailed distribution of management strategies and outcomes is presented in Table 4. Table 4. Management and Outcomes Parameter n (%) Surgical management 42 (84%) Laparoscopic appendectomy 30 (60%) Open appendectomy 12 (24%) Conservative management 8 (16%) Successful conservative response 6 (12%) Required delayed surgery 2 (4%) Intraoperative: congested appendix 22 (52%) Intraoperative: gangrenous appendix 9 (21%) Intraoperative: perforated appendix 8 (19%) Hospital stay, uncomplicated (median) 3 days Hospital stay, complicated (mean) 6 ± 1.8 days Wound infection 4 (8%) Postoperative abscess 1 (2%) Mortality 0

This study offers insight into the presentation patterns and management outcomes of pediatric acute appendicitis, reflecting several trends described in contemporary literature. The predominance of children in the middle childhood age group parallels established epidemiological observations, where appendicitis is most common between 8 and 12 years of age [9]. The slight male predominance noted here also aligns with large cohort analyses reporting similar gender trends [9]. A key finding of this study was the high proportion of children presenting more than 24 hours after symptom onset. Delayed presentation is strongly associated with a higher risk of perforation and complicated disease, a relationship consistently emphasized in prior pediatric studies [7,14]. Similar to these earlier reports, children who arrived late in this study demonstrated more pronounced abdominal signs, elevated inflammatory markers, and a greater likelihood of perforation or gangrene. Ultrasonography remained central to diagnosis in most children. Although imaging sensitivity may vary by operator and patient factors, previous systematic reviews support its value as a reliable first-line modality in pediatric appendicitis [8]. The presence of peri-appendiceal fluid and appendicoliths in a subset of children in the current study mirrors predictors of complicated disease described in recent modelling studies, particularly among younger children [14]. Surgical management was the primary treatment approach, and the strong preference for laparoscopic appendectomy reflects a global shift toward minimally invasive techniques. Comparable to findings reported in multicenter and pandemic-era studies, postoperative complication rates in the present series remained low, with only a few wound infections and one abscess [8,12]. The favourable outcomes observed reinforce the safety and effectiveness of current surgical practices. Conservative treatment succeeded in selected cases, echoing emerging evidence supporting nonoperative management in carefully chosen children with uncomplicated appendicitis [11]. However, the small number of such cases in this study underscores the need for cautious interpretation and further study. Overall, these findings complement international reports that highlight early evaluation, timely imaging, and prompt surgical intervention as key factors in reducing morbidity in pediatric appendicitis [10,13]. The higher complication rate among children with delayed presentation reinforces the ongoing need for caregiver education and improved access to prompt medical assessment.

This study highlights the varied clinical patterns with which children present in acute appendicitis and shows that timely diagnosis remains central to achieving good outcomes. Most children had uncomplicated disease at presentation, and surgical treatment particularly laparoscopy resulted in rapid recovery with minimal complications. Conservative treatment was successful in selected mild cases but required careful monitoring. Complicated appendicitis occurred mainly in children who presented late, reinforcing the impact of delayed care on morbidity. Overall, the findings underscore the value of early clinical evaluation, appropriate imaging, and prompt management in reducing complications and improving recovery in pediatric acute appendicitis.

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