The emergency physician must keep in mind the many variations in the way appendicitis can present Patients with equivocal findings should be admitted for monitoring and serial examinations or have imaging studies to demonstrate a normal appendix If the imaging studies are equivocal, the surgeon will decide to operate or continue to monitor Patients who have a typical history for appendicitis but suddenly have diminished pain may actually have undergone perforation of the appendix Such patients should be observed for several hours before declaring an improved condition Even in the presence of negative imaging studies, the emergency physician should arrange close follow-up for any patient with abdominal pain For those patients with progressive pain, significant pain requiring narcotic medications, or persistent emesis, admission for further care and subsequent evaluation might be necessary PERFORATED APPENDICITIS Goals of Treatment When a perforated appendicitis is suspected, surgical consultation should be obtained promptly and adjusted for the stability of the patient Early restoration of intravascular volume, correction of electrolyte derangements, pain control, and antibiotics are essential parts of early care In collaboration with surgery colleagues, decisions about which patients need immediate operative care versus advanced imaging can be discussed When an abscess is identified, the surgeons will determine the need for a drainage procedure in addition to antibiotic therapy prior to a delayed appendectomy Short-term treatment outcomes include clearance of the intraperitoneal infection while limiting the duration of hospitalization and the need for repeated imaging or drainage procedures Clinical Considerations Clinical Recognition Ideally, once the diagnosis of appendicitis is considered, the patient will proceed with an efficient evaluation to establish the diagnosis and then definitive care before perforation Unfortunately, some patients, particularly younger children, may arrive for emergency care with an already perforated appendix because of a delay in seeking treatment or in making the diagnosis Although the time to perforation is variable, the time prior to ED presentation is a more important determinant of perforation than the time of evaluation in the ED Once the appendix has perforated, there may be signs of generalized, rather than localized, peritonitis In a young child, the omentum is thin and often incapable of walling