Purpose of review: The diagnostic approach to children with possible appendicitis remains challenging. Although advances in imaging have improved diagnostic accuracy over clinical judgment alone, new management strategies continue to evolve. This review serves as an update on imaging, biomarkers, and management of appendicitis. Recent findings: Abdominal computed tomography (CT) and ultrasound continue to be the ancillary radiologic studies of choice for appendicitis. Recent studies on the use of CT have focused on the need for intravenous or enteral contrast. Despite lower diagnostic performance, ultrasound has the advantage of sparing patients from radiation exposure. MRI is being evaluated as an additional diagnostic modality. New biomarkers, beyond a standard white blood cell count or absolute neutrophil count, continue to be investigated, but these are not being routinely used in practice. Different management approaches are also being investigated, including nonoperative treatment with antibiotic therapy for early, acute appendicitis. Summary: The best use of advanced radiologic imaging for children with possible appendicitis is actively debated. CT continues to show superior accuracy as compared with ultrasound; however, screening ultrasounds for nonobese children have advantages. The combination of robust decision rules that incorporate biomarkers and the judicious use of CT will help define diagnostic strategies for appendicitis over the next decade.