BACKGROUND Appendicitis is the most common cause of an acute abdomen in children. With perforation, multiple intraperitoneal collections can be seen at presentation. In this situation, surgical treatment alone is rarely effective. OBJECTIVE To determine the role of image-guided drainage in treating patients with acute appendicitis complicated by multiple intraabdominal collections. METHODS A retrospective review of patient charts and interventional radiology records was performed to identify all patients with acute complicated appendicitis treated by multiple image-guided drainage procedures. Data reviewed included the number of drainages and aspirations performed, drain dwell time, the clinical course and temperature profile, and the length of inpatient hospital stay and any complications experienced. RESULTS The study population comprised 42 children with a mean age of 107.6 months. A total of 100 drainage catheters were inserted and 56 aspirations were performed. Of the 42 children, 24 were successfully treated at a single sitting, while 18 returned for further intervention. The mean drain dwell time was 8.18 days. The mean inpatient stay was 15.02 days. Treatment of the acute presentation with image-guided intervention was successful in 92.3% of children. CONCLUSIONS Successful management of acute perforated appendicitis with multiple intraabdominal abscesses can be achieved with multiple minimally invasive image-guided drainage procedures.