What is the management of acute appendicitis?

From the Guidelines

Appendicitis management requires prompt surgical intervention through appendectomy, which remains the gold standard treatment, with laparoscopic appendectomy preferred over open surgery when possible, as it results in less pain, shorter hospital stays, and quicker recovery 1. When appendicitis is suspected based on symptoms like right lower quadrant pain, nausea, and fever, patients should be evaluated with blood tests (looking for elevated white blood cell count) and imaging studies (typically ultrasound or CT scan). Once diagnosed, patients should receive intravenous antibiotics such as piperacillin-tazobactam 3.375g every 6 hours, or a combination of cefazolin 2g every 8 hours plus metronidazole 500mg every 8 hours, started preoperatively and continued for 24 hours after surgery in uncomplicated cases, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. For uncomplicated appendicitis, patients typically return home within 24-48 hours post-surgery with oral pain management using acetaminophen 1000mg every 6 hours and ibuprofen 600mg every 6 hours as needed. In select cases of uncomplicated appendicitis, a non-operative approach with antibiotics alone (such as ertapenem 1g daily for 3 days followed by 7 days of oral amoxicillin-clavulanate 875/125mg twice daily) may be considered, though this carries a 30% risk of recurrence within one year. Complicated appendicitis with perforation or abscess formation requires longer antibiotic courses (5-7 days) and possibly percutaneous drainage before definitive surgery, with laparoscopic surgery in experienced hands being a safe and feasible first-line treatment for appendiceal abscess, being associated with fewer readmissions and fewer additional interventions than conservative treatment, with a comparable hospital stay 1. Some key points to consider in appendicitis management include:

• Routine histopathology after appendectomy is necessary, as the incidence of unexpected findings in appendectomy specimens is low, and intra-operative diagnosis alone is insufficient for identifying unexpected disease 1.
• Intra-operative grading systems can help the identification of homogeneous groups of patients, determining optimal postoperative management according to the grade of the disease and ultimately improve the utilization of resources 1.
• Non-operative management with antibiotics and—if available—percutaneous drainage is a reasonable first-line treatment for appendicitis with phlegmon or abscess, especially in settings where laparoscopic expertise is not available 1.
• The laparoscopic approach is the treatment of choice for patients with complicated appendicitis with phlegmon or abscess where advanced laparoscopic expertise is available, with a low threshold for conversion 1.

From the Research

Appendicitis Management Overview

• Appendicitis is a common abdominal surgical emergency, with an annual incidence of 96.5 to 100 cases per 100,000 adults 2.
• The clinical diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging 2, 3.

Treatment Options

• Surgery has been the standard of care for acute appendicitis, but recent studies have shown the feasibility of antibiotic therapy for uncomplicated appendicitis 4, 2, 5.
• Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission, while the other 10% require a rescue appendectomy 4.
• Recurrence rates of non-operated patients within 1 year are as high as 20-30% 4.
• Laparoscopic appendectomy remains the most common treatment, but broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2.

Patient Selection for Antibiotic Therapy

• Patients with uncomplicated appendicitis without risk factors for failure of non-operative management can be considered for antibiotic therapy 4, 2.
• Specific imaging findings on computed tomography (CT), such as appendiceal dilatation or presence of appendicoliths, can identify patients for whom an antibiotics-first management strategy is more likely to fail 2.
• CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure of an antibiotics-first approach 2.

Special Considerations

• Pregnant patients and immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications 3.
• Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management 3.
• A simplified once-daily regimen of ceftriaxone and metronidazole can be cost-effective in pediatric patients with appendicitis 6.