What is appendagitis (inflammation of the appendix)?

From the Guidelines

Appendagitis is a rare inflammatory condition that can be effectively managed with conservative treatment, focusing on pain management and rest, without the need for surgical intervention in most cases. The condition, also known as epiploic appendagitis, affects the small fat-filled pouches (epiploic appendages) attached to the outer wall of the colon, causing localized abdominal pain that can mimic other conditions like appendicitis or diverticulitis.

Diagnosis and Treatment

• The diagnosis of appendagitis usually involves CT imaging to differentiate it from more serious conditions, such as appendicitis, which has a higher incidence rate and requires prompt surgical intervention 1.
• Treatment for appendagitis is typically conservative, focusing on pain management with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-600mg every 6-8 hours) or naproxen (250-500mg twice daily) for 7-10 days, as recommended by recent guidelines 1.
• Rest and avoiding strenuous activity until symptoms resolve is also recommended, as most cases of appendagitis are self-limiting and resolve within 1-2 weeks without surgical intervention.
• The condition occurs due to torsion or venous thrombosis of the epiploic appendages, leading to inflammation and pain, and if symptoms worsen or don't improve within a few days of conservative treatment, medical attention should be sought to rule out other abdominal conditions that may require more aggressive intervention 1.

Comparison with Appendicitis

• Appendicitis, on the other hand, is a more serious condition that requires prompt surgical intervention, with appendectomy being the gold standard of treatment, especially for complicated cases 1.
• The natural history of appendicitis has been described in three stages: (1) a normal appendix, (2) uncomplicated acute appendicitis, and (3) complicated appendicitis, according to their macroscopic and microscopic appearance and clinical relevance 1.
• The high morbidity and occasional mortality associated with acute appendicitis are related to delay in presentation by patients or delay in diagnosis by the clinician, highlighting the importance of prompt diagnosis and treatment 1.

Recent Guidelines and Recommendations

• Recent guidelines, such as the 2020 update of the WSES Jerusalem guidelines, recommend laparoscopic appendectomy (LA) as the most effective surgical treatment for acute appendicitis, due to its association with a lower incidence of wound infection and post-intervention morbidity, shorter hospital stay, and better quality of life scores compared to open appendectomy (OA) 1.
• The guidelines also recommend antibiotic therapy as a safe means of primary treatment for patients with uncomplicated acute appendicitis, but note that it is less effective in the long-term due to significant recurrence rates and probably needs the certainty of a CT-proven diagnosis of uncomplicated appendicitis 1.

From the Research

Definition and Diagnosis of Appendagitis

• Appendagitis, also known as acute appendicitis, is a common abdominal surgical emergency worldwide, 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 findings 2.
• Classic symptoms of appendicitis include vague periumbilical pain, anorexia, nausea, intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever 2.

Treatment Options for Appendagitis

• Laparoscopic appendectomy remains the most common treatment for acute appendicitis, but increasing evidence suggests that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2.
• The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with classic symptoms, and treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis 2, 3.
• 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.

Comparison of Laparoscopic and Open Appendectomy

• Laparoscopic appendectomy offers several advantages over open appendectomy, including shorter hospital stay, better postoperative pain recovery, and reduced need for analgesics 4, 5.
• The laparoscopic approach also results in earlier return of normal bowel activity, oral intake tolerance, and return to routine activities, with higher patient satisfaction 4.
• However, the operative time is longer for laparoscopic appendectomy compared to open appendectomy, and there is a risk of complications such as intra-abdominal abscess or wound infection with both procedures 4, 5.

Management of Complicated Appendagitis

• Complicated acute appendicitis, such as cases with appendiceal abscess or phlegmon, requires timely surgical intervention or percutaneous drainage and antibiotic management 6, 3.
• Pregnant patients and immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications 6.
• The management of acute appendicitis depends on the presentation of the patient and dividing it into uncomplicated and complicated disease, with each requiring management with antibiotics and followed with timely appendectomy 6, 3.