From the Guidelines
Afebrile appendicitis requires the same urgent evaluation and treatment as typical appendicitis, with surgical intervention and antibiotics being the cornerstone of treatment. The diagnosis of afebrile appendicitis should be considered in patients with right lower quadrant abdominal pain, even without fever, as the absence of fever does not rule out the possibility of appendicitis 1. Evaluation typically includes a complete blood count, C-reactive protein measurement, and imaging studies such as ultrasound or CT scan.
Key Considerations
- The incidence of appendicitis has been declining steadily since the late 1940s, but it remains a common cause of lower abdominal pain in young patients 1.
- The rate of perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups and in patients older than 50 years 1.
- Appendiceal perforation is associated with increased morbidity and mortality compared with non-perforating appendicitis, with a mortality rate of around 5% 1.
Treatment Approach
- Surgical intervention with appendectomy, either via laparoscopic or open approach, is the recommended treatment for afebrile appendicitis 1.
- Antibiotics should be initiated once the diagnosis is suspected, typically with a broad-spectrum regimen such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours 1.
- For uncomplicated cases, antibiotics can be discontinued within 24 hours after surgery, as recommended by the 2020 update of the WSES Jerusalem guidelines 1.
- In select cases of uncomplicated appendicitis, an antibiotics-only approach may be considered using regimens such as ertapenem 1g IV daily for 2-3 days followed by oral antibiotics to complete 7-10 days 1.
From the Research
Afebrile Appendicitis
- Afebrile appendicitis refers to appendicitis without fever, which can make diagnosis more challenging 2, 3.
- The clinical diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging 3.
- Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever, although some patients may not present with fever 3.
Diagnosis and Management
- The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with classic symptoms 3.
- Laparoscopic appendectomy remains the most common treatment, but increasing evidence suggests that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 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 3.
Treatment Options
- Appendectomy is still the treatment recommended for cases with risk factors, while antibiotic therapy can be considered for uncomplicated appendicitis without risk factors 2.
- In cases with uncertain diagnosis or mild clinical symptoms, antibiotic therapy should be started 2.
- The choice of treatment depends on the clinical state, with either immediate surgery or primarily antibiotic therapy, combined with drainage of abscess, being followed by interval appendectomy in some cases 2.
Outcomes and Complications
- Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission, while the other 10% require a rescue appendectomy 2.
- Recurrence rates of non-operated patients within 1 year are as high as 20-30% 2.
- Wound complications, antibiotic use, total analgesic requirements, length of operation, and hospital length of stay were not statistically different between patients who underwent appendectomy within 10 hours of CT diagnosis and those who underwent appendectomy greater than 10 hours after diagnosis 4.