Should a 21-year-old female with right lower quadrant abdominal pain and back pain, having a computed tomography (CT) scan showing a mildly prominent appendix measuring 6 millimeters without definitive surrounding fat stranding, be discharged with antibiotics (e.g. ciprofloxacin (ciprofloxacin)) and close follow-up precautions?

From the Guidelines

The patient should undergo further evaluation in the hospital setting and surgical consultation for possible appendectomy, rather than being discharged with antibiotics alone, due to the uncertainty of the diagnosis and the potential risks of perforation or other complications. The CT findings of a mildly prominent appendix at 6mm, without definitive fat stranding, do not provide a clear diagnosis of appendicitis 1. The combination of right lower quadrant pain with back pain could indicate appendicitis, but might also suggest other conditions such as pyelonephritis, ovarian pathology, or musculoskeletal issues. Additional diagnostic workup, including complete blood count, urinalysis, and possibly gynecological evaluation, would be appropriate to rule out other causes of the patient's symptoms.

According to the WSES guidelines for diagnosis and treatment of acute appendicitis, appendectomy remains the treatment of choice for acute appendicitis, and antibiotic therapy is a safe means of primary treatment for patients with uncomplicated acute appendicitis, but it is less effective in the long-term due to significant recurrence rates 1. The APPAC trial reported a 1-year recurrence rate of 27% in patients with uncomplicated appendicitis treated with antibiotic therapy alone 1. Therefore, surgical consultation for possible appendectomy would be indicated if appendicitis is confirmed.

The patient's young age and female gender also warrant consideration of gynecological causes for her symptoms, which should be ruled out before finalizing treatment decisions. Serial abdominal examinations over several hours can also help clarify the diagnosis. Discharging with antibiotics could risk progression to perforation if this is indeed early appendicitis, and the potential benefits of antibiotic therapy alone do not outweigh the risks of complications or recurrence in this case.

Some key points to consider in the management of this patient include:

• The importance of a thorough diagnostic workup to rule out other causes of the patient's symptoms
• The potential risks and benefits of antibiotic therapy alone versus surgical consultation for possible appendectomy
• The need for close monitoring and follow-up to ensure that the patient's condition does not worsen or progress to complications. The WSES guidelines recommend that patients with uncomplicated acute appendicitis can be treated with antibiotic therapy, but this approach requires careful selection of patients and close monitoring for signs of complications or recurrence 1. In this case, the uncertainty of the diagnosis and the potential risks of complications or recurrence make surgical consultation for possible appendectomy the more appropriate course of action.

From the Research

Patient Assessment

• The patient is a 21-year-old female presenting with right lower quadrant abdominal pain and back pain.
• A CT scan shows a mildly prominent appendix measuring 6 mm, with no definitive surrounding fat stranding.

Diagnosis and Management

• According to 2, acute appendicitis is the most common abdominal surgical emergency, and the diagnosis is based on history, physical examination, laboratory evaluation, and imaging.
• The patient's symptoms and CT findings do not show clear signs of acute appendicitis, but the appendix is mildly prominent.
• 2 suggests that an antibiotics-first approach can be considered for patients with uncomplicated acute appendicitis, but the success rate is approximately 70%.
• However, CT findings such as appendiceal dilatation (≥7 mm) or presence of appendicoliths may indicate a higher risk of treatment failure with an antibiotics-first approach.

Treatment Options

• Laparoscopic appendectomy is a common treatment for acute appendicitis, but 2 suggests that an antibiotics-first approach can be considered for selected patients.
• 3 recommends that pain control with opioids, nonsteroidal anti-inflammatory drugs, and acetaminophen should be a priority and does not result in delayed or unnecessary intervention.
• 4 suggests that patients with atypical symptoms and equivocal imaging may still have acute appendicitis and could benefit from laparoscopic appendectomy.

Discharge with Antibiotics

• Given the patient's mild symptoms and CT findings, discharge with antibiotics and close return precautions may be considered.
• However, 5 emphasizes the importance of diagnostic accuracy, patient age and co-morbidity, and patient's own wishes in decision-making for suspected appendicitis.
• 6 reviews current techniques for surgical management of acute appendicitis, including laparoscopic appendectomy, but does not provide specific guidance on discharge with antibiotics.