From the Guidelines
Laparoscopic appendectomy (LA) is the recommended treatment for acute appendicitis due to its association with 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 diagnosis of acute appendicitis is often challenging and involves a synthesis of clinical, laboratory, and radiological findings, with clinical scoring systems and diagnostic imaging such as ultrasound, computed tomography, or magnetic resonance imaging playing a crucial role 1. Prior to surgery, patients should receive nothing by mouth, intravenous fluids for hydration, and antibiotics such as a combination of cefazolin and metronidazole, or piperacillin-tazobactam for broader coverage 1. Some key points to consider in the management of acute appendicitis include:
- The incidence of acute appendicitis has been declining steadily since the late 1940s, with a peak between the ages of 10 and 30 1
- Geographical differences are reported, with a lifetime risk for acute appendicitis of 9% in the USA, 8% in Europe, and 2% in Africa 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 acute appendicitis 1. The clinical presentation of acute appendicitis typically includes right lower quadrant pain, nausea, fever, and elevated white blood cell count, with imaging such as ultrasound or CT scan confirming the diagnosis 1. It is essential to note that complications of untreated appendicitis include perforation, peritonitis, and abscess formation, which significantly increase morbidity and mortality 1.
From the Research
Definition and Incidence of Acute Appendicitis
- Acute appendicitis is the most common abdominal surgical emergency in the world, 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 and physical, laboratory evaluation, and imaging 2.
Symptoms and Diagnosis of Acute Appendicitis
- 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.
- The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms 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.
Treatment Options for Acute Appendicitis
- Laparoscopic appendectomy remains the most common treatment for acute appendicitis 2.
- However, increasing evidence suggests that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2, 4.
- Antibiotic therapy can be offered as the first-line therapy to a majority of unselected patients with acute appendicitis without medical drawbacks other than the unknown risk for long-term relapse 4.
- In patients with high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix, surgical management should be recommended 2.
- In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy 2.