What is the medical management of acute appendicitis?

From the Guidelines

Acute appendicitis is primarily managed surgically through appendectomy, not medically, as it is the most effective treatment in preventing morbidity, mortality, and improving quality of life. However, in select cases where surgery is not immediately available or contraindicated, medical management may be attempted. This approach typically involves intravenous antibiotics, usually a combination therapy targeting gram-negative and anaerobic bacteria. A common regimen includes piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, typically for 7-10 days, as recommended by the WSES guidelines 1.

Some key points to consider in the medical management of acute appendicitis include:

• Adequate pain control with medications like morphine 0.1mg/kg IV every 4 hours as needed or hydromorphone 0.5-1mg IV every 4 hours is essential.
• Patients should remain NPO (nothing by mouth) initially, with IV fluids (typically normal saline at 125-150ml/hr) to maintain hydration.
• Close monitoring is crucial, with vital signs checked every 4 hours and regular abdominal examinations to detect any worsening.
• Medical management is considered successful if symptoms resolve within 48-72 hours, but any clinical deterioration warrants immediate surgical intervention, as stated in the WSES guidelines 1.
• The use of non-operative management for complicated appendicitis with peri-appendicular abscess is suggested, with antibiotics and percutaneous drainage if available, as recommended by the WSES guidelines 1.

It's worth noting that the WSES guidelines also recommend against routine interval appendectomy after non-operative management for complicated appendicitis in young adults and children, and suggest elective colonic screening in all patients with appendicitis treated non-operatively, especially if they are over 40 years old 1.

In terms of antibiotic therapy, the WSES guidelines recommend a single preoperative dose of broad-spectrum antibiotics in patients with acute appendicitis undergoing appendectomy, and suggest against prolonging antibiotics longer than 3-5 days postoperatively in case of complicated appendicitis with adequate source-control 1.

Overall, while medical management may be attempted in select cases, surgery remains the definitive treatment for acute appendicitis, as it is the most effective way to prevent morbidity, mortality, and improve quality of life, as supported by the WSES guidelines 1.

From the Research

Medical Management of Acute Appendicitis

The medical management of acute appendicitis involves a combination of diagnostic techniques, antibiotic therapy, and surgical intervention. The following points highlight the key aspects of medical management:

• Diagnosis: The diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging studies such as computed tomography (CT) scans, ultrasound, and magnetic resonance imaging (MRI) 2, 3, 4.
• Antibiotic Therapy: Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with cephalosporins or fluoroquinolones with metronidazole, can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2, 5.
• Surgical Intervention: Laparoscopic appendectomy remains the most common treatment for acute appendicitis, but surgical management should be recommended in patients with high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix greater than 13 mm 2, 3, 4.
• Non-Operative Management: Non-operative management with antibiotics may be considered as first-line therapy in patients without high-risk CT findings, and in unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended 2, 4, 6.
• Complicated Appendicitis: Complicated acute appendicitis should undergo timely surgical intervention, and patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management 3, 4.
• Special Populations: Pregnant patients and immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications 3, 4.
• Recurrence Rates: Recurrence rates of non-operated patients within 1 year are as high as 20-30%, and the risk of recurrence at 1 year with antibiotics-first treatment was 15.8% (95% confidence interval, 12.05-118.63) 4, 6.

Key Considerations

The following points highlight key considerations in the medical management of acute appendicitis:

• CT Findings: CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach 2.
• Patient Preferences: In uncomplicated appendicitis without risk factors for failure of non-operative management, a shared decision based on the patient's preferences should be made 4.
• Perioperative Risk Assessment: In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered 2.