What is the treatment for suspected appendicitis?

From the Guidelines

The treatment for suspected appendicitis is surgical removal of the appendix, known as an appendectomy, which is typically performed urgently once the diagnosis is suspected, as delaying treatment can lead to appendix rupture and serious complications. This procedure can be performed laparoscopically (minimally invasive) or as an open procedure, with laparoscopic being preferred when available due to faster recovery times and fewer wound complications 1. Before surgery, patients receive intravenous antibiotics such as a combination of cefazolin (1-2g) and metronidazole (500mg), or piperacillin-tazobactam (3.375g) for broader coverage, with a single preoperative dose of broad-spectrum antibiotics recommended for patients with acute appendicitis undergoing appendectomy 1.

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

• The use of a single preoperative dose of broad-spectrum antibiotics, with postoperative antibiotics recommended for patients with complicated acute appendicitis, especially if complete source control has not been achieved 1
• The consideration of non-operative management with antibiotics alone in select cases of uncomplicated appendicitis, though surgery remains the standard of care due to lower recurrence rates 1
• The importance of prompt treatment to prevent progression to perforation, abscess formation, and peritonitis, which can significantly increase morbidity and recovery time
• The role of laparoscopic appendectomy as a safe and effective alternative to open appendectomy, with benefits including shorter length of hospital stay, less postoperative pain, and earlier postoperative recovery 1

In terms of specific management strategies, the following are recommended:

• Appendectomy is recommended as the treatment of choice for acute appendicitis, with antibiotic therapy as a safe means of primary treatment for patients with uncomplicated acute appendicitis, but with a higher risk of recurrence 1
• Laparoscopic appendectomy is recommended as a viable approach to surgical treatment of acute appendicitis, with benefits including shorter length of hospital stay, less postoperative pain, and earlier postoperative recovery 1
• Non-operative management with antibiotics alone may be considered in select cases of uncomplicated appendicitis, though surgery remains the standard of care due to lower recurrence rates 1
• Interval appendectomy may not be necessary following initial non-operative treatment of complicated appendicitis, but should always be performed for patients with recurrent symptoms 1

From the Research

Symptoms of Appendicitis

• Vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever are classic symptoms of appendicitis 2
• Right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant are the best signs for ruling in acute appendicitis in adults 3
• Absent or decreased bowel sounds, a positive psoas sign, a positive obturator sign, and a positive Rovsing sign are most reliable for ruling in acute appendicitis in children 3

Treatment for Suspected Appendicitis

• Laparoscopic appendectomy remains the most common treatment for acute appendicitis 2, 3
• Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2
• Antibiotics may be considered as first-line therapy in selected patients with uncomplicated appendicitis 2, 4, 5
• Surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery 2

Antibiotic Treatment

• Antibiotic treatment 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 5
• Postoperative use of piperacillin/tazobactam for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to ceftriaxone with metronidazole 6
• Antibiotics may reduce wound infections, but may increase the number of negative appendectomies at surgery 4