What is the treatment for appendagitis (inflammation of the appendix)?

From the Guidelines

The treatment for appendagitis, which is inflammation of the appendix, is typically surgical removal of the appendix, called an appendectomy, and the most recent guidelines recommend laparoscopic appendectomy as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, where laparoscopic equipment and expertise are available 1.

Key Considerations

• The diagnosis of appendagitis is crucial and may involve clinical scores and imaging to confirm the condition.
• The use of antibiotics is recommended before surgery, with options including a combination of cefazolin and metronidazole, or piperacillin-tazobactam for more severe cases.
• Pain management is also important and may include medications like morphine or hydromorphone.
• In select uncomplicated cases, a non-surgical approach with antibiotics alone may be considered, but surgery remains the definitive treatment.

Surgical Approach

• Laparoscopic appendectomy is preferred due to its advantages over open appendectomy, including less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, and better quality of life scores 1.
• The timing of appendectomy is important, with short, in-hospital surgical delay up to 24 h considered safe in uncomplicated acute appendicitis, and delaying appendectomy for acute appenditis needing surgery beyond 24 h from admission not recommended 1.

Post-Surgical Care

• After appendectomy, patients typically stay in the hospital for 1-2 days and can resume normal activities within 1-3 weeks.
• The treatment of appendagitis requires prompt attention because a ruptured appendix can lead to peritonitis, a serious infection of the abdominal cavity that can be life-threatening.

Evidence-Based Recommendations

• The 2020 update of the WSES Jerusalem guidelines provides evidence-based statements and recommendations for the diagnosis and treatment of acute appendicitis, including the use of clinical scores, imaging, and non-operative management with antibiotics 1.
• The guidelines also recommend laparoscopic appendectomy as the preferred approach and provide guidance on the timing of surgery and post-operative care.

From the Research

Treatment Options for Appendagitis

• Appendectomy is the standard treatment for acute appendicitis, but antibiotic therapy has been proposed as an alternative in some cases 2, 3, 4, 5, 6
• The use of broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, has been shown to successfully treat uncomplicated acute appendicitis in approximately 70% of patients 3
• A systematic review with meta-analysis found that antibiotic therapy was associated with fewer immediate complications than surgery, but more subsequent failures 2
• The overall incidence of complications of appendicitis was 25% in the immediate appendectomy group versus 18% in the antibiotic group 2
• Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission, but recurrence rates of non-operated patients within 1 year are as high as 20-30% 4

Antibiotic Therapy

• 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 5
• The antibiotics used in the treatment of appendicitis include amoxicillin + clavulanic acid, cefotaxime, or a fluoroquinolone, often with the addition of metronidazole or tinidazole 2
• The total duration of antibiotic treatment is typically 8 to 15 days 2

Surgical Management

• 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 3
• Appendectomy is still the treatment recommended for patients with risk factors for failure of non-operative management 4

Patient Selection

• The decision to use antibiotic therapy or surgery should be based on the patient's preferences and the presence of risk factors for failure of non-operative management 3, 4
• Patients without high-risk CT findings may be considered for either appendectomy or antibiotics as first-line therapy 3