What is the treatment for appendicitis?

From the Guidelines

The primary treatment for appendicitis is surgical removal of the inflamed appendix, known as an appendectomy, which can be performed laparoscopically or through traditional open surgery. This procedure is typically performed as soon as possible after diagnosis to prevent complications such as rupture, which can lead to peritonitis (infection of the abdominal cavity) 1. Before surgery, patients usually receive intravenous antibiotics such as a combination of cefazolin and metronidazole, or piperacillin-tazobactam for more severe cases, to control infection 1. Pain management typically includes medications like morphine or hydromorphone.

Key Considerations

• In some cases of uncomplicated appendicitis, a non-surgical approach with antibiotics alone (such as ertapenem 1g daily for 3 days followed by oral antibiotics for 7 days) may be considered, though this carries a risk of recurrence 1.
• The success of non-operative management (NOM) requires careful patient selection and exclusion of patients with gangrenous appendicitis, abscesses, and diffuse peritonitis 1.
• Recent studies have shown that NOM for uncomplicated appendicitis can be effective, with a success rate of around 70-80% 1.
• However, the risk of recurrence with NOM is significant, with a reported rate of 27.4% within 1 year of initial presentation 1.

Surgical Approach

• Laparoscopic appendectomy is recommended as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, where laparoscopic equipment and expertise are available 1.
• The laparoscopic approach is associated with less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, and better quality of life scores 1.

Postoperative Care

• After surgery, patients typically stay in the hospital for 1-2 days for laparoscopic procedures or 2-5 days for open surgery, followed by 2-4 weeks of recovery at home with gradually increasing activity.
• Postoperative antibiotics can be administered orally if the patient is otherwise well enough to be discharged 1.

Special Considerations

• In elderly patients, the decision to perform surgery or attempt non-operative management should be made on a case-by-case basis, taking into account the patient's overall health and preferences 1.
• In pregnant patients, the approach to appendicitis treatment should be individualized, with consideration given to the risks and benefits of surgery versus non-operative management 1.

From the Research

Treatment Options for Appendicitis

The treatment for appendicitis typically involves either surgical removal of the appendix (appendectomy) or antibiotic therapy.

• Appendectomy is the standard treatment for acute appendicitis, as it is effective in removing the infected appendix and preventing further complications 2.
• However, antibiotic therapy has been proposed as an alternative to immediate appendectomy, with studies showing that it can be effective in treating uncomplicated acute appendicitis in adults 2, 3, 4.
• The antibiotics used to treat appendicitis typically include amoxicillin + clavulanic acid, cefotaxime, or a fluoroquinolone, often in combination with metronidazole or tinidazole 2.

Effectiveness of Antibiotic Therapy

• A systematic review with meta-analysis found that antibiotic therapy was effective in treating uncomplicated acute appendicitis, with 78% of patients experiencing no relapse or rehospitalisation during the first month 2.
• Another study found that 77% of patients treated with antibiotics recovered without the need for surgery beyond 1 year of follow-up 4.
• However, the cumulative incidence of appendicitis recurrence was 39.1% at 5 years in patients treated with antibiotics alone 5.

Factors Influencing Treatment Choice

• The choice of treatment for appendicitis depends on various factors, including the severity of symptoms, the presence of complications, and the patient's overall health status 3.
• Patients with high-risk CT findings, such as appendicolith or a dilated appendix, may be more likely to require surgical management 3.
• In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy 3.

Comparison of Treatment Outcomes

• A study comparing appendectomy and antibiotic therapy found that the overall complication rate was higher in the appendectomy group (24.4% vs 6.5%) 5.
• However, the study also found that the likelihood of late recurrence within 5 years was 39.1% in patients treated with antibiotics alone 5.
• Another study found that delaying operative intervention for acute appendicitis did not pose a significant risk to the patient, with no significant differences in wound complications, antibiotic use, or length of stay between patients who underwent appendectomy within 10 hours of diagnosis and those who underwent appendectomy after 10 hours 6.