What is the management of appendicitis?

Management of Appendicitis

The management of appendicitis should follow a structured approach based on disease severity, with laparoscopic appendectomy remaining the standard treatment for uncomplicated appendicitis, while non-operative management with antibiotics is a reasonable alternative in select cases. 1, 2

Classification and Initial Assessment

• Uncomplicated appendicitis: Inflamed appendix without perforation, gangrene, or abscess
• Complicated appendicitis: Perforated appendix with periappendiceal abscess, phlegmon, or generalized peritonitis

Diagnostic Approach

• Imaging is recommended for all patients with suspected appendicitis
  • CT scan is preferred for adults
  • Ultrasound is recommended for children and pregnant women in first trimester 1
• For equivocal imaging findings, close follow-up is essential with repeat evaluation at 24 hours 1

Treatment Algorithm

1. Uncomplicated Appendicitis

Surgical Management (First-line)

• Laparoscopic appendectomy is preferred when surgical expertise is available 1, 2
• Open appendectomy remains acceptable based on surgeon expertise 1
• Operative intervention should be performed as soon as reasonably feasible 1
• Routine histopathology of the appendix specimen is recommended 1

Antibiotic Management (Alternative)

• May be considered in selected patients, particularly:
  • Patients showing marked improvement with initial antibiotics 1
  • Male patients who can be hospitalized for 48 hours with close monitoring 1
  • Patients without high-risk CT findings (appendicolith, mass effect, appendix >13mm) 2
• Success rate of approximately 70% with antibiotics alone 2
• Antibiotic regimen should cover both aerobic and anaerobic organisms:
  • Piperacillin-tazobactam for intra-abdominal infections 3
  • Or cephalosporins/fluoroquinolones plus metronidazole 2

2. Complicated Appendicitis with Abscess/Phlegmon

Non-operative Management

• Recommended in settings where laparoscopic expertise is limited 1
• Components:
  • Broad-spectrum antibiotics
  • Percutaneous drainage of well-circumscribed abscesses if accessible 1, 4
  • Close monitoring for clinical improvement

Surgical Management

• Laparoscopic approach is preferred where advanced expertise is available 1
• May be associated with shorter hospital stay and fewer additional interventions 1
• Low threshold for conversion to open surgery should be maintained 1

3. Perforated Appendicitis without Abscess

• Urgent surgical intervention for source control is recommended 1
• Broad-spectrum antibiotics covering aerobic and anaerobic organisms 1, 3

Antibiotic Recommendations

• Preoperative: Single dose of broad-spectrum antibiotics 0-60 minutes before incision 1
• Postoperative:
  • Uncomplicated appendicitis: No postoperative antibiotics needed 1
  • Complicated appendicitis: Continue antibiotics for at least 3-5 days or until clinical improvement 1

Special Considerations

Interval Appendectomy

• Not recommended routinely after successful non-operative management in young adults (<40 years) and children 1
• Only recommended for patients with recurrent symptoms 1

Patients ≥40 Years Old

• Higher risk of appendiceal neoplasms (3-17%) 1
• Recommend colonoscopy and contrast-enhanced CT scan after non-operative management 1

Pregnant Patients

• Ultrasound or MRI preferred in first trimester 1
• Consider laparoscopy or limited CT if other imaging is inconclusive 1

Complications to Monitor

• Inadequate source control may lead to progressive sepsis and organ failure 4
• Recurrence rates after non-operative management range from 12-24% 1
• Wound infections are less common with antibiotic-first approach 5

Key Pitfalls to Avoid

• Delaying source control in patients with sepsis or peritonitis
• Failing to provide adequate antibiotic coverage for both aerobic and anaerobic organisms
• Routine interval appendectomy after successful non-operative management
• Missing potential neoplasms in older patients treated non-operatively

The management approach should be tailored based on disease severity, patient factors, and available expertise, with the primary goal of minimizing morbidity and mortality.