What is the treatment for suspected appendicitis?

Treatment of Suspected Appendicitis

The standard treatment for suspected appendicitis is surgical appendectomy, with antimicrobial therapy administered to all patients who receive a diagnosis of appendicitis, though non-operative management with antibiotics may be considered in selected patients with uncomplicated appendicitis. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Clinical Assessment and Risk Stratification

   • Use validated scoring systems (AIR score, Alvarado score, AAS score) to stratify patients 1
   • High-risk patients younger than 40 years with high scores may not require pre-operative imaging 1
   • Intermediate-risk patients should undergo systematic diagnostic imaging 1

2. Imaging

   • First-line imaging:
     • Adults: Point-of-care ultrasound (POCUS) is recommended as first-line 1
     • Children: Ultrasound is preferred to avoid radiation exposure 1
     • Pregnant women: Ultrasound or MRI in first trimester 1, 2
   • Second-line imaging:
     • Low-dose contrast-enhanced CT scan if ultrasound is negative or inconclusive 1
   • For negative imaging but persistent symptoms, follow-up at 24 hours is recommended 1

Treatment Algorithm

1. Uncomplicated Appendicitis

Surgical Management (First-line):

• Appendectomy should be performed as soon as reasonably feasible 1
• Both laparoscopic and open appendectomy are acceptable approaches 1
  • Laparoscopic approach is preferred when surgical expertise is available 2
• Preoperative single dose of broad-spectrum antibiotics covering aerobic and anaerobic organisms 1, 2
• Postoperative antibiotics are not recommended for uncomplicated appendicitis 2

Non-Operative Management (Alternative):

• Can be discussed as a safe alternative in selected patients 1:
  • Absence of appendicolith 1, 3
  • No high-risk CT findings (appendix >13mm, mass effect) 3
  • Marked improvement with initial antibiotics 1
  • Male patients who can be hospitalized for 48 hours with close monitoring 1
• Antibiotic regimen:
  • Initial intravenous antibiotics with subsequent switch to oral antibiotics 1
  • Coverage for aerobic and anaerobic organisms 1, 2
  • Minimum 3 days treatment until symptoms resolve 1
• Recurrence rates after non-operative management range from 12-24% 2, 3

2. Complicated Appendicitis (Perforation, Abscess, Peritonitis)

• Perforated appendicitis: Urgent surgical intervention for source control 1
• Well-circumscribed periappendiceal abscess:
  • Percutaneous drainage or operative drainage when necessary 1, 2
  • Appendectomy is generally deferred 1
• Periappendiceal phlegmon:
  • Selected patients may delay or avoid immediate surgery 1
  • Treated with antimicrobial therapy 1
• Postoperative antibiotics:
  • Continue for 3-5 days or until clinical improvement 2
  • Early switch to oral antibiotics based on clinical condition 1

Special Considerations

• Pregnant patients: Ultrasound first, MRI if inconclusive, limited CT if necessary 1
• Children: Non-operative management can be considered in uncomplicated cases without appendicolith 1
• Equivocal diagnosis: Close follow-up with repeat evaluation at 24 hours 1, 2
• Post non-operative management: Consider colonoscopy and contrast-enhanced CT due to higher risk of appendiceal neoplasms 2

Common Pitfalls to Avoid

• Delaying source control in patients with sepsis or peritonitis 2
• Failing to provide adequate antibiotic coverage for both aerobic and anaerobic organisms 1, 2
• Prolonging antibiotics unnecessarily in uncomplicated appendicitis 2
• Routine interval appendectomy after successful non-operative management 2
• Missing the diagnosis in pregnant women, very young, elderly, or immunosuppressed patients who may present atypically 4

By following this structured approach to the diagnosis and management of suspected appendicitis, clinicians can optimize patient outcomes while minimizing unnecessary interventions and complications.