What is the management of acute appendicitis without perforation (perf) or abscess and without leukocytosis, as diagnosed on computed tomography (CT)?

Management of Acute Appendicitis on CT Without Perforation or Abscess and Without Leukocytosis

Laparoscopic appendectomy is the recommended treatment for acute appendicitis diagnosed on CT scan without perforation or abscess, even in the absence of leukocytosis. 1

Diagnostic Considerations

When evaluating a patient with CT-diagnosed acute appendicitis without leukocytosis:

• The absence of leukocytosis does not rule out appendicitis when CT findings are positive
• CT scan is highly sensitive (>90%) for diagnosing appendicitis, making it a reliable diagnostic tool even when laboratory markers are normal 1
• Clinical scoring systems like Alvarado or AIR scores should be used in conjunction with imaging, but CT findings take precedence in diagnosis 1

Management Algorithm

First-line Treatment:

1. Surgical Management:

   • Laparoscopic appendectomy is preferred over open appendectomy due to:
     • Shorter length of hospital stay
     • Less postoperative pain
     • Earlier recovery
     • Lower overall complication rates 1

2. Preoperative Care:

   • Administer broad-spectrum antibiotics preoperatively 1
   • Single dose of antibiotics effective against enteric gram-negative organisms and anaerobes

Alternative Approach - Non-Operative Management (NOM):

NOM with antibiotics may be considered in selected patients who:

• Have uncomplicated appendicitis confirmed by CT
• Wish to avoid surgery and accept the risk of recurrence
• Have no clinical signs of complicated appendicitis 1

However, NOM has important limitations:

• High recurrence rates (approximately 27%) 1
• Not recommended if appendicolith is present (47-60% failure rate) 2
• Requires close follow-up and clear return precautions

Special Considerations

Absence of Leukocytosis:

• Normal white blood cell count does not exclude appendicitis when CT findings are positive
• The WSES guidelines emphasize that diagnosis should not rely solely on elevated leukocyte count and CRP values 1
• CT findings take precedence over laboratory values in confirming diagnosis

Appendicolith:

• If an appendicolith is identified on CT, appendectomy is strongly recommended due to:
  • Higher failure rates with non-operative management (47-60%)
  • Increased risk of progression to complicated appendicitis 2

Age Considerations:

• For elderly patients (>40 years):
  • CT scan is recommended for all with Alvarado score ≥5 1
  • Elective colonic screening is recommended after treatment 1
  • Laparoscopic approach is preferred due to reduced length of stay and morbidity 1

Postoperative Care

• For uncomplicated appendicitis, postoperative antibiotics are not necessary 1
• Routine histopathology is recommended after appendectomy 1
• Intra-operative grading systems should be used to determine optimal postoperative management 1

Follow-up

• If the patient undergoes appendectomy, routine follow-up is sufficient
• If non-operative management is chosen:
  • Schedule clinical follow-up within 2-4 weeks
  • Consider repeat imaging to assess for any changes
  • Provide clear instructions about warning signs requiring immediate medical attention 2

Pitfalls to Avoid

• Don't dismiss appendicitis based solely on normal white blood cell count when CT is positive
• Don't delay appendectomy when indicated, as this can lead to progression to perforation
• Don't attempt non-operative management if an appendicolith is present, as failure rates are high
• Don't forget to consider underlying conditions (like malignancy) in patients over 40 years old