What is the treatment for a stone in the appendix?

Treatment for a Stone in the Appendix

The recommended treatment for a stone in the appendix (appendicolith) is surgical removal through laparoscopic appendectomy, which is the safest and most effective approach to prevent complications such as perforation and abscess formation. 1

Treatment Algorithm

Initial Assessment

• Evaluate for signs of complicated appendicitis (phlegmon or abscess formation)
• Check serum C-reactive protein (CRP) levels and stone size on imaging
  • CRP >10 mg/dL and stone diameter >10 mm are significantly associated with appendiceal perforation 2

Treatment Options Based on Clinical Presentation:

1. Uncomplicated Appendicitis with Appendicolith

• Primary Treatment: Laparoscopic Appendectomy
  • Preferred over open appendectomy due to:
    • Shorter length of hospital stay
    • Less postoperative pain
    • Earlier postoperative recovery
    • Lower overall complication rate 1
  • Technical considerations:
    • Use of safety wire recommended
    • Careful removal of appendix with stone to prevent dropped appendicoliths 3

2. Appendicitis with Phlegmon or Abscess

• If laparoscopic expertise is available:

  • Laparoscopic appendectomy is recommended as first-line treatment 1
  • Associated with fewer readmissions and fewer additional interventions than conservative treatment

• If laparoscopic expertise is not available:

  • Non-operative management with antibiotics and percutaneous drainage (if available) 1
  • Antibiotic regimens:
    • Amoxicillin/clavulanate 1.2-2.2g every 6 hours, OR
    • Ceftriaxone 2g daily + metronidazole 500mg every 6 hours, OR
    • Cefotaxime 2g every 8 hours + metronidazole 500mg every 6 hours 4

3. Special Considerations for Small Appendicoliths

• For appendicoliths ≤5 mm with CRP ≤5 mg/dL, non-surgical therapy could be considered 2
• However, surgery remains the standard of care for appendicoliths due to higher failure rates with non-operative management 5, 2

Important Caveats and Pitfalls

1. Risk of Dropped Appendicoliths

   • Can lead to abscess formation in other locations if inadvertently dropped during laparoscopic surgery 3
   • Careful extraction technique is essential

2. Interval Appendectomy After Non-Operative Management

   • Not routinely recommended for young adults (<40 years) and children 1
   • Should be performed only for patients with recurrent symptoms
   • For patients ≥40 years, colonoscopy and interval CT scan are recommended due to higher incidence of appendicular neoplasms (3-17%) 1

3. Failure of Non-Operative Management

   • Presence of appendicolith increases risk of failure with antibiotic-only approach 4, 5
   • CT findings of appendicolith, mass effect, and dilated appendix >13 mm are associated with higher risk of treatment failure (approximately 40%) 5

4. Intraoperative Considerations

   • Routine intraoperative irrigation does not prevent intra-abdominal abscess formation and may be avoided 1
   • Histopathological examination of the appendix is recommended after appendectomy 1

The evidence strongly supports laparoscopic appendectomy as the treatment of choice for appendicitis with appendicolith, with non-operative management reserved for specific clinical scenarios where surgical expertise is limited or in cases with very small stones and minimal inflammation 1, 2.