Standard Treatment for Suspected Appendicitis
The standard treatment for suspected appendicitis includes imaging (preferably CT scan for adults and ultrasound for children/pregnant women), followed by appendectomy within 24 hours of diagnosis for most cases, although non-operative management with antibiotics is an acceptable alternative for selected patients with uncomplicated appendicitis. 1, 2
Diagnostic Approach
Clinical Assessment
- Initial evaluation should include assessment for classic symptoms:
- Periumbilical pain migrating to right lower quadrant
- Anorexia, nausea, vomiting
- Low-grade fever
- Right lower quadrant tenderness
Laboratory Tests
- Complete blood count (elevated leukocytes and neutrophils)
- C-reactive protein (>10 mg/L suggests inflammation)
- Note: Laboratory tests alone should not be used to confirm or exclude diagnosis 2
Imaging Studies
- Adults: CT scan with IV contrast is the preferred imaging modality (sensitivity and specificity >95%) 2
- Children: Ultrasound as first-line imaging 1, 2
- Pregnant women: Graded compression transabdominal ultrasound as initial imaging; MRI if ultrasound is inconclusive 1, 2
Treatment Options
Surgical Management
- Appendectomy remains the standard treatment for acute appendicitis 1, 3
- Laparoscopic approach is preferred over open appendectomy when feasible 2
- Surgery should be performed within 24 hours of diagnosis to minimize complications 2
- Short in-hospital delay (up to 24 hours) is safe for uncomplicated cases and does not increase complication rates 1, 4
Antibiotic Therapy
- All patients diagnosed with appendicitis should receive antimicrobial therapy 1
- Preoperative antibiotics should be administered 0-60 minutes before surgical incision 2
- Antibiotics should cover aerobic gram-negative, facultative, and anaerobic organisms 1, 2
- For perforated/gangrenous appendicitis, antibiotics should be continued for 3-5 days postoperatively 2
Non-Operative Management (NOM)
- Antibiotic therapy alone can be considered for selected patients with uncomplicated appendicitis 1, 2, 3
- Success rate of approximately 70% with antibiotic-only approach 3
- NOM should be avoided in patients with:
- Initial IV antibiotics with subsequent switch to oral antibiotics is recommended for NOM 1
Special Considerations
Children
- All children, especially those <3 years, should undergo imaging when diagnosis is uncertain 1
- NOM with antibiotics is feasible and safe in selected pediatric patients without appendicolith 1
- Children <5 years require prompt evaluation due to less specific symptoms and higher perforation risk 2
Elderly Patients
- Higher risk of appendiceal neoplasms (3-17%) in adults >40 years 2
- CT with IV contrast is essential in this population 2
Pregnant Women
- Pregnancy test before imaging studies 2
- Ultrasound as first-line imaging; MRI if ultrasound is inconclusive 1, 2
Management Algorithm
Initial Presentation:
- Clinical assessment + laboratory tests
- Place patient NPO during evaluation 2
Imaging Decision:
- Adults: CT scan with IV contrast
- Children/Pregnant women: Ultrasound first
Treatment Decision:
- Uncomplicated appendicitis:
- Without high-risk CT findings: Either appendectomy or antibiotics
- With high-risk CT findings (appendicolith, mass effect, diameter ≥13 mm): Appendectomy preferred
- Complicated appendicitis (perforation, abscess): Appendectomy + extended antibiotic course
- Uncomplicated appendicitis:
Timing of Surgery:
Pitfalls and Caveats
- Do not rely solely on laboratory tests for diagnosis 2
- Never omit imaging in women regardless of clinical presentation 2
- Do not perform CT without IV contrast in adults 2
- Recognize that imaging has a small but measurable false-negative rate; follow-up at 24 hours is recommended for patients with negative imaging but persistent symptoms 1
- Delaying antibiotics can increase complication rates 2
- Perforation risk increases with prolonged symptoms before intervention 6