What is the best management for acute appendicitis?

Management of Acute Appendicitis

For acute appendicitis, laparoscopic appendectomy within 24 hours of admission for uncomplicated cases and within 8 hours for complicated cases is the preferred treatment approach, with appropriate antibiotic therapy based on the severity of infection. 1, 2

Diagnostic Approach

• Imaging studies are essential for confirming diagnosis:
  • CT scan is preferred for adults
  • Ultrasound or MRI recommended for pregnant women and children (to avoid radiation) 1, 2
• Laboratory tests should include:
  • Complete blood count
  • Basic metabolic panel 2

Surgical Management

Timing of Surgery

• Uncomplicated appendicitis: Appendectomy within 24 hours of admission 1
• Complicated appendicitis: Early appendectomy within 8 hours 1
• Delaying surgery beyond these timeframes does not significantly improve outcomes and may increase complications in complicated cases 1

Surgical Approach

• Laparoscopic appendectomy is strongly preferred over open appendectomy due to: 1, 2
  • Less postoperative pain
  • Lower incidence of surgical site infections
  • Shorter hospital stay
  • Earlier return to work and physical activity
  • Better cosmetic results
  • Lower overall hospital costs

Special Situations

• Periappendiceal abscess: Can be managed with percutaneous image-guided drainage followed by antibiotics 1
• Pregnancy: Laparoscopic approach remains safe with special attention to port placement based on gestational age 2
• Appendiceal phlegmon: May be managed initially with antibiotics, with interval appendectomy if symptoms recur 1, 2

Antibiotic Management

Uncomplicated Appendicitis

• Single preoperative dose of broad-spectrum antibiotics 2
• No postoperative antibiotics needed 2

Complicated Appendicitis

• Preoperative antibiotics plus continued postoperative antibiotics 2
• Recommended regimens: 1, 2
  • Amoxicillin/clavulanate
  • Ceftriaxone + metronidazole
  • Cefotaxime + metronidazole
  • For critically ill patients: carbapenems (meropenem, doripenem, or imipenem/cilastatin)

Non-Operative Management

• May be considered in select patients with uncomplicated appendicitis without appendicolith 3
• Success rate approximately 70% with broad-spectrum antibiotics 3
• Higher risk of failure with: 3
  • Appendicolith on imaging
  • Appendiceal diameter ≥13 mm
  • Mass effect

Post-Operative Care

• Most uncomplicated cases can be discharged within 24-48 hours 2
• Criteria for safe same-day discharge: 2
  • Adequate pain control
  • Ability to tolerate oral intake
  • Available transportation and support at home
  • No significant comorbidities requiring monitoring

Follow-up Considerations

• For patients ≥40 years with complicated appendicitis treated non-operatively, consider colonoscopy and interval CT scan 2
• Monitor for complications: surgical site infections, intra-abdominal abscess, urinary retention, ileus, and bleeding 2

Pitfalls to Avoid

• Delaying surgery beyond recommended timeframes for complicated appendicitis
• Failing to provide appropriate antibiotic coverage for complicated cases
• Overlooking the need for drainage in patients with periappendiceal abscess
• Dismissing non-operative management in appropriate candidates, particularly those with high surgical risk