What is the treatment for acute appendicitis?

Treatment of Acute Appendicitis

The treatment of choice for acute appendicitis is laparoscopic appendectomy, which offers shorter hospital stays, reduced readmissions, and fewer additional interventions compared to conservative treatment. 1

Diagnostic Approach

• Right lower quadrant pain, anorexia, nausea/vomiting, and low-grade fever are classic symptoms
• CT scan is the preferred imaging modality for confirmation
• CT findings that predict higher failure rates with antibiotic-only approach include:
  • Appendicolith
  • Mass effect
  • Dilated appendix greater than 13 mm 2

Treatment Algorithm

1. Uncomplicated Appendicitis

• Primary treatment: Laparoscopic appendectomy within 24 hours of hospital admission 1
• Antibiotic management:
  • Single preoperative dose of broad-spectrum antibiotics (e.g., amoxicillin/clavulanate, ceftriaxone + metronidazole) 3, 1
  • Postoperative antibiotics are NOT recommended 3, 1

2. Complicated Appendicitis (with perforation or abscess)

• With diffuse peritonitis:

  • Immediate laparoscopic appendectomy 3
  • Postoperative broad-spectrum antibiotics for 3-5 days 3

• With localized phlegmon or abscess:

  • Laparoscopic approach is recommended where advanced expertise is available 3
  • Alternative: Non-operative management with antibiotics and percutaneous drainage (if accessible) 3, 1
  • Antibiotics should not be prolonged beyond 3-5 days with adequate source control 3, 1

3. Special Considerations for Non-Operative Management (NOM)

• Appendicular abscess: Percutaneous drainage plus antibiotics 3, 1
• After successful NOM:
  • Routine interval appendectomy is NOT recommended for young adults (<40 years) and children 3
  • For patients ≥40 years: Both colonoscopy and interval CT scan are recommended due to higher incidence (3-17%) of appendicular neoplasms 3

Antibiotic Selection

For complicated appendicitis, appropriate options include:

• Piperacillin-tazobactam (FDA-approved for appendicitis complicated by rupture or abscess) 4
• Ceftriaxone + metronidazole
• Cefotaxime + metronidazole 1

Important Considerations

Limitations of Antibiotic-Only Approach

While antibiotics alone may treat uncomplicated appendicitis in approximately 70% of patients 2, there are significant limitations:

• 30.7% of antibiotic-treated patients require appendectomy within one year 5
• Higher rates of unsuccessful treatment (76 more people per 1000) compared to surgery 5
• Increased risk of negative appendectomies if surgery is eventually needed 5

Benefits of Laparoscopic Approach

• Reduced wound infections compared to open appendectomy 5
• Shorter hospital stay and reduced morbidity, especially in elderly patients 3
• Lower overall complication rates 3

Common Pitfalls to Avoid

1. Delaying surgery beyond 24 hours for uncomplicated appendicitis
2. Prolonging antibiotics beyond 3-5 days in complicated appendicitis with adequate source control
3. Failing to arrange colonoscopy and CT scan for patients ≥40 years treated non-operatively
4. Missing appendicular neoplasms in older patients (3-17% incidence in those ≥40 years) 3

The evidence strongly supports laparoscopic appendectomy as the gold standard treatment for acute appendicitis, with specific antibiotic protocols and management strategies based on the severity and complications of the disease.