What is the treatment for acute appendicitis?

Treatment of Acute Appendicitis

Laparoscopic appendectomy within 24 hours of hospital admission is the recommended primary treatment for acute appendicitis, with a single preoperative dose of broad-spectrum antibiotics. 1

Surgical Management

Uncomplicated Appendicitis

• Laparoscopic approach is preferred over open appendectomy due to:
  • Shorter hospital stay
  • Lower overall complication rates
  • Reduced morbidity, especially in elderly patients 1
• Timing: Surgery should be performed within 24 hours of hospital admission
• Antibiotic protocol:
  • Single preoperative dose of broad-spectrum antibiotics (e.g., amoxicillin/clavulanate or ceftriaxone + metronidazole)
  • No postoperative antibiotics needed for uncomplicated cases 1
• Simple ligation of the appendiceal stump is recommended over stump inversion 1

Complicated Appendicitis (with peritonitis, perforation, or abscess)

• Immediate laparoscopic appendectomy remains the preferred approach where advanced laparoscopic expertise is available 1
• Antibiotic protocol:
  • Preoperative broad-spectrum antibiotics
  • Postoperative antibiotics for 3-5 days 1
  • Options include piperacillin-tazobactam which is indicated for appendicitis complicated by rupture or abscess 2
• Drains are not recommended following appendectomy for complicated appendicitis unless there is a high risk of infection 1

Non-Operative Management

Appendiceal Abscess or Phlegmon

• Non-operative management with antibiotics and percutaneous drainage (if available) is suggested, particularly when laparoscopic expertise is not available 1
• Percutaneous drainage plus antibiotics is suitable for patients with appendicular abscess 1
• This approach reduces the risk of surgical complications 1

Antibiotics-First Approach for Uncomplicated Appendicitis

• May be considered in select patients without high-risk CT findings 3
• Success rate: approximately 70% of patients with uncomplicated appendicitis can be successfully treated with antibiotics 3
• Higher failure rates (≈40%) are associated with:
  • Appendicolith on CT
  • Mass effect
  • Dilated appendix >13 mm 3
• Antibiotic options include:
  • Piperacillin-tazobactam monotherapy 2, 3
  • Cephalosporins or fluoroquinolones with metronidazole 3

Post-Treatment Considerations

After Non-Operative Management

• Routine interval appendectomy after successful non-operative management is not recommended for young adults (<40 years) and children 1
• For patients ≥40 years old treated non-operatively:
  • Both colonoscopy and interval full-dose contrast-enhanced CT scan are suggested
  • Higher incidence (3-17%) of appendicular neoplasms in this age group 1

Criteria for Same-Day Discharge

• Uncomplicated appendicitis
• Adequate pain control
• Ability to tolerate oral intake
• Availability of transportation and support at home
• No significant comorbidities requiring monitoring 1

Special Populations

Pregnant Patients

• Laparoscopic appendectomy is safe and preferred over open appendectomy
• Special attention to port placement based on gestational age 1
• Timely surgical intervention is recommended to decrease risk of complications 4

Immunosuppressed Patients

• Timely surgical intervention is recommended to decrease risk of complications 4

Elderly Patients

• Laparoscopic approach is particularly beneficial with reduced morbidity 1
• Consider comorbidities when determining surgical approach

Complications to Monitor

• Surgical site infections (reduced with laparoscopic approach)
• Intra-abdominal abscess formation
• Urinary retention
• Ileus
• Bleeding 1

While antibiotics-only treatment has shown some promise in select cases of uncomplicated appendicitis, laparoscopic appendectomy remains the gold standard treatment with the highest success rate and lowest risk of recurrence, particularly for complicated cases or those with high-risk features on imaging.