What is the management for a patient with a CT abdomen consistent with appendicitis?

Management of CT-Confirmed Appendicitis

Appendectomy remains the treatment of choice for acute appendicitis, including cases confirmed by CT scan. 1

Surgical Management

• Timing: Surgery should be performed as soon as reasonably feasible after diagnosis 1
• Surgical approach:
  • Both laparoscopic and open appendectomy are acceptable approaches 1
  • Laparoscopic appendectomy offers benefits including:
    • Less post-operative pain
    • Lower wound infection rates
    • Shorter hospital stay 2, 3
  • The choice between open and laparoscopic should be based on surgeon expertise 1

Antibiotic Therapy

• All patients diagnosed with appendicitis should receive antimicrobial therapy 1
• Preoperative antibiotics: Should be administered 0-60 minutes before surgical incision 2
• Antibiotic coverage: Should include agents effective against:
  • Facultative and aerobic gram-negative organisms
  • Anaerobic organisms 1
• Antibiotic options:
  • Piperacillin-tazobactam monotherapy
  • Cephalosporins with metronidazole
  • Fluoroquinolones with metronidazole 3
• Duration:
  • Uncomplicated appendicitis: Single preoperative dose is sufficient
  • Perforated/gangrenous appendicitis: Continue antibiotics for 3-5 days 2

Special Considerations

Uncomplicated Appendicitis

• While appendectomy remains the standard treatment, antibiotic therapy alone may be considered in selected patients 1, 3
• Success rate of antibiotic-only approach: Approximately 70-73% of patients avoid surgery within 1 year 3, 4
• CT findings predicting antibiotic failure:
  • Appendicolith (appendiceal fecalith)
  • Appendiceal diameter ≥13 mm
  • Mass effect 3

Periappendiceal Abscess

• Patients with periappendiceal abscess can be managed with percutaneous image-guided drainage if available 1
• When percutaneous drainage is not available, surgical intervention is recommended 1
• Interval appendectomy may not be necessary after successful non-operative treatment, but should be performed for patients with recurrent symptoms 1

Perforated Appendicitis

• Requires more aggressive management with longer courses of antibiotics (3-5 days) 2
• Higher risk of complications including intra-abdominal abscess formation

Monitoring and Follow-up

• For patients with uncomplicated appendicitis treated non-operatively:
  • Close clinical monitoring is mandatory
  • Follow-up at regular intervals to assess for recurrence
  • Approximately 27% may require appendectomy within 1 year 4

Pitfalls and Caveats

• Delaying surgery beyond 24 hours increases risk of perforation
• Routine intraoperative irrigation during appendectomy does not prevent intra-abdominal abscess formation and may be avoided 1
• Antibiotic-only approach requires careful patient selection and should not be used in patients with:
  • Appendicolith
  • Significantly dilated appendix (>13 mm)
  • Evidence of perforation or abscess 3
• Non-operative management requires CT confirmation of uncomplicated appendicitis for optimal patient selection 1

In summary, while antibiotic therapy alone can be successful in selected patients with uncomplicated appendicitis, appendectomy remains the gold standard treatment for CT-confirmed appendicitis due to the significant recurrence rates with antibiotic therapy alone and the need for CT-proven diagnosis of uncomplicated appendicitis.