What is the standard treatment for appendicitis?

Standard Treatment for Appendicitis

The standard treatment for appendicitis is laparoscopic appendectomy, which is strongly recommended over open appendectomy for both uncomplicated and complicated acute appendicitis, due to its association with less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, and better quality of life. 1, 2

Treatment Algorithm

Initial Assessment and Management

• Imaging diagnosis: Ultrasound as first-line imaging for children and pregnant women; CT scan for adults
• Antibiotic initiation: Single preoperative dose of broad-spectrum antibiotics (e.g., amoxicillin/clavulanate or ceftriaxone + metronidazole) for all patients undergoing appendectomy 2

Treatment Options Based on Appendicitis Type

Uncomplicated Appendicitis:

1. Surgical Management (First-line):

   • Laparoscopic appendectomy using conventional three-port technique 1
   • Should be performed within 24 hours of admission 1
   • Simple ligation of appendiceal stump rather than stump inversion 1, 2
   • No postoperative antibiotics needed 2

2. Non-operative Management (Alternative):

   • Can be discussed as a safe alternative to surgery in selected patients without appendicolith 1, 2
   • Initial IV antibiotics with subsequent switch to oral antibiotics 1
   • Total duration of antibiotic treatment: 7-10 days 2
   • Recurrence rate approximately 27% at 1 year 2

Complicated Appendicitis (Perforation/Abscess):

1. Surgical Management:

   • Early appendectomy (within 8 hours) recommended 1, 2
   • Laparoscopic approach preferred 1
   • Postoperative broad-spectrum antibiotics for 3-5 days 2
   • Against the use of drains following appendectomy 1

2. Abscess Management:

   • Small abscesses (<4-5cm): Antibiotics alone
   • Larger abscesses: Percutaneous drainage plus antibiotics 2

Special Considerations

Pediatric Patients

• Laparoscopic appendectomy recommended where equipment and expertise are available 1
• Early appendectomy within 8 hours for complicated appendicitis 1
• Non-operative management can be considered for uncomplicated appendicitis without appendicolith 1, 2

Pregnant Patients

• Laparoscopic appendectomy preferred over open appendectomy 1, 2
• Transabdominal ultrasound as first-line imaging 2
• MRI without contrast as second-line imaging 2

Outpatient Management

• Outpatient laparoscopic appendectomy is feasible for uncomplicated appendicitis when ambulatory setting is available 1
• Criteria for same-day discharge: uncomplicated appendicitis, adequate pain control, ability to tolerate oral intake, availability of transportation and support at home 2

Important Caveats

• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
• Appendicolith presence predicts higher failure rates with non-operative management 2, 3
• CT findings of mass effect and dilated appendix >13mm are associated with higher risk of antibiotic treatment failure (~40%) 3
• Routine histopathology examination of the appendix is recommended after appendectomy to rule out underlying conditions 1, 2

While recent evidence suggests that antibiotic therapy can successfully treat uncomplicated appendicitis in approximately 70% of patients 3, laparoscopic appendectomy remains the gold standard treatment with the highest success rate and lowest risk of recurrence.