What is the plan of care for a patient with suspected perforated appendicitis?

Management of Suspected Perforated Appendicitis

Patients with perforated appendicitis should undergo urgent surgical intervention to provide adequate source control. 1

Initial Assessment and Diagnosis

• Clinical presentation: Evaluate for right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant
• Laboratory tests: Check WBC count, neutrophil count, and CRP (elevated values together have 96% sensitivity)
• Imaging:
  • First-line: POCUS (Point-of-care Ultrasound) if performed by an experienced operator
  • Second-line: Abdominal CT scan for non-pregnant adults
  • For pregnant women: MRI after inconclusive ultrasound to avoid radiation exposure 2

Management Algorithm

1. Immediate Interventions

• Start broad-spectrum antibiotics immediately upon diagnosis 1
  • Coverage must include agents effective against facultative and aerobic gram-negative organisms and anaerobic organisms 1
  • Recommended regimens:
    • Piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate, or imipenem-cilastatin
    • Alternative: Ceftriaxone-metronidazole or ticarcillin-clavulanate plus gentamicin 1
    • For pediatric patients: Ertapenem has shown 83.7% clinical success rate in complicated intra-abdominal infections 3

2. Source Control Options

A. Surgical Management (Primary Approach)

• Urgent surgical intervention is required for perforated appendicitis 1
• Both laparoscopic and open appendectomy are acceptable approaches 1
  • Choice should be based on surgeon expertise 1
  • In COVID-19 positive patients, open approach may be preferred to minimize aerosolization risk 1
• Timing: Perform surgery as soon as reasonably feasible after diagnosis and initial stabilization 1

B. Alternative Management for Specific Scenarios

• For well-circumscribed periappendiceal abscess:

  • Percutaneous drainage (if technically feasible) plus IV antibiotics 1
  • Appendectomy is generally deferred in these patients 1

• For periappendiceal phlegmon or small abscess not amenable to drainage:

  • Initial conservative management with IV antibiotics 1
  • Plan for interval appendectomy 6-12 weeks later 4
  • Close monitoring with clinical and radiological surveillance at 12-24 hour intervals 1

Antibiotic Therapy Details

• Duration:

  • Continue antibiotics for 3-5 days postoperatively in cases of perforated appendicitis 1
  • For patients managed non-operatively, continue until clinical symptoms and signs of infection resolve 1

• Transition to oral antibiotics:

  • In children with complicated appendicitis, early switch (after 48h) to oral antibiotics is safe and cost-effective 1

Special Considerations

• Complications to monitor:

  • Intraperitoneal abscess formation (occurs in up to 27% of cases) 5
  • Risk factors for treatment failure with non-operative management: WBC >15,000, presence of fecalith, and symptoms >48 hours 5

• Abdominal drainage:

  • Evidence is uncertain whether abdominal drainage prevents intraperitoneal abscess formation 6
  • May potentially increase hospital stay and mortality risk 6

• Pregnant patients:

  • Require timely surgical intervention to decrease risk of complications 7
  • Use ultrasound as first-line imaging, MRI as second-line 2

• Immunocompromised patients:

  • Should undergo appendectomy as soon as possible (within 24 hours of diagnosis) 1

Follow-up Care

• For patients managed non-operatively with interval appendectomy, plan for surgery in 6-12 weeks 4
• Monitor closely for signs of clinical deterioration during conservative management
• If patient fails to improve with conservative management, proceed to immediate surgical intervention 1