What is the complete treatment for appendicitis?

Complete Treatment for Appendicitis

Laparoscopic appendectomy within 24 hours of admission is the standard treatment for acute appendicitis, with intravenous antibiotics started immediately upon diagnosis. 1

Diagnosis

• Clinical assessment combined with laboratory tests and imaging:

  • Adults: Contrast-enhanced low-dose CT scan
  • Children and pregnant women: Ultrasound (first-line)
  • Pregnant women: MRI without contrast (second-line) 1

• Classic symptoms:

  • Periumbilical pain migrating to right lower quadrant
  • Anorexia, nausea, vomiting
  • Low-grade fever 2

Initial Management

Antibiotic Therapy

• Start immediately upon diagnosis:

  • First-line regimens:

    • Amoxicillin/clavulanate
    • Ceftriaxone + Metronidazole
    • Cefotaxime + Metronidazole 1

  • For beta-lactam allergic patients:

    • Ciprofloxacin + Metronidazole
    • Moxifloxacin 1

  • For complicated appendicitis with abscess/peritonitis:

    • Piperacillin-tazobactam (FDA-approved for complicated appendicitis) 3
    • Broader coverage for severe sepsis: meropenem, doripenem, or imipenem/cilastatin 1

Surgical Management

• Laparoscopic appendectomy is preferred over open appendectomy for both uncomplicated and complicated appendicitis 4
• Surgery should be performed within 24 hours of admission to reduce adverse outcomes 4, 1
• Conventional three-port laparoscopic approach is recommended over single-incision technique due to shorter operative times, less pain, and lower wound infection rates 4
• Simple ligation of the appendiceal stump is recommended over stump inversion 1
• Primary skin closure with absorbable intradermal suture for open appendectomy wounds 4
• Routine histopathology examination of the appendix is recommended 4

Treatment Approaches Based on Presentation

Uncomplicated Appendicitis

1. Standard Approach: Laparoscopic appendectomy within 24 hours + antibiotics 4, 1

2. Alternative Approach: Non-operative management with antibiotics may be considered in selected patients without appendicolith or signs of perforation 1, 5

   • Initial IV antibiotics for 48 hours, then oral antibiotics for 7-10 days total
   • Close monitoring for clinical improvement
   • Note: About one-third of patients initially treated with antibiotics will require appendectomy within one year 5

3. Outpatient Management: Outpatient laparoscopic appendectomy is feasible for uncomplicated cases when ambulatory setting is available 4, 1

   • Criteria for same-day discharge: adequate pain control, ability to tolerate oral intake, availability of transportation and support at home 1

Complicated Appendicitis (Perforation, Abscess, Peritonitis)

1. Perforated Appendicitis: Immediate laparoscopic appendectomy + IV antibiotics 4, 1

   • Postoperative broad-spectrum antibiotics for 3-5 days 1

2. Appendiceal Abscess or Phlegmon:

   • Option 1 (preferred where laparoscopic expertise available): Laparoscopic approach 4, 1
   • Option 2: Non-operative management with antibiotics and percutaneous drainage (if available) 4, 1
     • Small abscesses (<4-5cm): Antibiotics alone
     • Larger abscesses: Percutaneous drainage + antibiotics 1
   • Interval appendectomy is not routinely recommended after successful non-operative management 4

Special Populations

Children

• Laparoscopic appendectomy is preferred where equipment and expertise are available 4
• Single incision/transumbilical extracorporeal technique may be considered based on local expertise 4
• Early appendectomy within 8 hours should be performed for complicated appendicitis 4

Pregnant Women

• Transabdominal ultrasound is first-line imaging, MRI without contrast is second-line 1
• Higher risk of complicated appendicitis, requiring careful monitoring 1

Postoperative Care

• Monitor for complications: surgical site infections, intra-abdominal abscess, urinary retention, ileus, and bleeding 1
• For uncomplicated appendicitis: Short course of antibiotics (24 hours or less) 1
• For complicated appendicitis: 3-5 days of broad-spectrum antibiotics 1
• Early switch (after 48h) to oral antibiotics for complicated cases 1

Common Pitfalls and Caveats

• Delaying appendectomy beyond 24 hours increases risk of adverse outcomes 4, 1
• Presence of appendicolith doubles the failure rate of non-operative management 1, 2
• CT findings of appendicolith, mass effect, or dilated appendix >13mm indicate higher risk of antibiotic treatment failure 2
• Prolonged symptom duration before intervention increases perforation risk (17-32% of cases) 6
• Routine use of drains after appendectomy for complicated appendicitis is not recommended unless high infection risk 1