What is the treatment for a ruptured appendix?

Treatment for a Ruptured Appendix

The treatment for a ruptured appendix requires immediate surgical intervention with laparoscopic appendectomy, combined with broad-spectrum antibiotics and possible abscess drainage, as recommended by the World Journal of Emergency Surgery guidelines. 1

Initial Management

• Immediate intervention: Surgical management should be initiated within 8 hours of diagnosis for complicated appendicitis to reduce adverse outcomes 1
• Antibiotic therapy: Start intravenous broad-spectrum antibiotics immediately upon diagnosis 1
  • Recommended regimens include:
    • Amoxicillin/clavulanate
    • Ceftriaxone + Metronidazole
    • Cefotaxime + Metronidazole
    • For beta-lactam allergic patients: Ciprofloxacin + Metronidazole or Moxifloxacin

Surgical Approach

• Laparoscopic appendectomy is preferred over open appendectomy for complicated appendicitis 2, 1
• Conventional three-port laparoscopic approach is recommended over single-incision technique due to:
  • Shorter operative times
  • Less pain
  • Lower wound infection rates 1
• Simple ligation of the appendiceal stump is recommended over stump inversion 1

Management of Abscess or Phlegmon

For cases with appendiceal abscess or phlegmon, two approaches may be considered:

1. Surgical approach: Early appendectomy has shown superior outcomes compared with initial non-operative management, with lower incidence of bowel resection (3.3% vs 17.1%) 2

2. Non-operative management: For selected cases with well-circumscribed abscesses:

   • Antibiotics and percutaneous drainage (if available) 1
   • Small abscesses (<4-5cm) may be treated with antibiotics alone
   • Larger abscesses require percutaneous drainage combined with antibiotics 1
   • If percutaneous drainage is not possible, laparoscopic drainage is a safe and effective alternative 3

Antibiotic Management

• Duration: Postoperative broad-spectrum antibiotics are recommended for 3-5 days in patients with complicated appendicitis 1
• Early switch: After 48 hours, switch to oral antibiotics with total therapy duration less than 7 days 1
• Extended coverage: Total antibiotic treatment may be extended to 7-10 days in severe cases 1

Post-Surgical Care

• Monitoring: Close observation for complications including:

  • Surgical site infections
  • Intra-abdominal abscess formation
  • Urinary retention
  • Ileus
  • Bleeding 1

• Abdominal drainage: The evidence is very uncertain whether abdominal drainage prevents intraperitoneal abscess after appendectomy for complicated appendicitis, and may actually increase hospital stay and mortality 4

Special Considerations

• Pregnant patients: More likely to present with complicated (perforated or gangrenous) appendicitis; laparoscopic approach is still preferred with modifications based on gestational age 1

• Children: Similar principles apply, with emphasis on timely surgical intervention and appropriate antibiotic coverage 1

• Elderly patients: May require more aggressive initial management due to higher risk of complications

Follow-up

• Routine histopathology examination of the appendix is recommended after appendectomy to rule out any underlying conditions 1

• Clinical follow-up to monitor for post-operative complications and ensure complete resolution of infection

The evidence strongly supports early surgical intervention for ruptured appendix, with laparoscopic appendectomy being the preferred approach when expertise is available. Delaying appendectomy beyond 24 hours increases the risk of adverse outcomes 1, making timely surgical management crucial for optimal patient outcomes.