What is the best treatment approach for a patient with a ruptured appendix and peritonitis?

Treatment of Ruptured Appendix with Peritonitis

Patients with a ruptured appendix and peritonitis should undergo immediate surgical intervention with source control, along with broad-spectrum antibiotics and appropriate fluid resuscitation to reduce mortality and morbidity. 1

Initial Management

Resuscitation

• Rapid restoration of intravascular volume to promote physiological stability 1
• For patients with septic shock, resuscitation should begin immediately when hypotension is identified 1
• For patients without volume depletion, intravenous fluid therapy should begin when diagnosis is first suspected 1

Antimicrobial Therapy

• Initiate broad-spectrum antibiotics immediately once diagnosis is made or considered likely 1
• For patients with septic shock, antibiotics should be administered as soon as possible 1
• Recommended regimens include:
  • Piperacillin-tazobactam (13.5g/day divided q6h) 2
  • Other options: carbapenems or cephalosporins with metronidazole 1
• Ensure antimicrobial drug levels are maintained during source control intervention 1

Surgical Management

Timing of Surgery

• Patients with diffuse peritonitis should undergo emergency surgical procedure as soon as possible, even if ongoing resuscitation measures need to be continued during the procedure 1
• For hemodynamically stable patients without evidence of acute organ failure, intervention may be delayed for up to 24 hours if appropriate antimicrobial therapy is given and careful clinical monitoring is provided 1

Surgical Approach

• Laparoscopic appendectomy is preferred when expertise is available, as it's associated with reduced length of stay, morbidity, and costs 1
• Open surgery should be considered when laparoscopic expertise is unavailable or in cases of extensive peritonitis 1
• Primary objectives of surgical intervention include:
  • Determining the cause of peritonitis
  • Draining fluid collections
  • Controlling the origin of abdominal sepsis (appendectomy) 1

Perioperative Considerations

• Abdominal drainage may be considered in cases of complicated appendicitis with perforation/abscess/peritonitis, though evidence is uncertain 1, 3
• In patients with severe peritonitis, mandatory or scheduled relaparotomy is not recommended in the absence of intestinal discontinuity, abdominal fascial loss, or intra-abdominal hypertension 1

Special Scenarios

Appendicular Abscess

• If a well-circumscribed periappendiceal abscess is present, consider percutaneous drainage rather than immediate appendectomy 1
• Appendectomy may be deferred in such patients 1
• For patients with periappendiceal phlegmon or small abscess not amenable to percutaneous drainage, antimicrobial therapy alone may be appropriate with close clinical monitoring 1, 4

Elderly Patients

• Conservative management with antibiotics alone is not recommended for elderly patients with complicated appendicitis with diffuse peritonitis or free-perforated appendicitis 1
• Laparoscopic appendectomy is suggested for elderly patients due to reduced length of stay, morbidity, and costs 1

Postoperative Care

Antimicrobial Duration

• For complicated appendicitis, postoperative broad-spectrum antibiotics are suggested 1
• Recommended duration is 3-5 days, though discontinuation should be based on clinical and laboratory criteria such as resolution of fever and leukocytosis 1

Monitoring for Complications

• Monitor for potential complications including:
  • Intra-abdominal abscess formation
  • Wound infection
  • Septicemia
  • Paralytic ileus 5

Pitfalls and Caveats

• Delayed source control can lead to increased morbidity and mortality, especially in critically ill patients 1
• Perforated appendicitis is associated with a 5% mortality rate compared to <0.1% for non-perforated appendicitis 6
• CT scan is the imaging modality of choice in adults not undergoing immediate laparotomy 1
• Further diagnostic imaging is unnecessary in patients with obvious signs of diffuse peritonitis who will undergo immediate surgical intervention 1
• Blood cultures do not provide additional clinically relevant information for patients with community-acquired intra-abdominal infection and are not routinely recommended 1

By following this algorithmic approach to managing ruptured appendix with peritonitis, clinicians can optimize outcomes and reduce the significant morbidity and mortality associated with this condition.