What are the medical and surgical management options for acute appendicitis?

Management of Acute Appendicitis: Medical and Surgical Options

Appendectomy remains the treatment of choice for acute appendicitis, though non-operative management with antibiotics is a safe alternative in selected patients with uncomplicated appendicitis without appendicolith. 1

Diagnostic Approach

• A step-up approach from clinical and laboratory examination to imaging should be used based on hospital resources 1
• Graded compression trans-abdominal ultrasound is recommended as the first-line imaging method in children and pregnant patients 1
• CT scan is useful for confirming diagnosis and determining if appendicitis is complicated or uncomplicated 2

Management Options

Non-Operative Management (NOM)

• NOM with antibiotics is safe and effective for selected patients with uncomplicated acute appendicitis without appendicolith 1, 3
• Patients should be informed about the possibility of failure and risk of misdiagnosing complicated appendicitis 1
• Initial intravenous antibiotics with subsequent conversion to oral antibiotics is recommended 1
• Antibiotic therapy typically includes:
  • Broad-spectrum antibiotics such as piperacillin-tazobactam monotherapy or combination therapy with cephalosporins/fluoroquinolones plus metronidazole 2
  • Total duration of 8-15 days 4
• Limitations of antibiotic therapy:
  • Approximately 30% of patients require subsequent appendectomy within one year 3, 4
  • Higher risk of treatment failure (≈40%) with CT findings of appendicolith, mass effect, or dilated appendix >13mm 2

Surgical Management

• Laparoscopic appendectomy is strongly recommended over open appendectomy for both uncomplicated and complicated appendicitis 1, 3
• Benefits of laparoscopic approach include:
  • Less postoperative pain 1
  • Lower incidence of surgical site infection 1
  • Decreased length of hospital stay 1
  • Earlier return to work 1
  • Better quality of life scores 1
  • Particularly beneficial for obese patients, older patients, patients with comorbidities, and pregnant patients 3
• Conventional three-port laparoscopic technique is preferred over single-incision approach due to:
  • Shorter operative times 1
  • Less postoperative pain 3
  • Lower incidence of wound infection 1, 3
• Timing of surgery:
  • Appendectomy should be performed within 24 hours of admission for uncomplicated appendicitis 1, 3
  • Early appendectomy within 8 hours is recommended for complicated appendicitis 3
  • Delaying beyond 24 hours increases risk of adverse outcomes 1, 3

Management of Complicated Appendicitis

• For periappendiceal abscess:
  • Percutaneous image-guided drainage plus antibiotics is recommended when available 1, 5
  • When percutaneous drainage is not available, surgery is suggested 1
• For patients treated conservatively:
  • Interval appendectomy may not be necessary following successful non-operative treatment 1
  • However, interval appendectomy should be performed for patients with recurrent symptoms 1, 5
• Routine use of intra-operative irrigation for appendectomies does not prevent intra-abdominal abscess formation and may be avoided 1
• Abdominal drains are not recommended following appendectomy for complicated appendicitis 3

Special Considerations

• Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined protocols is available 1, 3
• During COVID-19 pandemic, NOM with antibiotics may be preferred to minimize hospital exposure, with close monitoring and surgical intervention if the patient deteriorates 1
• The normal-appearing appendix should be removed during surgery when no other pathology is found, as macroscopic judgment of early appendicitis is often inaccurate 3

Common Pitfalls

• Delaying appendectomy beyond 24 hours increases complications 1, 3
• Underestimating the recurrence rate with antibiotic therapy alone (up to 39% after 5 years) 1, 4
• Failing to recognize high-risk CT findings that predict antibiotic treatment failure 2
• Not considering percutaneous drainage for periappendiceal abscesses when available 1, 5