Should a patient with appendicitis and a fecalith undergo an appendectomy or receive antibiotics?

Management of Appendicitis with a Fecalith: Appendectomy is the Recommended Treatment

For patients with appendicitis and a fecalith, appendectomy is strongly recommended over antibiotic therapy alone due to higher risk of treatment failure and complications with antibiotics. 1

Rationale for Surgical Management

• Appendectomy remains the gold standard treatment for acute appendicitis, particularly in cases complicated by the presence of a fecalith 1
• The presence of an appendicolith (fecalith) is a specific risk factor for treatment failure with antibiotics-only approach, with approximately 40% failure rate 2
• Fecaliths can escape into the abdominal cavity before or during appendicitis, causing complications including intra-abdominal abscess formation 3
• Unrecognized fecaliths are associated with abscess formation occurring from 14 days to as long as 17 months postoperatively 3

Evidence Supporting Surgical Management

• The 2023 WSES guidelines specifically state that appendectomy (laparoscopic or open) is the gold standard treatment for acute appendicitis 1
• The 2020 WSES Jerusalem guidelines update reinforces that appendectomy remains the treatment of choice for acute appendicitis 1
• While antibiotic therapy can be successful in selected patients with uncomplicated appendicitis, the risk of disease recurrence (up to 27% at one year) limits this treatment strategy 1
• CT findings of appendicolith specifically identify patients for whom an antibiotics-first management strategy is more likely to fail 2

Surgical Approach Considerations

• Both open and laparoscopic appendectomies are viable approaches to surgical treatment of acute appendicitis 1
• Laparoscopic appendectomy provides benefits including shorter hospital stay, less postoperative pain, earlier recovery, and lower overall complication rates 1
• However, laparoscopic approach may be associated with slightly increased risk of intra-abdominal abscess compared to open surgery 1
• The choice between open and laparoscopic approach should consider surgeon expertise and available resources 1

Antibiotic Considerations

• A single preoperative dose of broad-spectrum antibiotics should be administered prior to appendectomy 1
• For uncomplicated appendicitis, postoperative antibiotics are not recommended 1
• In complicated cases (perforation, abscess), postoperative antibiotics should be continued but not longer than 3-5 days with adequate source control 1

Special Considerations with Fecaliths

• Fecaliths increase the risk of perforation and abscess formation 3
• During surgery, careful inspection of the peritoneal cavity should be performed to identify and remove any escaped fecaliths 3
• If a fecalith is missed during surgery and an intra-abdominal abscess develops, surgical removal of the fecalith is necessary for definitive healing 3

Alternative Management in Specific Scenarios

• In patients with periappendiceal abscess and a fecalith who are hemodynamically stable but unfit for immediate surgery, percutaneous image-guided drainage may be considered as a bridge to definitive surgical management 1
• However, this approach should be reserved for patients with major comorbidities unfit for surgery, as the presence of a fecalith significantly increases the risk of treatment failure with non-operative management 1

Conclusion

The presence of a fecalith in a patient with appendicitis significantly increases the risk of complications and treatment failure with antibiotics alone. Appendectomy should be the primary treatment approach for these patients to achieve definitive source control and prevent recurrent infections or abscess formation.