What is the treatment for appendicitis?

Treatment of Appendicitis

Appendectomy remains the treatment of choice for acute appendicitis, though antibiotic therapy can be considered as an alternative in select cases of uncomplicated appendicitis. 1

Diagnosis

• Clinical diagnosis is based on history, physical examination, laboratory studies, and imaging 2
• Classic symptoms include periumbilical pain migrating to right lower quadrant, anorexia, nausea/vomiting, and low-grade fever 3
• Clinical scoring systems (Alvarado, Pediatric Appendicitis Score, Appendicitis Inflammatory Response score) can help stratify patients into low, moderate, or high risk 3
• Imaging is recommended for diagnosis confirmation:
  • Ultrasound is the preferred initial imaging method, especially in children and pregnant women 1
  • CT scan may be used if ultrasound is inconclusive, particularly in adults 1

Treatment Options

1. Surgical Management (Primary Approach)

• Laparoscopic appendectomy is the preferred surgical approach for both uncomplicated and complicated appendicitis due to less pain, lower incidence of surgical site infection, decreased hospital stay, earlier return to work, and better quality of life 1
• Open appendectomy remains a viable alternative when laparoscopic expertise is not available 1
• Surgery should be performed within 24 hours of admission to reduce risk of complications 1
• Appendix should be removed even if it appears "normal" during surgery when no other cause of symptoms is found 1

2. Antibiotic Therapy

• Can be considered as an alternative to surgery in selected patients with uncomplicated appendicitis without appendicolith 1, 2
• Patients should be informed about the possibility of treatment failure and recurrence (approximately 27% at 1 year) 1, 4
• Initial intravenous antibiotics followed by oral antibiotics is recommended 1
• CT findings that predict higher failure rates with antibiotic therapy include:
  • Presence of appendicolith
  • Appendiceal diameter ≥13 mm
  • Mass effect 2

3. Management of Complicated Appendicitis

• Complicated appendicitis (gangrenous or perforated) requires prompt treatment 3
• For periappendiceal abscess:
  • Percutaneous image-guided drainage plus antibiotics is recommended when available 1
  • Surgical intervention is suggested when percutaneous drainage is not available 1
• For appendiceal phlegmon:
  • Non-operative management with antibiotics is an option 1
  • Early laparoscopic appendectomy may be preferred when expertise is available, as it can reduce hospital stay and readmission rates 1
• Interval appendectomy (delayed surgery after initial non-operative treatment) is not routinely necessary but should be performed for patients with recurrent symptoms 1

Antibiotic Recommendations

For Uncomplicated Appendicitis:

• Single preoperative dose of broad-spectrum antibiotics is recommended 1
• Postoperative antibiotics are not recommended for uncomplicated appendicitis 1

For Complicated Appendicitis:

• Intravenous antibiotics effective against enteric gram-negative organisms and anaerobes should be initiated promptly 1
• Options include:
  • Piperacillin-tazobactam (FDA-approved for complicated appendicitis) 5
  • Second/third-generation cephalosporins with metronidazole 1
  • Ampicillin with clindamycin/metronidazole and gentamicin 1
• Duration of postoperative antibiotics should not exceed 3-5 days with adequate source control 1
• In children, early switch to oral antibiotics after 48 hours is recommended, with total therapy duration less than 7 days 1

Special Considerations

• Pregnant patients and immunosuppressed patients should undergo timely surgical intervention to decrease complication risks 6
• In patients ≥40 years old with complicated appendicitis treated non-operatively, colonic screening and interval CT scan are recommended due to higher risk of appendiceal neoplasms (3-17%) 1
• Abdominal drainage after appendectomy for complicated appendicitis remains controversial, with evidence suggesting it may not prevent intraperitoneal abscess and could potentially increase hospital stay 7

Common Pitfalls to Avoid

• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
• Misdiagnosing complicated appendicitis as uncomplicated when considering non-operative management 1
• Prolonged antibiotic therapy beyond recommended duration does not improve outcomes 1
• Routine interval appendectomy after successful non-operative management is unnecessary in most cases 1