What are the signs, symptoms, and treatment options for acute appendicitis (inflammation of the appendix)?

From the Guidelines

Appendicitis is a medical emergency that requires prompt surgical intervention, and the standard treatment is surgical removal of the appendix (appendectomy), which can be performed as a traditional open surgery or laparoscopically with smaller incisions, as recommended by the 2020 WSES Jerusalem guidelines update 1. The signs and symptoms of acute appendicitis include pain that typically begins around the navel and shifts to the lower right abdomen, becoming more intense over hours, as well as nausea, vomiting, loss of appetite, low-grade fever, abdominal bloating, and difficulty passing gas. The pain often worsens with movement, coughing, or deep breathing. Some key points to consider in the diagnosis and treatment of acute appendicitis include:

• The use of scoring systems, such as the Alvarado score, to exclude acute appendicitis in patients with a low-probability score, as suggested by the SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly 1.
• The importance of imaging studies, such as CT scans, to confirm or exclude the diagnosis of acute appendicitis, especially in elderly patients, as recommended by the SIFIPAC/WSES/SICG/SIMEU guidelines 1.
• The role of non-operative management (NOM) in selected patients with uncomplicated appendicitis, as suggested by the SIFIPAC/WSES/SICG/SIMEU guidelines 1.
• The use of laparoscopic appendectomy, which is associated with reduced length of stay, morbidity, and costs, as suggested by the SIFIPAC/WSES/SICG/SIMEU guidelines 1.
• The importance of pre-operative broad-spectrum antibiotics in patients undergoing appendectomy for acute appendicitis, as recommended by the SIFIPAC/WSES/SICG/SIMEU guidelines 1. It is essential to note that delaying treatment can lead to appendix rupture, causing peritonitis, a serious infection of the abdominal cavity that can be life-threatening. After surgery, most patients can return home within 1-2 days and resume normal activities within 2-4 weeks, with complete recovery taking 4-6 weeks. In terms of specific treatment options, the SIFIPAC/WSES/SICG/SIMEU guidelines suggest the following:
• For uncomplicated acute appendicitis, laparoscopic appendectomy is recommended, with a suggested period of 3-5 days of post-operative broad-spectrum antibiotics 1.
• For complicated acute appendicitis, the guidelines recommend pre-operative broad-spectrum antibiotics and suggest post-operative broad-spectrum antibiotics for 3-5 days, although discontinuation of antimicrobial treatment should be based on clinical and laboratory criteria such as fever and leucocytosis 1.

From the Research

Signs and Symptoms of Acute Appendicitis

• Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever 2
• The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms 2

Treatment Options for Acute Appendicitis

• Appendectomy is the standard treatment for acute appendicitis, but antibiotic therapy has been proposed as an alternative to immediate appendectomy 3, 2, 4, 5
• Laparoscopic appendectomy remains the most common treatment, but broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2
• Antibiotic therapy is usually administered intravenously first, then orally, with a total duration of treatment of 8 to 15 days 3
• The antibiotics used include amoxicillin + clavulanic acid, cefotaxime, or a fluoroquinolone, often with metronidazole or tinidazole added 3

Effectiveness and Safety of Treatment Options

• The overall incidence of complications of appendicitis (perforation, peritonitis, and surgical wound infections) was 25% in the immediate appendectomy group versus 18% in the antibiotic group 3
• All symptoms of appendicitis disappeared, without relapse or rehospitalisation during the first month, in 78% of patients in the antibiotic group 3
• After one year of follow-up, 63% of patients treated with antibiotics were asymptomatic and had no complications or recurrences 3
• Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission, but recurrence rates of non-operated patients within 1 year are as high as 20-30% 5

Factors Influencing Treatment Choice

• Specific imaging findings on computed tomography (CT), such as appendiceal dilatation or presence of appendicoliths, identify patients for whom an antibiotics-first management strategy is more likely to fail 2
• CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach 2
• In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy, while in unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended 2