What is the recommended non-surgical management for appendicitis?

Non-Surgical Management of Appendicitis

Non-operative management (NOM) with antibiotics is a safe and effective alternative to surgery for uncomplicated acute appendicitis in selected patients, particularly those without an appendicolith, with success rates of 62-81% after one year of follow-up. 1

Patient Selection for Non-Surgical Management

Appropriate Candidates:

• Patients with uncomplicated acute appendicitis confirmed by imaging 1
• Absence of appendicolith (stone in the appendix) 1
• Patients without signs of perforation or periappendiceal abscess 1
• Children with uncomplicated appendicitis may also be considered for NOM 1

Poor Candidates (Surgery Recommended):

• Patients with appendicolith (failure rate more than twice that of patients without appendicolith) 1
• CT findings of mass effect or dilated appendix >13 mm (associated with ~40% failure rate) 2
• Complicated appendicitis with perforation without phlegmon/abscess 1
• Immunocompromised patients 3

Antibiotic Regimens for Non-Operative Management

Initial Intravenous Therapy (48 hours minimum):

• Amoxicillin/clavulanate 1.2-2.2 g every 6 hours, OR
• Ceftriaxone 2 g every 24 hours + Metronidazole 500 mg every 6 hours, OR
• Cefotaxime 2 g every 8 hours + Metronidazole 500 mg every 6 hours 1

For Beta-Lactam Allergic Patients:

• Ciprofloxacin 400 mg every 8 hours + Metronidazole 500 mg every 6 hours, OR
• Moxifloxacin 400 mg every 24 hours 1

For Risk of ESBL-Producing Enterobacteriaceae:

• Ertapenem 1 g every 24 hours, OR
• Tigecycline 100 mg initial dose, then 50 mg every 12 hours 1

Oral Continuation Therapy:

• Continue antibiotics for a total of 7-10 days 1
• Transition to oral antibiotics after clinical improvement 1

Management of Complicated Appendicitis with Abscess/Phlegmon

For patients presenting with appendiceal abscess or phlegmon:

• Non-operative management with antibiotics is recommended as first-line treatment 1
• Percutaneous drainage should be added if accessible, especially for larger abscesses 1
• Laparoscopic surgery is a safe alternative in experienced hands and may be associated with fewer readmissions and additional interventions 1
• Interval appendectomy is NOT routinely recommended after successful NOM for patients <40 years old 1
• Interval appendectomy IS recommended for patients with recurrent symptoms 1

Follow-up Considerations

• For patients ≥40 years old treated non-operatively: colonoscopy and full-dose contrast-enhanced CT scan are recommended due to higher incidence (3-17%) of appendicular neoplasms 1
• Monitor for recurrence, which occurs in approximately 12-24% of cases after non-surgical treatment 1
• Two-thirds of patients initially treated with antibiotics avoid surgery within one year 4

Potential Advantages of Non-Operative Management

• Fewer wound infections compared to surgery (RR 0.25,95% CI 0.09-0.68) 4
• Fewer disability days and lower healthcare costs in children 1
• Avoidance of surgical complications 5

Potential Disadvantages of Non-Operative Management

• Treatment failure rate of approximately 23% requiring subsequent appendectomy 5
• Higher readmission rates compared to surgery (RR 6.98,95% CI 2.07-23.6) 1
• Risk of recurrence (approximately 11% at one-year follow-up) 5
• Possibility of missing appendicular neoplasms, particularly in older adults 1

Common Pitfalls to Avoid

• Attempting NOM in patients with appendicolith, which significantly increases failure rates 1
• Failing to recognize complicated appendicitis, which requires surgical intervention 1
• Not providing adequate follow-up for patients ≥40 years old due to higher risk of neoplasms 1
• Underestimating the recurrence risk when counseling patients about NOM 1