What is the initial management and treatment for a patient suspected of having appendicitis?

Initial Management and Treatment of Suspected Appendicitis

The initial management of suspected appendicitis should include diagnostic imaging (preferably CT scan with IV contrast in adults), administration of appropriate antibiotics, and timely surgical consultation for appendectomy, which remains the standard of care for most patients with acute appendicitis. 1

Diagnosis

Clinical Evaluation

• Diagnosis should begin with assessment of characteristic clinical findings including abdominal pain (typically starting periumbilically and migrating to the right lower quadrant), localized abdominal tenderness, and laboratory evidence of acute inflammation 1
• Clinical findings should be used to risk-stratify patients and guide decisions about further testing and management 1
• Laboratory tests including white blood cell count and C-reactive protein can support the diagnosis, though neither is consistently diagnostic when used alone 1

Imaging

• Helical CT of the abdomen and pelvis with intravenous contrast (not oral or rectal) is the recommended imaging procedure for adults with suspected appendicitis 1
• All female patients should undergo diagnostic imaging, with pregnancy testing prior to imaging in those of childbearing potential 1
• Pregnant patients in the first trimester should undergo ultrasound or MRI instead of CT to avoid ionizing radiation 1
• For children, imaging should be performed when the diagnosis is uncertain, with ultrasound as a reasonable alternative to CT to avoid radiation exposure 1
• If imaging findings are negative but clinical suspicion remains high, follow-up at 24 hours is recommended to ensure resolution of symptoms 1

Treatment

Antimicrobial Therapy

• Antimicrobial therapy should be administered to all patients diagnosed with appendicitis 1
• Appropriate antibiotics should cover both aerobic gram-negative organisms and anaerobes 1
• For complicated intra-abdominal infections, combination therapy such as metronidazole with either cephalosporins or fluoroquinolones is recommended 2, 3
• For patients with equivocal diagnostic imaging, antimicrobial therapy should be initiated along with appropriate pain medication and antipyretics 1
• In adults, antimicrobial therapy should be provided for a minimum of 3 days until clinical symptoms and signs of infection resolve or a definitive diagnosis is made 1

Surgical Management

• Operative intervention for acute, non-perforated appendicitis should be performed as soon as reasonably feasible 1
• Both laparoscopic and open appendectomy are acceptable procedures, with the approach dictated by the surgeon's expertise 1
• Laparoscopic appendectomy is generally preferred due to advantages including less pain, lower incidence of surgical site infection, shorter hospital stay, and faster return to work 2
• Patients with perforated appendicitis should undergo urgent intervention to provide adequate source control 1
• Surgery may be deferred for a short period of time according to individual institutional circumstances without significant risk to the patient 4

Non-Operative Management

• Non-operative management with antibiotics alone can be considered in selected patients with acute, non-perforated appendicitis who show marked improvement in their condition 1
• This approach may be particularly suitable for male patients, provided they are hospitalized for 48 hours and show sustained improvement in clinical symptoms within 24 hours while receiving antimicrobial therapy 1
• Patients should be informed that approximately 30% of those initially treated with antibiotics will require appendectomy within one year 5
• CT findings of appendicolith, mass effect, or a dilated appendix greater than 13 mm are associated with higher risk of antibiotic treatment failure, and surgical management should be recommended for these patients 6

Special Considerations

Complicated Appendicitis

• Patients with a well-circumscribed periappendiceal abscess can be managed with percutaneous drainage or operative drainage when necessary 7
• In these cases, appendectomy is generally deferred 7
• Patients with perforated appendicitis should undergo urgent intervention for source control 1

Pediatric Patients

• The American College of Surgeons recommends laparoscopic appendectomy as the preferred treatment approach for children with acute appendicitis 7
• Surgery should be performed within 24 hours of admission for uncomplicated appendicitis, with early appendectomy (within 8 hours) recommended for complicated appendicitis 7
• In very young children (<5 years), diagnosis may be delayed due to atypical presentation, potentially leading to higher rates of perforation 7

Pitfalls and Caveats

• Relying solely on clinical findings without appropriate imaging can lead to missed diagnoses or unnecessary surgeries 1
• Delaying antibiotics in confirmed or strongly suspected cases can increase the risk of complications 1
• Failing to consider non-operative management in appropriate candidates may result in unnecessary surgical risks 5
• Not recognizing the signs of complicated appendicitis can lead to inadequate treatment and increased morbidity 8
• Routine histopathology after appendectomy is recommended to identify unexpected findings, including rare malignancies 2