What is the management plan for a patient with appendicitis who has ruptured on the third day?

Management of Ruptured Appendicitis on the Third Day

Patients with perforated appendicitis should undergo urgent intervention to provide adequate source control through either surgical management or percutaneous drainage when appropriate.1

Initial Assessment and Management

• Administer broad-spectrum antibiotics immediately, covering both aerobic gram-negative organisms and anaerobes 1
• Recommended empiric antibiotic regimens include:
  • Piperacillin-tazobactam (recommended for complicated intra-abdominal infections including ruptured appendicitis) 2
  • Ceftriaxone plus metronidazole 3
  • Cefotaxime plus metronidazole 3
• For patients with beta-lactam allergy, alternatives include ciprofloxacin plus metronidazole or moxifloxacin 3
• Obtain baseline laboratory tests including complete blood count, C-reactive protein, and basic metabolic panel 4
• Document the severity using a standardized grading system (e.g., WSES 2015 grading score or AAST EGS grading score) 4

Definitive Management Options

Surgical Management

• Laparoscopic approach is preferred over open appendectomy when expertise is available, offering advantages including less pain, lower surgical site infection rates, decreased hospital stay, and earlier return to work 4
• For ruptured appendicitis, perform surgery within 8 hours if possible 4
• Use suction alone (rather than irrigation) for intra-abdominal collections during laparoscopic appendectomy 4
• Send the appendix specimen for routine histopathology examination 1

Alternative Management for Specific Scenarios

• For patients with a well-circumscribed periappendiceal abscess:
  • Percutaneous drainage combined with antibiotics is recommended 1
  • Appendectomy is generally deferred in these patients 1
• For patients with periappendiceal phlegmon or small abscess not amenable to percutaneous drainage:
  • Initial treatment with antibiotics may be appropriate 1
  • This approach may help avoid a potentially more morbid procedure than simple appendectomy 1

Antibiotic Therapy Duration

• For complicated appendicitis (including rupture), continue antibiotics postoperatively 4
• Typically, antibiotics should be continued for at least 4-7 days, guided by clinical response 3
• Clinical parameters to monitor include:
  • Resolution of fever
  • Normalization of white blood cell count
  • Return of normal bowel function
  • Adequate pain control 3

Postoperative Care

• Monitor for potential complications including:
  • Intra-abdominal abscess formation (higher risk with perforated appendicitis) 2
  • Wound infections (more common with open procedures) 4
  • Prolonged ileus 4
• For open appendectomy wounds in perforated cases, consider delayed primary closure or leaving the wound open 4

Follow-up Considerations

• For patients managed non-operatively with abscess drainage:
  • Routine interval appendectomy is not recommended for young adults (<40 years) and children 1
  • Interval appendectomy should be performed only for those with recurrent symptoms 1
• For patients ≥40 years old with complicated appendicitis treated non-operatively:
  • Consider both colonoscopy and interval full-dose contrast-enhanced CT scan due to higher incidence (3-17%) of appendicular neoplasms 1

Pitfalls and Caveats

• Failure to recognize the severity of peritoneal contamination may lead to inadequate antibiotic coverage and increased morbidity 3
• Delay in source control (surgical or percutaneous drainage) beyond 8 hours may increase complication rates 4
• Inadequate duration of antibiotic therapy can lead to treatment failure and recurrent intra-abdominal infection 3
• Patients with ruptured appendicitis are at higher risk for postoperative complications including intra-abdominal abscess formation and wound infections 2