What is the treatment for acute appendicitis?

Treatment of Acute Appendicitis

For acute appendicitis, laparoscopic appendectomy is the treatment of choice due to less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, and better quality of life compared to open appendectomy. 1

Treatment Algorithm Based on Type of Appendicitis

Uncomplicated Appendicitis

Two viable treatment options exist:

1. Surgical Management (First-line)

   • Laparoscopic appendectomy is preferred where equipment and expertise are available 1
   • Surgery should be performed within 24 hours of admission to minimize complications 1
   • A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 1
   • Postoperative antibiotics are not recommended for uncomplicated appendicitis with adequate source control 1

2. Non-Operative Management (NOM)

   • Can be discussed as a safe alternative to surgery in selected patients 1
   • Best candidates: patients without appendicolith 1, 2
   • Patients should be advised about the possibility of treatment failure and risk of misdiagnosing complicated appendicitis 1
   • Treatment involves initial intravenous antibiotics with subsequent switch to oral antibiotics 1
   • Success rate: approximately 70% of patients respond to antibiotic therapy 2
   • Recurrence rate: 11-14% within one year of follow-up 3, 4

Complicated Appendicitis (Perforation or Abscess)

1. Surgical Management

   • Laparoscopic approach is recommended where advanced laparoscopic expertise is available 1
   • Low threshold for conversion to open procedure should be maintained 1
   • Early appendectomy (within 8 hours) should be performed in pediatric patients with complicated appendicitis 1

2. Periappendiceal Abscess or Phlegmon

   • Options include:
     • Laparoscopic management by experienced surgeons (associated with shorter length of stay, fewer readmissions, and fewer additional interventions) 1, 5
     • Non-operative management with antibiotics and percutaneous drainage (if available) 5
   • Routine interval appendectomy after successful non-operative management is not recommended for young adults (<40 years) and children unless they develop recurrent symptoms 1, 5
   • For patients ≥40 years treated non-operatively, colonoscopy and interval CT scan are recommended due to higher incidence (3-17%) of appendicular neoplasms 1, 5

Antibiotic Therapy

Uncomplicated Appendicitis

• Single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 5
• No postoperative antibiotics needed 1, 5

Complicated Appendicitis

• Postoperative broad-spectrum antibiotics are recommended 1
• Duration should not exceed 3-5 days with adequate source control 1, 5
• For children, early switch (after 48 hours) to oral antibiotics is safe, with total therapy less than 7 days 1, 5
• Appropriate antibiotics include:
  • Piperacillin-tazobactam for complicated appendicitis (rupture or abscess) 6
  • Alternative regimens: cephalosporins with metronidazole or fluoroquinolones with metronidazole 2, 7

Special Considerations

• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1, 5
• CT findings of appendicolith, mass effect, or dilated appendix >13mm are associated with higher risk of antibiotic treatment failure (≈40%) 2
• Pregnant patients with equivocal appendicitis may benefit from short in-hospital observation with repeated ultrasound 1
• Immunosuppressed patients should undergo timely surgical intervention to decrease risk of complications 8

Pitfalls and Caveats

• Avoid delaying surgery beyond 24 hours in patients requiring appendectomy 1
• Do not routinely perform interval appendectomy after successful non-operative management in young patients 1
• Recognize that approximately 23-30% of patients initially treated with antibiotics may eventually require surgery 2, 3
• Be aware that all patients ≥40 years treated non-operatively should undergo colonoscopy and CT scan due to risk of underlying neoplasm 1
• Drains provide no benefit following appendectomy for complicated appendicitis and may lead to longer hospitalization 5