What is the recommended management for acute appendicitis?

Management of Acute Appendicitis

For acute appendicitis, laparoscopic appendectomy is the recommended first-line treatment for both uncomplicated and complicated cases, with non-operative management with antibiotics being a safe alternative for selected patients with uncomplicated appendicitis without appendicolith. 1, 2

Diagnosis and Initial Assessment

• Obtain baseline vital signs and laboratory tests including complete blood count, C-reactive protein, and basic metabolic panel 2
• Ultrasound is recommended as first-line imaging in pediatric patients with suspected appendicitis 1
• CT findings of appendicolith, mass effect, or a dilated appendix >13 mm are associated with higher risk of treatment failure with antibiotics 3
• Document the severity of appendicitis using a standardized grading system (e.g., WSES 2015 or AAST EGS grading score) based on clinical, imaging, and operative findings 1, 2

Treatment Options

Surgical Management

• Laparoscopic appendectomy is preferred over open appendectomy due to:

  • Less postoperative pain
  • Lower incidence of surgical site infections
  • Decreased length of hospital stay
  • Earlier return to work
  • Better quality of life scores 1, 2, 4

• Timing considerations:

  • Perform surgery within 24 hours of admission for uncomplicated appendicitis 1, 2, 4
  • Early appendectomy within 8 hours should be performed for complicated appendicitis 1, 2
  • Delaying appendectomy beyond 24 hours is associated with increased risk of adverse outcomes 1, 4

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 2, 4

Non-Operative Management (NOM)

• NOM with antibiotics is a safe alternative to surgery for selected patients with:

  • Uncomplicated acute appendicitis
  • Absence of appendicolith 1, 2

• For NOM, administer initial intravenous antibiotics with subsequent switch to oral antibiotics based on patient's clinical condition 1

• Approximately 70% of patients with uncomplicated appendicitis can be successfully treated with antibiotics 3

• At one year, about 30.7% of patients initially treated with antibiotics will require appendectomy 5

Management of Complicated Appendicitis

• For appendiceal phlegmon or abscess:

  • In settings with laparoscopic expertise: laparoscopic appendectomy is recommended 1, 2
  • In settings without laparoscopic expertise: non-operative management with antibiotics and percutaneous drainage (if available) 1, 2, 6

• Laparoscopic management of complicated appendicitis is associated with fewer readmissions and fewer additional interventions than conservative treatment 1, 2, 4

• Routine interval appendectomy after successful non-operative management is not recommended for young adults (<40 years) and children 1, 2

• For patients ≥40 years old treated non-operatively, both colonoscopy and interval CT scan are recommended due to higher incidence (3-17%) of appendicular neoplasms 1

Perioperative Considerations

• Remove the appendix even if it appears "normal" during surgery when no other disease is found in symptomatic patients 1, 2

• Send all appendix specimens for routine histopathology examination 1, 2

• Drains are not recommended following appendectomy for complicated appendicitis as they provide no benefit in preventing intra-abdominal abscess and lead to longer hospitalization 4

• Simple ligation of the appendiceal stump is recommended over stump inversion in both open and laparoscopic appendectomy 4

Special Considerations

• For pregnant patients with equivocal appendicitis, short in-hospital delay with observation and repeated ultrasound is acceptable 1

• For obese patients and older patients with comorbidities, laparoscopic approach is particularly beneficial 2

• Single-incision laparoscopic appendectomy is associated with longer operative times, higher analgesic requirements, and higher wound infection rates compared to conventional three-port laparoscopic appendectomy 4

Pitfalls and Caveats

• CT findings of appendicolith, mass effect, and a dilated appendix >13 mm identify patients for whom an antibiotics-first approach is more likely to fail (≈40% failure rate) 3

• Routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation and may be avoided 4

• While antibiotics may reduce wound infections compared to surgery, they are associated with higher rates of unsuccessful treatment and may increase length of hospital stay 5