What is the management of a perforated appendix?

Management of Perforated Appendicitis

Patients with perforated appendicitis should undergo urgent surgical intervention to provide adequate source control, with the exception of those presenting with well-circumscribed periappendiceal abscesses who may be managed with percutaneous or operative drainage followed by interval appendectomy. 1

Immediate Surgical Management

Primary Approach for Diffuse Peritonitis

• Urgent appendectomy (laparoscopic or open) is the standard of care for perforated appendicitis with diffuse peritoneal contamination 1
• Both laparoscopic and open approaches are acceptable, with the choice dictated by surgeon expertise 1
• Surgery should not be delayed once the diagnosis is established, as delayed intervention increases peritonitis severity, colonic wall inflammation, and requires more invasive procedures with poorer prognosis 1

Antimicrobial Therapy

• Broad-spectrum antibiotics effective against facultative/aerobic gram-negative organisms and anaerobes must be administered to all patients with appendicitis 1
• Postoperative antibiotic therapy is required for complicated appendicitis, unlike uncomplicated cases where low-risk patients may not need postoperative antibiotics 2

Alternative Management for Localized Disease

Periappendiceal Abscess Management

• Patients with well-circumscribed periappendiceal abscesses can be managed with percutaneous drainage when necessary, with appendectomy generally deferred 1
• Conservative management with IV antibiotics alone is safe and effective, with 92% of patients improving without immediate surgery 3
• Only 58% of abscesses actually require percutaneous drainage; many resolve with antibiotics alone 3
• CT-guided drainage should be reserved for patients who fail to improve after 48-72 hours of antibiotic therapy 3

Interval Appendectomy Considerations

• Interval appendectomy is typically performed 6-12 weeks after successful conservative management 3
• This approach is associated with 10% morbidity, mean hospital stay of 1.4 days, and shorter overall surgery time 3, 4
• Interval appendectomy should be performed within 4 months of discharge, particularly when an appendicolith is present 4

Phlegmon Management

• Selected patients presenting several days after symptom onset with a periappendiceal phlegmon or small abscess not amenable to percutaneous drainage may be treated with antimicrobial therapy alone to avoid a more morbid procedure than simple appendectomy 1

Critical Risk Stratification

Predictors of Conservative Management Failure

• Presence of appendicolith (strongly associated with progression to complicated disease) 5, 2, 6
• Leukocytosis >15,000 WBC/μL 6
• Elevated bands 6
• CT evidence of disease extending beyond the right lower quadrant 6

High-Risk Populations Requiring Surgery

• Immunosuppressed patients 1
• Transplant recipients 1
• Patients with concomitant colonic diseases requiring surgery 1
• Elderly patients (perforation rates 55-70%, mortality risk increases threefold per decade after age 65) 2

Monitoring Requirements for Conservative Management

Strict Clinical Surveillance

• Serial clinical and imaging monitoring every 3-6 hours 1
• Absolute bowel rest with IV hydration 1
• Close multidisciplinary follow-up to detect sepsis or peritoneal signs 1
• Clinical improvement should occur within 24 hours; if deterioration or progression to sepsis occurs, surgical treatment must not be delayed 1

Important Caveat

• Early success with non-surgical treatment does not eliminate the potential need for surgery 1
• Complication rates and hospital stays are significantly higher in patients requiring delayed surgery after failed conservative management compared to those treated surgically from the outset 1

Mortality Considerations

The mortality risk stratifies dramatically by disease severity: perforated appendicitis carries approximately 5% mortality compared to <0.1% for non-gangrenous appendicitis, making timely source control critical 5, 2