What is the recommended management for acute appendicitis?

Management of Acute Appendicitis

Laparoscopic appendectomy is the definitive treatment of choice for acute appendicitis, offering superior outcomes including less pain, lower infection rates, shorter hospital stays, and faster return to work compared to both open surgery and antibiotic therapy. 1, 2, 3, 4

Diagnostic Approach

Clinical Assessment

• Look for the classic triad: periumbilical pain migrating to the right lower quadrant, anorexia/nausea/vomiting, and low-grade fever—this presentation achieves approximately 90% diagnostic accuracy 5
• Use the Adult Appendicitis Score (AAS) to stratify patients: those with AAS ≥16 may not require preoperative imaging and can proceed directly to surgery 2
• In pediatric patients, ultrasound should be the first-line imaging modality 1

Laboratory Findings

• Elevated C-reactive protein is more reliable than white blood cell count, particularly in immunocompromised patients 1
• Important caveat: Transplant patients with appendicitis often lack leukocytosis (median WBC 7,500 vs 12,500 in immunocompetent patients) but consistently show elevated CRP 1

Imaging Strategy

• CT imaging is the gold standard for adults to differentiate uncomplicated from complicated appendicitis and identify high-risk features 3, 5
• Critical CT findings that predict treatment failure with antibiotics: appendicolith presence, appendiceal diameter >13mm, and mass effect 5

Surgical Management (Primary Recommendation)

Timing of Surgery

• Perform appendectomy within 24 hours of admission for uncomplicated appendicitis—delays beyond 24 hours increase adverse outcomes 1, 2, 3, 4
• For complicated appendicitis (perforation, abscess), operate within 8 hours when possible 2, 4
• In transplanted or immunocompromised patients, appendectomy should be performed as soon as possible, ideally within 24 hours, due to higher rates of complicated disease 1

Surgical Technique

• Use the conventional three-port laparoscopic technique rather than single-incision approach—it provides shorter operative times, less postoperative pain, and lower wound infection rates 3, 4
• Simple ligation of the appendiceal stump is preferred over inversion in both laparoscopic and open procedures 2, 4
• Remove the appendix even if it appears normal intraoperatively when no other pathology is identified 4
• Send all specimens for routine histopathology to identify unexpected findings including malignancy (0.3% incidence) 3, 4

Perioperative Antibiotics

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before incision 2, 4
• For uncomplicated appendicitis, a single preoperative dose is sufficient 4
• For complicated appendicitis, use piperacillin-tazobactam (FDA-approved for appendicitis complicated by rupture or abscess) or combination therapy with metronidazole plus vancomycin 2, 6, 5

Non-Operative Management (Alternative for Selected Patients)

Patient Selection Criteria

• Only offer antibiotic therapy to patients with CT-confirmed uncomplicated appendicitis AND absence of appendicolith 1, 3, 5
• Patients must accept a 27-30% failure rate requiring surgery within one year 3, 5
• Contraindications to antibiotic-first approach: appendicolith on imaging, appendiceal diameter >13mm, mass effect, or complicated features 3, 5

Antibiotic Regimen

• Start with intravenous broad-spectrum antibiotics (piperacillin-tazobactam monotherapy or cephalosporin/fluoroquinolone plus metronidazole) 1, 5
• Convert to oral antibiotics based on clinical improvement 1, 3
• Critical warning: Approximately one-third of antibiotic-treated patients will require appendectomy within one year 7

Pediatric Considerations

• Antibiotic therapy is feasible in children with uncomplicated appendicitis without appendicolith, but evidence is weaker (moderate quality, weak recommendation) 1, 3
• Counsel families about failure rates and potential for delayed surgery 1

Management of Complicated Appendicitis

Appendiceal Abscess or Phlegmon

• Proceed with laparoscopic appendectomy if expertise is available—this approach results in fewer readmissions and additional interventions compared to conservative management 1, 4
• If laparoscopic expertise unavailable, consider percutaneous drainage plus antibiotics 4, 8
• Use suction alone rather than irrigation during laparoscopic management of intra-abdominal collections 4

Interval Appendectomy

• Do not routinely perform interval appendectomy after successful non-operative management in young adults (<40 years) and children 4
• Consider interval appendectomy in older patients to exclude malignancy 9

Special Populations

Pregnant Patients

• Laparoscopic appendectomy is preferred over open surgery when expertise is available 4
• Short in-hospital delays with repeated ultrasound are acceptable for equivocal cases 1
• Proceed with surgery promptly once diagnosis is confirmed to minimize maternal and fetal complications 1

Immunocompromised/Transplant Patients

• There is no role for conservative antibiotic treatment—these patients should undergo appendectomy as soon as possible 1
• Laparoscopic approach is feasible and preferred when not contraindicated 1
• Maintain high clinical suspicion despite atypical laboratory findings (often no leukocytosis) 1

Postoperative Management

Discharge Criteria

• Tolerating oral intake, adequate pain control with oral analgesics, and no signs of complications 4
• Outpatient laparoscopic appendectomy is safe for uncomplicated cases in selected patients with established Enhanced Recovery After Surgery (ERAS) protocols 4, 10

Wound Management

• For open appendectomy, use primary skin closure with absorbable intradermal suture 4
• Antibiotics reduce wound infection rates compared to surgery alone (RR 0.25) 7