Does a 27-year-old male with a large appendicolith, proximal appendiceal dilatation, and minimal periappendiceal fat stranding on CT require hospital admission?

Hospital Admission Required for This Patient

Yes, this 27-year-old male with a large appendicolith, proximal appendiceal dilatation, and minimal periappendiceal fat stranding should be admitted to the hospital for treatment. The presence of an appendicolith with appendiceal dilatation represents acute appendicitis requiring intervention, not outpatient observation.

Rationale for Admission

Appendicolith as a High-Risk Feature

• The presence of an appendicolith on CT is a well-established predictor of treatment failure with antibiotics alone, with failure rates approaching 40%. 1
• Appendicoliths are associated with higher risk of perforation and complicated appendicitis, making surgical management the preferred approach in patients fit for surgery. 1
• The combination of appendicolith with appendiceal dilatation indicates obstructive appendicitis that is unlikely to resolve spontaneously. 1, 2

Current Clinical Picture Indicates Active Appendicitis

• The CT findings of proximal appendiceal dilatation with periappendiceal fat stranding, even if minimal, represent acute appendicitis requiring treatment. 3
• All patients who receive a diagnosis of appendicitis should receive antimicrobial therapy and be hospitalized. 3
• The absence of abscess or phlegmon means this patient has uncomplicated appendicitis, which is optimally managed with appendectomy performed as soon as reasonably feasible. 3

Recommended Management Algorithm

Immediate Actions Upon Admission

• Initiate broad-spectrum antibiotics immediately covering gram-negative organisms and anaerobes (e.g., piperacillin-tazobactam, ceftriaxone plus metronidazole, or ampicillin-sulbactam). 3
• Proceed with laparoscopic appendectomy as soon as reasonably feasible, which can be performed safely within hours of admission. 3

Why Surgery Over Conservative Management

• In a 27-year-old male with an appendicolith, appendectomy should be the first-line therapy rather than attempting non-operative management. 1
• Non-operative management may be considered in select patients with uncomplicated appendicitis on imaging who strongly prefer to avoid surgery, but the presence of an appendicolith significantly increases the risk of failure. 3
• For male patients specifically, laparoscopic appendectomy does not offer significant advantages over open appendectomy in terms of hospital stay, though either approach is acceptable. 3

Surgical Approach

• Both laparoscopic and open appendectomy are acceptable, with the choice based on surgeon expertise. 3
• Surgery should not be delayed unnecessarily, as operative intervention may be performed as soon as reasonably feasible once the diagnosis is established. 3

Key Clinical Pitfalls to Avoid

• Do not discharge this patient for outpatient follow-up. The CT findings confirm appendicitis requiring intervention, not an equivocal diagnosis. 3
• Do not attempt prolonged antibiotic therapy alone in the presence of an appendicolith. This specific CT finding predicts antibiotic failure and warrants surgical management. 1
• Do not confuse the absence of abscess/phlegmon with the absence of appendicitis—this patient has uncomplicated appendicitis that still requires treatment. 3, 4

Special Considerations

• If the patient were to refuse surgery or have significant medical comorbidities making him unfit for operation, then admission for intravenous antibiotics with close monitoring would be the alternative, but this should be discussed as a higher-risk approach given the appendicolith. 1
• The minimal fat stranding suggests early inflammation, making this an ideal time for straightforward appendectomy before progression to complicated disease. 3, 2