What is the recommended treatment for a typical case of appendicitis?

Treatment of Typical Appendicitis in Females

For a typical case of appendicitis in a female patient, proceed directly to appendectomy (either laparoscopic or open) as the first-line treatment, but first obtain diagnostic imaging—specifically ultrasound as initial imaging, followed by CT or MRI if ultrasound is inconclusive—because all females of childbearing potential require imaging to confirm the diagnosis and avoid unnecessary surgery. 1

Diagnostic Approach for Female Patients

Mandatory Imaging Requirement

• All female patients must undergo diagnostic imaging before surgery 1
• This is a critical guideline specifically for females due to the broader differential diagnosis (gynecologic pathology) and higher rates of negative appendectomy historically 1

Imaging Algorithm for Females of Childbearing Age

• First, perform a pregnancy test before any imaging 1
• If pregnant (first trimester): Use ultrasound or MRI instead of CT to avoid ionizing radiation 1
• If non-pregnant: Start with ultrasound (preferably point-of-care ultrasound/POCUS) as the first-line imaging modality 1
• If ultrasound is inconclusive: Proceed to contrast-enhanced low-dose CT scan 1
• If CT is contraindicated (renal disease): Use MRI as the next option 1

When Imaging is Negative or Equivocal

• If imaging is negative but clinical suspicion remains high: Perform 24-hour follow-up to ensure symptom resolution, as false-negative imaging occurs 1
• If imaging is equivocal and symptoms persist: Consider diagnostic laparoscopy to establish or exclude appendicitis 1

Definitive Treatment: Appendectomy

Surgical Approach

• Both laparoscopic and open appendectomy are acceptable and equally effective 1
• Laparoscopic appendectomy is generally preferred when expertise is available, offering shorter hospital stays, less pain, and lower surgical site infection rates 1
• Surgery should be performed as soon as reasonably feasible once diagnosis is confirmed, though brief delays for institutional logistics are acceptable 1

Antibiotic Administration

• Administer broad-spectrum antibiotics to all patients with confirmed appendicitis before surgery 1
• Appropriate regimens include agents effective against gram-negative organisms and anaerobes (e.g., piperacillin-tazobactam, cefoxitin, or combination therapy with cephalosporins/fluoroquinolones plus metronidazole) 1, 2
• For uncomplicated appendicitis: No postoperative antibiotics are needed 1, 3
• For complicated/perforated appendicitis: Continue postoperative antibiotics for a limited duration 1

Alternative: Non-Operative Management (Selected Cases Only)

When to Consider Antibiotics Alone

• Non-operative management with antibiotics may be considered only in highly selected patients with CT-proven uncomplicated appendicitis who strongly prefer to avoid surgery 1
• This approach has a 27-37% recurrence rate within one year and requires CT confirmation of uncomplicated disease 1, 2
• Patients with appendicoliths, dilated appendix >13mm, or mass effect on CT have ~40% failure rates with antibiotics and should undergo surgery 2

Why Surgery Remains First-Line

• Appendectomy should be considered first-line therapy and recommended to the patient because it definitively treats the condition without risk of recurrence 1
• The high recurrence rate and need for CT confirmation limit antibiotic therapy's applicability 1
• In the era of antimicrobial resistance, avoiding unnecessary antibiotic courses is important 1

Common Pitfalls and Caveats

Critical Mistake to Avoid

• Never proceed to appendectomy in a female without imaging confirmation 1
• This is the single most important distinction for female patients compared to males, where high clinical probability may sometimes justify surgery without imaging in resource-limited settings 1

Radiation Considerations

• Always use pregnancy testing and ultrasound first in women of childbearing age to minimize radiation exposure 1
• Low-dose CT protocols should be used when CT is necessary in younger patients 1

Management of Complicated Cases

• If a periappendiceal abscess is found on imaging: Consider percutaneous drainage plus antibiotics rather than immediate surgery 1
• Interval appendectomy after successful non-operative treatment of abscess is not routinely necessary unless symptoms recur 1