Does acute appendicitis always require surgical intervention?

From the Guidelines

Appendicitis doesn't always require surgery, though it remains the standard treatment in most cases. According to the 2020 update of the WSES Jerusalem guidelines 1, some cases of uncomplicated appendicitis can be treated with antibiotics alone. The guidelines suggest that non-operative management with antibiotics and—if available—percutaneous drainage can be a reasonable first-line treatment for appendicitis with phlegmon or abscess, especially in settings where laparoscopic expertise is not available. However, surgery (appendectomy) is still necessary for complicated appendicitis with perforation, abscess formation, or when symptoms worsen despite antibiotic treatment.

The decision between antibiotics and surgery depends on the severity of inflammation, patient factors, and local medical protocols. Patients treated with antibiotics should understand there's a chance they'll eventually need surgery due to recurrence. A study by Kaminski et al 1 found that approximately 25% of patients with appendiceal abscess fail percutaneous catheter drainage (PCD) and require operative intervention.

Key points to consider in the management of appendicitis include:

• The use of broad-spectrum antibiotics, with a single preoperative dose recommended for patients with acute appendicitis undergoing appendectomy 1
• The consideration of non-operative management for complicated appendicitis with peri-appendicular abscess, in settings where laparoscopic expertise is not available 1
• The importance of prompt medical evaluation to determine the appropriate treatment approach, as delayed treatment of severe cases can lead to serious complications
• The need for patients to understand the potential for recurrence and the possibility of eventual surgery, even with initial antibiotic treatment. The treatment approach should be individualized based on the patient's specific condition and medical history.

From the Research

Appendicitis Treatment Options

• Appendicitis is a common abdominal surgical emergency that can be treated with surgery or antibiotics, depending on the severity and patient characteristics 2, 3, 4, 5.
• Laparoscopic appendectomy is a common surgical treatment for appendicitis, but antibiotics can be an effective alternative for uncomplicated cases 2, 3, 4.
• The decision to use antibiotics or surgery depends on factors such as the presence of appendicoliths, mass effect, and appendiceal dilatation, as well as patient fitness and preferences 2, 5.

Antibiotic Therapy

• Antibiotic therapy can be an effective treatment for uncomplicated acute appendicitis, with success rates ranging from 63% to 77% 3, 4.
• Antibiotics can reduce the risk of immediate complications compared to surgery, but may increase the risk of subsequent failures or recurrences 3, 4.
• The choice of antibiotics and duration of treatment can vary, but common regimens include intravenous piperacillin-tazobactam followed by oral ciprofloxacin and metronidazole 3.

Surgical Intervention

• Surgical intervention is recommended for patients with complicated appendicitis, such as those with appendicoliths, mass effect, or significant appendiceal dilatation 2, 5.
• Laparoscopic appendectomy is the preferred surgical approach due to its benefits in terms of access trauma, postoperative pain, and convalescence 6.
• Open appendectomy may still be necessary in some cases, such as when laparoscopic equipment is not available or the patient has significant comorbidities 6.