What is the standard treatment for appendicitis?

Standard Treatment for Appendicitis

Appendectomy (either laparoscopic or open) remains the gold-standard treatment for acute appendicitis worldwide, though antibiotics alone may be considered for carefully selected patients with CT-confirmed uncomplicated appendicitis who understand the 27-30% one-year recurrence rate. 1, 2

Treatment Algorithm Based on Disease Complexity

Uncomplicated Acute Appendicitis

Surgical Management (Preferred)

• Laparoscopic appendectomy is the preferred surgical approach over open appendectomy, offering shorter hospital stays, less postoperative pain, faster recovery, and lower overall complication rates, though with a slightly increased risk of intra-abdominal abscess. 1
• Surgery should be performed as soon as feasible, ideally within 12-24 hours of diagnosis. 2
• Preoperative antibiotics (single dose of broad-spectrum coverage such as second- or third-generation cephalosporins like cefoxitin or cefotetan) should be administered within 1 hour of diagnosis. 1, 2
• Prophylactic antibiotics should NOT be continued beyond 24 hours postoperatively for uncomplicated appendicitis. 2

Non-Operative Management (Selected Cases Only)

• Antibiotics may be considered as primary treatment for uncomplicated appendicitis, but this approach has significant limitations. 1, 2
• Critical exclusion criteria for antibiotic therapy include presence of appendicolith (failure rates approach 40%), appendiceal diameter >13 mm, mass effect, or any signs of complicated appendicitis. 2, 3
• The APPAC trial demonstrated a 27% one-year recurrence rate requiring appendectomy in the antibiotic group, meaning only 63-73% of patients remain asymptomatic long-term. 1, 4
• Antibiotic regimens include 7-10 days of broad-spectrum coverage: piperacillin-tazobactam monotherapy, or combination therapy with cephalosporins/fluoroquinolones plus metronidazole. 1, 3
• This approach requires CT-confirmed diagnosis of uncomplicated appendicitis and informed patient consent regarding recurrence risks. 1

Complicated Acute Appendicitis (Perforation, Gangrene, Peritonitis)

Immediate Management

• Broad-spectrum intravenous antibiotics covering enteric gram-negative organisms and anaerobes (E. coli, Bacteroides) must be initiated immediately upon diagnosis. 1, 2
• Recommended regimens include piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate, imipenem-cilastatin, or the combination of ampicillin + clindamycin (or metronidazole) + gentamicin. 1

Surgical Approach Based on Presentation

• For periappendiceal abscess or phlegmon: Percutaneous image-guided drainage followed by interval appendectomy 6-8 weeks later is the preferred approach. 1, 2
• For diffuse peritonitis: Urgent laparoscopic or open appendectomy is required. 2
• Postoperative antibiotics should continue for complicated cases, with early switch to oral antibiotics after 48 hours being safe and effective, for total duration shorter than 7 days. 1

Special Population Considerations

Pediatric Patients

• Appendectomy remains standard treatment, with the same surgical principles as adults. 1, 2
• Postoperative antibiotics have no role in reducing surgical site infections for uncomplicated appendicitis in children and should NOT be used. 1
• For complicated appendicitis in children, early transition to oral antibiotics after 48 hours is safe, with total therapy duration less than 7 days. 1

Pregnant Patients

• Appendectomy remains the standard treatment, with laparoscopic approach safe in all trimesters. 1
• MRI is the preferred imaging modality after inconclusive ultrasound to confirm diagnosis before surgery. 1

Patients Over 40 Years

• All patients over 40 with complicated appendicitis treated non-operatively should undergo colonic screening and interval full-dose contrast-enhanced CT scan to exclude underlying malignancy (incidence 0.3% in antibiotic-treated groups). 1, 2

Critical Pitfalls to Avoid

• Never offer non-operative management if appendicolith is present on imaging - failure rates approach 40%. 2, 3
• Do not continue prophylactic antibiotics beyond 24 hours for uncomplicated appendicitis after surgery - this increases costs and antimicrobial resistance without benefit. 2
• Do not discharge intermediate-risk patients without imaging - false-negative rates exist even with normal imaging. 2
• In the era of antimicrobial resistance, the 27% recurrence rate with antibiotics and need for CT confirmation make routine antibiotic therapy problematic compared to definitive surgical management. 1