Treatment of Appendicolith in Acute Appendicitis
Appendectomy is strongly recommended for patients with acute appendicitis and an appendicolith, as the presence of an appendicolith is an independent predictor of perforation, treatment failure with antibiotics, and complicated disease. 1, 2
Key Clinical Decision Point
The presence of an appendicolith fundamentally changes the treatment algorithm for acute appendicitis:
- With appendicolith: Surgery is the preferred treatment 1, 2
- Without appendicolith: Non-operative management with antibiotics may be considered in selected patients with uncomplicated appendicitis 1
Evidence Supporting Surgical Management
Adult Patients
Appendicoliths are associated with increased perforation risk and serve as an independent prognostic risk factor for treatment failure when attempting non-operative management 1
The 2020 WSES Jerusalem Guidelines explicitly state that non-operative management with antibiotics should only be discussed in patients with uncomplicated acute appendicitis AND absence of appendicolith (Strong recommendation, High quality evidence) 1
Recent evidence demonstrates that CT findings of appendicolith predict approximately 40% failure rate with an antibiotics-first approach 3
A 2025 study found that appendicolith increases the odds of complicated appendicitis by 3.52-fold after adjusting for age, sex, and symptom duration 4
Pediatric Patients
The evidence is even more compelling in children:
Failure rates of non-operative management in pediatric patients with appendicolith range from 47-60% across multiple studies 1
Mahida et al. reported a 60% failure rate at median follow-up of less than 5 months in children with appendicolith treated non-operatively 1
Meta-analysis by Huang et al. concluded that surgery is preferred for uncomplicated appendicitis with appendicolith due to high failure rates 1
Surgical Approach
Laparoscopic appendectomy is the recommended surgical approach and can be performed safely as soon as reasonably feasible after diagnosis 2
- Both laparoscopic and open approaches are acceptable, with choice based on surgeon expertise 2
- Surgery should not be delayed unnecessarily once the diagnosis is established 2
Special Considerations
Small Appendicoliths with Low Inflammation
A 2022 study suggests that appendicoliths ≤5 mm diameter with CRP ≤5.36 mg/dL may potentially be managed non-operatively, though this contradicts guideline recommendations 5
However, appendicoliths >10 mm diameter or CRP >10 mg/dL are strong indications for surgery due to high perforation risk 5
Antibiotic Coverage
If surgery is performed, initiate broad-spectrum antibiotics covering gram-negative organisms and anaerobes 2, 3:
- Single-agent options: ertapenem, meropenem, imipenem-cilastatin, or piperacillin-tazobactam 6, 3
- Combination therapy: ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole 6, 3
Critical Pitfalls to Avoid
Do not attempt prolonged antibiotic therapy alone in the presence of an appendicolith – this predicts treatment failure and warrants surgical management 2
Retained appendicoliths after appendectomy can cause recurrent abscess formation and may require subsequent removal 7, 8
In patients ≥40 years treated for complicated appendicitis, perform colonoscopy to exclude underlying neoplasm 6