What is the recommended inpatient management for a patient with acute appendicitis from a hospitalist standpoint?

Inpatient Management of Acute Appendicitis from a Hospitalist Standpoint

For uncomplicated acute appendicitis, coordinate laparoscopic appendectomy within 24 hours of admission, or in highly selected patients with CT-confirmed disease and no appendicolith, consider antibiotic therapy as an alternative with clear counseling about 27-39% recurrence risk. 1, 2

Initial Assessment and Risk Stratification

Diagnostic Confirmation

• Obtain CT imaging to confirm diagnosis and distinguish uncomplicated from complicated appendicitis (appendiceal diameter ≥7mm confirms diagnosis; look specifically for appendicolith, abscess, perforation, or mass effect). 3
• Use an intraoperative grading system (WSES or AAST) to guide postoperative management decisions. 1, 4
• Order complete blood count looking for left shift or segmented neutrophils >75%; consider C-reactive protein if diagnosis uncertain. 1

Key Clinical Pitfalls

• Female patients have higher perforation rates—maintain high clinical suspicion. 4
• Surgeon's macroscopic judgment of "normal" appendix is unreliable (27.8% are inflamed histologically), so remove the appendix even if it appears normal during exploration. 1, 4

Management Pathway for Uncomplicated Appendicitis

Surgical Management (Standard Approach)

• Coordinate laparoscopic appendectomy within 24 hours of admission—delays beyond this timeframe increase complications and adverse outcomes. 1, 4
• Laparoscopic approach is superior to open surgery, offering less postoperative pain, lower surgical site infection rates, shorter hospital stay, earlier return to work, and better quality of life. 1, 4
• Administer single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision (amoxicillin/clavulanate, ceftriaxone + metronidazole, or cefotaxime + metronidazole). 1, 2, 4
• Do not continue postoperative antibiotics for uncomplicated appendicitis with adequate source control. 4

Conservative Management (Highly Selected Patients Only)

Patient selection criteria—ALL must be met: 2

• CT-confirmed uncomplicated appendicitis
• Absence of appendicolith on imaging (presence predicts ~40% treatment failure)
• No significant comorbidities or signs of sepsis
• Patient accepts recurrence risk of 14-31% at 1 year and up to 39% at 5 years

Antibiotic regimen if conservative management chosen: 2

• Start IV amoxicillin/clavulanate, ceftriaxone + metronidazole, or cefotaxime + metronidazole for minimum 48 hours
• For beta-lactam allergy: ciprofloxacin + metronidazole or moxifloxacin
• Transition to oral antibiotics based on clinical improvement (total duration guided by clinical response)
• Initial success rates 58-100%, but 30.7% require appendectomy within first year 2, 5

Critical contraindications to conservative management: 3

• Appendicolith on CT (associated with ~40% failure rate)
• Appendiceal diameter >13mm
• Mass effect on imaging
• Any signs of complicated disease

Management of Complicated Appendicitis

Perforated Appendicitis with Shock

• Proceed with appendectomy within 24 hours once hemodynamically stable—do not delay attempting prolonged conservative management. 4
• Maintain low threshold for conversion to open surgery if technical difficulties arise. 4
• Administer preoperative antibiotics 0-60 minutes before incision. 4
• Continue postoperative antibiotics for 3-5 days when adequate source control achieved. 4

Periappendiceal Abscess or Phlegmon

Two acceptable approaches based on available expertise: 1, 4

1. Non-operative management (when advanced laparoscopic expertise unavailable):

   • IV antibiotics plus percutaneous drainage if abscess accessible
   • Recurrence rate 12-24% after non-surgical treatment 1

2. Laparoscopic approach (preferred when advanced expertise available):

   • Associated with fewer readmissions and fewer additional interventions than conservative treatment
   • Comparable hospital stay to conservative management 1, 4

Interval Appendectomy Decisions

• Do not perform routine interval appendectomy in patients <40 years old after successful non-operative management of complicated appendicitis. 1, 4
• Reserve interval appendectomy only for recurrent symptoms. 1
• For patients ≥40 years old treated non-operatively, arrange colonoscopy and interval full-dose contrast-enhanced CT scan (3-17% incidence of appendicular neoplasms in this age group). 1, 4

Postoperative Management

Routine Care

• Request routine histopathology on all appendectomy specimens to identify unexpected findings (including malignancy). 1, 4
• Do not place drains following appendectomy for complicated appendicitis—they provide no benefit in preventing intra-abdominal abscess and prolong hospitalization. 4
• Use simple ligation rather than stump inversion for appendiceal stump closure. 4

Monitoring for Complications

• Wound infections occur in 25% fewer patients with antibiotics versus surgery. 5
• Laparoscopic approach has slightly increased risk of intra-abdominal abscess compared to open surgery, though overall complication rates favor laparoscopy. 1
• Watch for C. difficile diarrhea in patients receiving prolonged antibiotic courses. 5

Special Populations

Pregnant Patients

• Short in-hospital delay with observation and repeated ultrasound acceptable for equivocal cases. 1
• Proceed with timely surgical intervention rather than conservative management to decrease complication risk. 6

Immunosuppressed Patients

• Recommend timely surgical intervention rather than conservative management. 6

Pediatric Patients

• Antibiotics can be discussed as alternative for uncomplicated appendicitis without appendicolith (97% initial success, 14% recurrence rate). 2
• Do not delay appendectomy beyond 24 hours for children requiring surgery; perform within 8 hours for complicated appendicitis. 1