Treatment of Hyperemic Inflamed Appendix
A hyperemic inflamed appendix (uncomplicated acute appendicitis) should be treated with urgent appendectomy performed as soon as reasonably feasible, with a single preoperative dose of broad-spectrum antibiotics and no postoperative antibiotics required. 1
Surgical Management
Laparoscopic appendectomy is the preferred approach when surgical expertise is available, as it offers superior outcomes compared to open surgery. 2 Both laparoscopic and open appendectomy are acceptable procedures, with the choice dictated by surgeon expertise. 1
Timing of Surgery
- Surgery should be performed within 24 hours of admission to minimize complications. 2
- Operative intervention may be performed as soon as reasonably feasible and can be deferred for a short period according to institutional circumstances. 1
- Delays beyond 24-48 hours significantly increase the risk of surgical site infections and adverse events. 2
Intraoperative Considerations
- Remove the appendix even if it appears macroscopically normal during exploration, as surgeon judgment is unreliable—27.8% of "normal-appearing" appendices show inflammation on histology. 1, 2
- Simple ligation of the appendiceal stump is recommended over stump inversion. 2
- Routine intraoperative irrigation does not prevent abscess formation and may be avoided. 2
- Drains are not recommended following appendectomy as they provide no benefit and prolong hospitalization. 2
Antibiotic Management
Preoperative Antibiotics
A single dose of broad-spectrum antibiotics must be administered 0-60 minutes before surgical incision. 2 Appropriate agents include:
- Second- or third-generation cephalosporins (cefoxitin or cefotetan) for uncomplicated cases 1
- Agents effective against facultative/aerobic gram-negative organisms and anaerobes (E. coli and Bacteroides species) 1
Postoperative Antibiotics
Postoperative antibiotics are NOT recommended for uncomplicated acute appendicitis with adequate source control. 1, 2 This applies to both adults and children, as postoperative antibiotics have no role in reducing surgical site infection rates when the appendix is not perforated. 1
Alternative: Nonoperative Management
While appendectomy remains the gold standard, nonoperative management with antibiotics alone may be considered in highly selected patients with uncomplicated appendicitis who show marked clinical improvement. 1
Criteria for Nonoperative Consideration
- Male patients admitted for 48 hours showing sustained improvement within 24 hours on antimicrobial therapy 1
- Patients without high-risk CT findings (no appendicolith, appendiceal diameter <13mm, no mass effect) 3
- Success rate is approximately 63-73% at one year, with significant recurrence rates limiting long-term effectiveness 4, 3
Antibiotic Regimen for Nonoperative Management
If nonoperative management is chosen:
- Broad-spectrum antibiotics such as piperacillin-tazobactam monotherapy, or combination therapy with cephalosporins/fluoroquinolones plus metronidazole 3
- Minimum 3 days of therapy until clinical symptoms resolve 1
- Total duration typically 8-15 days in clinical trials 4
Critical Pitfalls to Avoid
- Do not delay surgery beyond 24 hours in patients fit for surgery, as this increases perforation risk and complications. 2
- Do not administer postoperative antibiotics for uncomplicated appendicitis—this increases antibiotic resistance without benefit. 1, 2
- Do not leave the appendix in place if it appears normal during exploration, as macroscopic judgment is unreliable. 1, 2
- Nonoperative management should not be attempted in Class C (critically ill) patients fit for surgery—these patients require emergent/urgent appendectomy. 1