Can appendicitis recur in a patient with a history of perforated appendicitis?

Can Perforated Appendicitis Recur?

Yes, appendicitis can recur after non-operative management of perforated appendicitis, with recurrence rates ranging from 12-24% depending on the patient population and follow-up duration. 1

Recurrence Rates After Non-Operative Management

The risk of recurrent appendicitis following successful non-operative treatment of perforated appendicitis is well-documented:

• Overall recurrence rate: 12-24% in patients managed conservatively with antibiotics ± percutaneous drainage 1
• Pediatric populations show 12-20.5% recurrence during follow-up after successful non-operative management 1
• Adult populations demonstrate up to 24.3% recurrence when managed with antibiotics for appendiceal abscess or phlegmon 1

Clinical Characteristics of Recurrent Episodes

When appendicitis does recur after initial non-operative management, the clinical presentation is typically milder than the original episode 2:

• Lower white blood cell counts (median 9.5 vs 13.1 at initial presentation) 2
• Lower maximum temperatures (98.6°F vs 100.3°F initially) 2
• Shorter duration of IV antibiotic therapy needed (3 vs 6 days) 2
• Shorter hospital stays (6 vs 7 days) 2

Risk Factors for Recurrence

Two specific factors significantly predict recurrence and should guide decision-making about interval appendectomy 3:

• Presence of calcified appendicolith on CT imaging (P<0.001) 3
• Prior history of appendicitis (P<0.05) 3

Interval appendectomy should be strongly considered in patients with either of these risk factors rather than adopting a wait-and-see approach 3.

Current Guideline Recommendations on Interval Appendectomy

The 2020 WSES Jerusalem Guidelines do not recommend routine interval appendectomy for all patients after successful non-operative management 1:

• Interval appendectomy carries its own morbidity rate of 12.4% 1
• The procedure prevents recurrence in only 1 out of 8 patients, making routine use not cost-effective 1
• A wait-and-see approach, reserving appendectomy for patients who develop recurrence, is the most cost-effective strategy 1

Important Caveat: Occult Malignancy Risk

In adults over 40 years old with complicated appendicitis treated non-operatively, there is a concerning rate of occult appendiceal neoplasms 1:

• Up to 11% of adult patients with complicated appendicitis have appendiceal neoplasm at interval appendectomy 1
• One RCT found a 17% rate of neoplasms in patients over 40 after periappendicular abscess, leading to premature termination on ethical grounds 1
• This argues for routine interval appendectomy in patients over 40 years old after successful non-operative management of perforated appendicitis 1

Surgical Challenges with Delayed Appendectomy

Second-date appendectomy (operating after failed non-operative treatment) presents greater technical challenges than prompt appendectomy 4:

• The appendix must be removed through scar tissue from previously unhealed perforated appendicitis 4
• Anatomic presentation is more difficult with incomplete healing and early recurrence 4
• Patients should be informed of this increased surgical complexity when choosing non-operative management 4

Clinical Bottom Line

Recurrence is a real risk after non-operative management of perforated appendicitis, but most patients (76-88%) avoid appendectomy during follow-up. 1 The decision about interval appendectomy should be based on:

1. Age: Strongly consider interval appendectomy in patients >40 years due to malignancy risk 1
2. Imaging findings: Perform interval appendectomy if calcified appendicolith present 3
3. History: Perform interval appendectomy if prior history of appendicitis 3
4. Patient preference: Inform patients of 12-24% recurrence risk versus 12.4% morbidity from interval appendectomy 1