Management of Acute Peritonitis Secondary to Perforated Appendix
Immediate Surgical Intervention is Mandatory
For patients with perforated appendicitis and diffuse peritonitis, immediate surgical exploration without delay is the standard of care, as delaying surgery for complete physiologic stabilization increases mortality. 1, 2
Initial Resuscitation and Preoperative Management
Concurrent Stabilization During Surgical Preparation
- Initiate aggressive fluid resuscitation immediately to address the volume depletion that universally accompanies peritonitis, but do not delay surgery for complete hemodynamic optimization 2
- Start broad-spectrum intravenous antibiotics within 1 hour of presentation, particularly in patients showing signs of septic shock 2, 3
- Ensure antimicrobial drug levels are maintained during the surgical procedure, which may require additional dosing just before entering the operating room 2
Antibiotic Selection
- Piperacillin-tazobactam is FDA-approved for appendicitis complicated by rupture or abscess and peritonitis, covering beta-lactamase producing E. coli and Bacteroides fragilis group organisms 3
- Standard dosing is 3.375 grams IV every 6 hours (totaling 13.5 grams daily) administered over 30 minutes for intra-abdominal infections 3
- In pediatric patients ≥2 months old, piperacillin-tazobactam 112.5 mg/kg IV every 8 hours is appropriate 3
Surgical Approach: Hemodynamic Status Determines Strategy
For Hemodynamically Stable Patients
- Laparoscopic appendectomy is the preferred approach in stable patients, even with peritonitis, as it reduces operative time, blood loss, and length of stay 1
- Perform thorough peritoneal lavage and drainage of all purulent collections during the procedure 1
- Consider placing an abdominal drain in cases of complicated appendicitis with perforation, abscess, or peritonitis 1
For Hemodynamically Unstable Patients
- Damage control surgery with open abdomen approach should be strongly considered in patients with persistent hemodynamic instability, severe peritonitis, and septic shock 1
- The open abdomen technique is indicated when there is severe physiological derangement, extensive visceral edema with risk of abdominal compartment syndrome, or failure of source control 1
- Plan for second-look laparotomy in 24-48 hours if there are concerns about ongoing contamination or questionable bowel viability 1
Surgical Goals and Technique
Primary Objectives
- Drain all infected foci and purulent collections throughout the peritoneal cavity 2
- Control ongoing peritoneal contamination by removing the perforated appendix 2
- Restore anatomic and physiological function while minimizing operative time in unstable patients 2
Technical Considerations
- Assess the entire abdomen systematically, as perforated appendicitis can cause widespread contamination 1
- Remove the appendix regardless of appearance once the decision for surgery is made, as leaving it risks ongoing sepsis 1
- Avoid routine closure of the appendiceal stump with expensive devices (staplers) unless necessary; endoloops or clips are equally effective based on surgeon preference 1
Postoperative Antibiotic Management
Duration Based on Source Control
- For adequate source control in immunocompetent patients, limit antibiotics to 3-5 days after surgery 1
- Extend antibiotic therapy to 7 days in immunocompromised or critically ill patients 1
- Discontinue antibiotics based on clinical criteria (resolution of fever, normalizing white blood cell count) rather than arbitrary time frames 1
Monitoring for Complications
- Evaluate patients every 3-6 hours initially for signs of ongoing sepsis or treatment failure 4
- Monitor for acute kidney injury, as piperacillin-tazobactam is associated with increased risk of renal failure (odds ratio 1.7) in critically ill patients 3
Special Populations and Considerations
Elderly Patients
- Perform appendectomy as soon as possible once the decision for surgery is made, as elderly patients have higher mortality with delayed intervention 1
- Strongly recommend against non-operative management in elderly patients with diffuse peritonitis or suspected free perforation 1
- Consider elective colonic screening after recovery in all elderly patients with appendicitis to exclude underlying malignancy 1
Pediatric Patients (≥2 months)
- Laparoscopic appendectomy is equally safe and effective in pediatric patients with perforated appendicitis 3
- The safety profile mirrors that of adults, with similar rates of adverse events when using appropriate weight-based dosing 3
Critical Pitfalls to Avoid
Timing Errors
- Never delay surgery attempting complete hemodynamic stabilization - resuscitation should continue concurrently with surgical intervention, as delayed source control dramatically increases mortality 2
- Do not perform mandatory scheduled relaparotomy unless there is intestinal discontinuity, inability to close the abdomen, or abdominal compartment syndrome 2
Antibiotic Management Errors
- Avoid inadequate antimicrobial coverage during the perioperative period, as this is associated with treatment failure 2
- Do not continue antibiotics beyond 5 days in uncomplicated cases after adequate source control, as this promotes resistance without benefit 1
Surgical Technique Errors
- Do not attempt conservative management in patients with diffuse peritonitis or free perforation, as this approach is contraindicated and increases mortality 1, 4
- Avoid converting stable patients to open procedures unnecessarily, as laparoscopy provides superior outcomes when feasible 1
Algorithm for Decision-Making
Step 1: Assess Hemodynamic Stability
- Stable (normal BP, no tachycardia, no septic shock) → Proceed to laparoscopic appendectomy 1
- Unstable (hypotension, tachycardia, septic shock) → Consider damage control surgery with open abdomen 1
Step 2: Initiate Concurrent Resuscitation
- Start IV fluids and broad-spectrum antibiotics immediately 2, 3
- Do not delay surgery for complete stabilization 2
Step 3: Surgical Intervention
- Remove appendix, drain all collections, lavage peritoneal cavity 1, 2
- Place drain if significant contamination present 1
Step 4: Postoperative Management