What is the best course of treatment for a patient diagnosed with perforated appendicitis?

Management of Perforated Appendicitis

Urgent appendectomy—preferably laparoscopic when expertise is available—combined with immediate broad-spectrum IV antibiotics is the standard of care for perforated appendicitis with diffuse peritoneal contamination. 1, 2

Immediate Surgical Intervention

Laparoscopic appendectomy is the first-line surgical approach when laparoscopic equipment and skills are available, as it results in shorter hospital stays (4-9.2 vs 6-10.5 days), lower overall complication rates (8.3-18.8% vs 12.5-26.8%), and fewer wound infections compared to open appendectomy. 3, 2, 4

• Open appendectomy remains acceptable when laparoscopic expertise is unavailable or in cases of diffuse peritonitis where open approach may be preferable. 1, 2
• Surgery should not be delayed once diagnosis is established, as delayed intervention increases peritonitis severity, colonic wall inflammation, and requires more invasive procedures with worse prognosis. 1
• Early appendectomy (within 24 hours) demonstrates superior outcomes compared to delayed management, with lower rates of bowel resection (3.3% vs 17.1%), fewer organ-space infections (14.0% vs 23.8%), and shorter hospital stays (3.1 vs 9.4 days). 2, 4

Important Caveat on Laparoscopic Approach

While laparoscopic appendectomy offers multiple advantages, some studies show a slightly increased risk of intra-abdominal abscesses (11.7% vs 4.5% in one randomized trial), though more recent large database analyses show lower abscess risk with laparoscopy (1.65% vs 3.57%). 3, 2, 4 This risk has diminished over time as surgical techniques have improved. 3

Antibiotic Management

Initiate broad-spectrum IV antibiotics immediately upon diagnosis that cover enteric gram-negative organisms (particularly E. coli) and anaerobes (particularly Bacteroides species). 1, 2

Recommended IV Antibiotic Regimens:

Single-agent options:

• Piperacillin-tazobactam
• Ampicillin-sulbactam
• Ticarcillin-clavulanate
• Imipenem-cilastatin, ertapenem, or meropenem 1, 2

Combination therapy options:

• Ampicillin + clindamycin (or metronidazole) + gentamicin
• Ceftriaxone + metronidazole
• Ciprofloxacin + metronidazole 2

Antibiotic Duration:

• Total duration should be 3-5 days postoperatively after adequate source control. 1, 2
• Transition to oral antibiotics after 48 hours if clinically improving. 1, 2
• Discontinuation after 24 hours may be considered in selected cases with excellent source control and clinical improvement. 2

Critical Pitfall to Avoid:

Do not add metronidazole when already using broad-spectrum agents like piperacillin-tazobactam or carbapenems, as these provide adequate anaerobic coverage. 1, 2 Prolonging antibiotics beyond 3-5 days when adequate source control has been achieved increases costs, hospital stay, and antimicrobial resistance without improving outcomes. 2

Alternative Management for Localized Disease

Patients with well-circumscribed periappendiceal abscesses can be managed conservatively with IV antibiotics and percutaneous drainage when necessary, with appendectomy generally deferred. 1

• This approach is safe for selected patients presenting several days after symptom onset with a periappendiceal phlegmon or small abscess not amenable to percutaneous drainage. 1
• Conservative management followed by interval appendectomy (6-12 weeks later) is effective in 92% of cases, with only 58% requiring percutaneous drainage. 5
• However, this conservative approach should NOT be used in patients with diffuse peritonitis, hemodynamic instability, or high-risk populations. 1, 2

Monitoring Requirements for Conservative Management:

• Serial clinical and imaging monitoring every 3-6 hours 1
• Absolute bowel rest with IV hydration 1
• Clinical improvement must occur within 24 hours; if deterioration or progression to sepsis occurs, surgical treatment must not be delayed. 1

Drainage Considerations

Prophylactic drainage is NOT recommended following appendectomy for perforated appendicitis, as it does not reduce abscess formation and is associated with increased complications and longer hospital stays. 4

• When drains are placed, early removal is favored, as it reduces morbidity (3.4% vs 17.9%) without increasing abscess risk. 4

High-Risk Populations Requiring Immediate Surgery

The following populations should proceed directly to surgical management regardless of presentation:

• Immunosuppressed patients and transplant recipients 1
• Patients with concomitant colonic diseases requiring surgery 1
• Elderly patients (age >65), who have 55-70% perforation rates and threefold increase in mortality per decade 1, 2
• Patients with hemodynamic instability or diffuse peritonitis 2

Mortality Risk Stratification

Perforated appendicitis carries approximately 5% mortality compared to <0.1% for non-gangrenous appendicitis, making timely source control critical. 1, 2

• Mortality risk increases dramatically with age, reaching more than 16% in nonagenarians. 1
• Peritoneal contamination >150 ml is associated with 100% increase in morbidity and mortality (54.5%). 6
• Delayed presentations in elderly populations with underlying comorbidities and severe peritoneal contamination are associated with higher mortality (26%). 6

Special Considerations

Patients ≥40 years old treated non-operatively must undergo colonoscopy due to higher risk of appendiceal neoplasms, and an interval full-dose contrast-enhanced CT scan should be performed. 2

• Routine interval appendectomy is NOT recommended after successful non-operative management in young adults (<40 years) and children. 2