Chronic Appendicitis: Recommended Treatment
Elective appendectomy is the recommended treatment for chronic appendicitis, particularly when patients present with recurrent or persistent right lower quadrant pain lasting more than 7 days without alternative diagnosis. 1
Defining Chronic Appendicitis
Chronic appendicitis represents a distinct clinical entity characterized by:
- Recurrent or persistent right lower quadrant pain lasting ≥7 days (optimal cut-off with 89.9% specificity and positive likelihood ratio of 4.64) 1
- Lower inflammatory markers compared to acute appendicitis (WBC ~8,700 vs 13,400; Alvarado score ~4 vs 7 points) 1
- Histological findings showing chronic inflammation (42%) or fibrosis (50.6%) rather than acute inflammation 1
The condition occurs when acute appendicitis resolves spontaneously but recurs repeatedly, and while not universally accepted as an independent entity, it accounts for a meaningful subset of appendiceal pathology. 2
Surgical Management: The Definitive Approach
Laparoscopic Appendectomy (Preferred)
Laparoscopic appendectomy should be performed as first-line treatment when expertise is available, offering superior outcomes compared to open surgery. 3, 4
Key advantages include:
- Shorter hospital stay (3 days for chronic vs 4 days for acute appendicitis) 1
- Lower surgical site infection rates 4
- Less postoperative pain 3
- Earlier return to normal activities 3
Open Appendectomy (Alternative)
Open appendectomy via Lanz incision remains acceptable when laparoscopic expertise is unavailable or in resource-limited settings. 3, 5
Perioperative Antibiotic Management
Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision, covering gram-negative organisms and anaerobes. 3, 4, 5
Recommended regimens include:
- Ceftriaxone + metronidazole
- Piperacillin-tazobactam
- Ampicillin-sulbactam 5
No postoperative antibiotics are needed for uncomplicated chronic appendicitis, as this represents a non-acute inflammatory process. 3, 4
Why Non-Operative Management Is NOT Recommended
While antibiotics alone may be considered for acute uncomplicated appendicitis in highly selected cases, this approach is inappropriate for chronic appendicitis for several critical reasons:
- High recurrence rates: 27-37% within one year for acute appendicitis treated non-operatively 4, 6, 7
- Treatment failure: 30.7% require appendectomy within the first year 6
- Persistent symptoms: The chronic nature implies failed spontaneous resolution 1, 2
- Antimicrobial stewardship concerns: Prolonged or repeated antibiotic courses promote resistance 3
Expected Outcomes
More than 93% of patients with chronic appendicitis remain asymptomatic long-term after appendectomy (median follow-up 50.2 months). 1
This excellent success rate strongly supports surgical intervention as definitive treatment rather than conservative management.
Critical Diagnostic Considerations
Before proceeding to appendectomy, ensure:
- Duration of symptoms ≥7 days to distinguish from acute appendicitis 1
- Imaging confirmation (preferably CT scan) to exclude alternative diagnoses and assess for complications 4
- No evidence of appendiceal abscess or phlegmon, which would require modified management 3
- Histological examination post-operatively to confirm chronic inflammation/fibrosis and exclude malignancy (0.3% incidence) 6
Common Pitfalls to Avoid
- Do not dismiss recurrent right lower quadrant pain as functional or non-surgical; a history of prior similar episodes should never dissuade consideration of appendiceal pathology 2
- Do not delay surgery in favor of repeated antibiotic trials, as this increases cumulative morbidity without addressing the underlying pathology 1, 2
- Do not proceed without imaging in female patients of childbearing age; always obtain pregnancy test and use ultrasound first to minimize radiation exposure 4
- Do not assume normal inflammatory markers exclude appendiceal pathology; chronic appendicitis characteristically presents with lower WBC and Alvarado scores than acute disease 1