What is the best course of treatment for a 28-year-old male with nausea (N) and vomiting (V), abdominal pain for 1 week, and no oral intake for 1 day, diagnosed with appendicitis based on a computed tomography (CT) scan of the abdomen and pelvis with contrast?

Management of Acute Appendicitis in a 28-Year-Old Male

Immediate Treatment Approach

This patient requires urgent laparoscopic appendectomy as the definitive treatment, with broad-spectrum intravenous antibiotics initiated immediately upon diagnosis. 1

Appendectomy remains the gold-standard treatment for acute appendicitis, with superior long-term outcomes compared to antibiotic therapy alone, particularly in patients with a week-long symptom duration and inability to tolerate oral intake. 1, 2

Pre-Operative Management

Fluid Resuscitation and Stabilization

• Initiate aggressive intravenous fluid resuscitation immediately given the patient's one-day history of no oral intake and ongoing nausea/vomiting. 1
• Correct electrolyte abnormalities and assess volume status before proceeding to surgery. 1

Antibiotic Administration

Administer broad-spectrum intravenous antibiotics as soon as the diagnosis is established, before surgical intervention. 1

For uncomplicated appendicitis, acceptable regimens include:

• Second- or third-generation cephalosporins (cefoxitin or cefotetan) as single agents 1
• Piperacillin-tazobactam monotherapy 1, 2
• Combination therapy: ceftriaxone plus metronidazole 1, 2

If the CT scan shows complicated appendicitis (perforation, abscess, or phlegmon), use broader coverage:

• Piperacillin-tazobactam 1
• Ampicillin-sulbactam 1
• Triple therapy: ampicillin, clindamycin (or metronidazole), and gentamicin 1

The antibiotics must cover enteric gram-negative organisms (particularly E. coli) and anaerobes (particularly Bacteroides species). 1

Surgical Intervention

Timing of Surgery

Proceed with appendectomy as soon as reasonably feasible once the patient is adequately resuscitated. 1, 3

The one-week duration of waxing and waning symptoms does not contraindicate immediate surgery, as delay in operation is not correlated with increased risk of perforation. 1

Surgical Approach

Laparoscopic appendectomy is the preferred approach over open appendectomy for this patient. 1

Laparoscopic appendectomy offers:

• Shorter hospital length of stay 1
• Less postoperative pain 1
• Earlier postoperative recovery 1
• Lower overall complication rates 1
• Reduced wound infection rates 1

Common pitfall: Laparoscopic appendectomy has a slightly higher risk of intra-abdominal abscess formation compared to open surgery, but the overall benefits outweigh this risk. 1

Special Considerations Based on CT Findings

If CT Shows Uncomplicated Appendicitis

• Proceed directly to laparoscopic appendectomy 1
• Single preoperative dose of antibiotics is sufficient 1
• No postoperative antibiotics are needed for uncomplicated appendicitis 1

If CT Shows Complicated Appendicitis (Perforation/Abscess/Phlegmon)

For well-defined appendiceal abscess or large phlegmon:

• Consider percutaneous drainage plus antibiotics as initial management if the abscess is accessible 1
• Success rate of percutaneous drainage is approximately 75% 1
• If drainage is successful, interval appendectomy can be performed 6-8 weeks later 1

For free perforation with diffuse peritonitis:

• Urgent appendectomy is mandatory regardless of drainage options 1
• This carries significantly higher mortality (11.9-15% vs 1.5-2.3% for non-perforated) 1

Postoperative antibiotic duration for complicated appendicitis:

• Continue IV antibiotics for 48 hours postoperatively 1
• Switch to oral antibiotics after 48 hours if clinically improving 1
• Total antibiotic duration should be less than 7 days 1

Why Not Antibiotics-First Approach?

Antibiotic therapy alone is NOT recommended for this patient despite recent evidence supporting it in highly selected cases. 2, 4

Reasons antibiotics-first is inappropriate here:

• One-week symptom duration increases likelihood of complicated appendicitis and treatment failure 2
• Inability to tolerate oral intake for 24 hours indicates more severe disease 2
• Antibiotic therapy has a 27-37% recurrence rate at one year 2, 4
• Only 63-73% of patients remain asymptomatic long-term with antibiotics alone 2, 4

High-risk CT findings that predict antibiotic failure (≈40% failure rate):

• Appendicolith present 2
• Appendiceal diameter >13 mm 2
• Mass effect 2

If any of these findings are present on the CT scan, surgical management is strongly recommended. 2

Post-Operative Management

Pain Control

• Multimodal analgesia with opioids, NSAIDs, and acetaminophen 5
• Aggressive pain control does not delay diagnosis or cause unnecessary intervention 5

Monitoring for Complications

• Watch for signs of intra-abdominal abscess (fever, leukocytosis, abdominal pain 5-7 days post-op) 1
• Monitor for wound infection 1
• Readmission rate is approximately 14-16% for complicated appendicitis 1

Diet Advancement

• Advance diet as tolerated once bowel function returns 1
• Early oral intake is safe and does not increase complications 1

Algorithm Summary

1. Immediate: IV fluid resuscitation + broad-spectrum IV antibiotics
2. Review CT findings: Determine if uncomplicated vs complicated appendicitis
3. Uncomplicated appendicitis: Urgent laparoscopic appendectomy (no postoperative antibiotics needed)
4. Complicated with abscess/phlegmon: Consider percutaneous drainage + antibiotics, then interval appendectomy vs immediate surgery based on clinical status
5. Complicated with free perforation/peritonitis: Urgent laparoscopic appendectomy + postoperative antibiotics for <7 days total