eMedicine Specialties > Emergency Medicine > Gastrointestinal

Appendicitis, Acute: Treatment & Medication

Author: Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Carolinas Medical Center
Contributor Information and Disclosures

Updated: Jun 1, 2009

Treatment

Emergency Department Care

  • Treatment guidelines for patients with suspected acute appendicitis
    • Establish intravenous access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration or septicemia.
    • Patients with suspected appendicitis should not receive anything by mouth.
    • Administer parenteral analgesic and antiemetic as needed for patient comfort. The administration of analgesics to patients with acute undifferentiated abdominal pain has historically been discouraged and criticized because of concerns that they render the physical findings less reliable. At least 8 randomized controlled studies now demonstrate that administering opioid analgesic medications to adult and pediatric patients with acute undifferentiated abdominal pain is safe; no study has shown that analgesics adversely affect the accuracy of physical examination. 
    • Consider ectopic pregnancy in women of childbearing age, and obtain a qualitative beta–human chorionic gonadotropin (beta-hCG) measurement in all cases.
    • Administer intravenous antibiotics to those with signs of septicemia and to those who are to proceed to laparotomy.
  • Nonsurgical treatment of appendicitis
    • Anecdotal reports describe the success of intravenous antibiotics in treating acute appendicitis in patients without access to surgical intervention (eg, submariners, individuals on ships at sea).
    • In one prospective study of 20 patients with sonography-proven appendicitis, symptoms resolved in 95% of patients receiving antibiotics alone, but 37% of these patients had recurrent appendicitis within 14 months.51
    • Nonsurgical treatment may be useful when appendectomy is not accessible or when it is temporarily a high-risk procedure.
  • Preoperative antibiotics
    • Preoperative antibiotics have demonstrated efficacy in decreasing postoperative wound infection rates in numerous prospective controlled studies.
    • Broad-spectrum gram-negative and anaerobic coverage is indicated.
    • Preoperative antibiotics should be given in conjunction with the surgical consultant.
    • Penicillin-allergic patients should avoid beta-lactamase type antibiotics and cephalosporins. Carbapenems are a good option in these patients.
    • Pregnant patients should receive pregnancy category A or B antibiotics.

Consultations

  • Consult a general surgeon.

Medication

The goals of therapy are to eradicate the infection and to prevent complications.

Antibiotics

These agents are effective in decreasing the rate of postoperative wound infection and in improving outcome in patients with appendiceal abscess or septicemia. The Surgical Infection Society recommends starting prophylactic antibiotics before surgery, using appropriate spectrum agents for less than 24 hours for nonperforated appendicitis and for less than 5 days for perforated appendicitis. Regimens are of approximately equal efficacy, so consideration should be given to features such as medication allergy, pregnancy category (if applicable), toxicity, and cost.


Metronidazole (Flagyl)

Used in combination with aminoglycoside (eg, gentamicin); broad gram-negative and anaerobic coverage. Appears to be absorbed into cells; intermediate metabolized compounds bind DNA and inhibit protein synthesis, causing cell death.

Adult

7.5 mg/kg IV before surgery

Pediatric

15-30 mg/kg/d IV divided bid/tid for 7 d, or 40 mg/kg PO once; not to exceed 2 g/d

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and peripheral neuropathy


Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with agent against gram-positive organisms and one against anaerobes. Not DOC. Consider if penicillins or other less toxic drugs contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Numerous regimens; adjust dose for CrCl and changes in volume of distribution. May be given IV/IM.

Adult

2 mg/kg IV loading dose before surgery; 3-5 mg/kg/d divided tid/qid thereafter

Pediatric

Infants/neonates: 7.5 mg/kg/d IV divided tid
Children: 6-7.5 mg/kg/d IV divided tid

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents; prolonged respiratory depression may occur; coadministration with loop diuretics may increase ototoxicity of aminoglycosides, which may cause irreversible hearing loss of varying degrees (monitor regularly)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment


Cefotetan (Cefotan)

Second-generation cephalosporin used as single-drug therapy for broad gram-negative and anaerobic coverage. Half-life is 3.5 h. Give with cefoxitin to achieve effectiveness of single dose.

Adult

2 g IV once before surgery

Pediatric

20-40 mg/kg IV/IM once before surgery

Consumption of alcohol within 72 h may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dose by half if CrCl 10-30 mL/min and by three quarters if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy


Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated as single agent for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Half-life is 0.8 h.

Adult

2 g IV before surgery, followed by 3 doses of 2 g q4-6h for 24 h

Pediatric

<3 months: Not established
>3 months: 30-40 mg/kg IV before surgery, followed by 3 doses of 2 g q4-6h for 24 h

Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis


Meropenem (Merrem)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Used as a single agent, effective against most gram-positive and gram-negative bacteria.

Adult

1 g IV q8h

Pediatric

40 mg/kg IV q8h

Probenecid may inhibit renal excretion, increasing levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pseudomembranous colitis and thrombocytopenia may occur (immediate discontinue)


Piperacillin and tazobactam sodium (Zosyn)

Drug combination of beta-lactamase inhibitor with piperacillin. Activity against some gram-positive organisms, gram-negative organisms, and anaerobic bacteria. Used as a single agent, inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Adult

3.375 g IV q6h

Pediatric

300-400 mg piperacillin/kg/d IV divided q6-8h

Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high dose parenteral penicillins may result in increased risk of bleeding

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions


Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Used as a single agent.
Activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria.

Adult

1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Pediatric

<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy
Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Analgesics

These agents can be used to relieve acute undifferentiated abdominal pain in patients presenting to the ED.


Morphine sulfate (Astramorph, Duramorph, MS Contin, MSIR, Oramorph)

DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used; commonly titrated to desired effect.

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relative hypovolemia: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose

Pediatric

Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may start at 0.05 mg/kg/dose

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine

Documented hypersensitivity; hypotension; potentially compromised airway in which rapid airway control may be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

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References
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Further Reading

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Keywords

appendicitis, acute appendicitis, appendectomy, acute inflammation of the appendix, abdominal pain, fecaliths, appendiceal perforation, right lower quadrant pain, vomiting, periumbilical pain, Rovsing sign, obturator sign, psoas sign, positive cough sign, burst appendix, luminal obstruction

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Contributor Information and Disclosures

Author

Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Carolinas Medical Center
Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William Lober, MD, Associate Professor, Department of Medical Education, Division of Biomedical and Health Informatics, University of Washington School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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