Appendicitis Treatment & Management
- Author: Sandy Craig, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Approach Considerations
Appendectomy remains the only curative treatment of appendicitis, but management of patients with an appendiceal mass can usually be divided into the following 3 treatment categories:
- Patients with a phlegmon or a small abscess: After intravenous (IV) antibiotic therapy, an interval appendectomy can be performed 4-6 weeks later.
- Patients with a larger well-defined abscess: After percutaneous drainage with IV antibiotics is performed, the patient can be discharged with the catheter in place. Interval appendectomy can be performed after the fistula is closed.
- Patients with a multicompartmental abscess: These patients require early surgical drainage.
Although many controversies exist over the nonoperative management of acute appendicitis, antibiotics have an important role in the treatment of patients with this condition. Antibiotics considered for patients with appendicitis must offer full aerobic and anaerobic coverage. The duration of the administration is closely related to the stage of appendicitis at the time of the diagnosis, considering either intraoperative findings or postoperative evolution. According to several studies, antibiotic prophylaxis should be administered before every appendectomy. When the patient becomes afebrile and the white blood cell (WBC) count normalizes, antibiotic treatment may be stopped. Cefotetan and cefoxitin seem to be the best choices of antibiotics. (See Medications).
Go to Pediatric Appendicitis for more information on this topic.
Emergency Department Care
The emergency department (ED) clinician must evaluate the larger group of patients who present to the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the diagnosis in a time-, cost-, and consultation-efficient manner.
Establish IV 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. However, at least 8 randomized controlled studies have demonstrated 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.[43]
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
Nonsurgical treatment may be useful when appendectomy is not accessible or when it is temporarily a high-risk procedure. Anecdotal reports describe the success of IV antibiotics in treating acute appendicitis in patients without access to surgical intervention (eg, submariners, individuals on ships at sea).
In a prospective study of 20 patients with ultrasonography-proven appendicitis, symptoms resolved in 95% of patients receiving antibiotics alone, but 37% of these patients had recurrent appendicitis within 14 months.[44]
Preoperative Antibiotics
Preoperative antibiotics have demonstrated efficacy in decreasing postoperative wound infection rates in numerous prospective controlled studies, and they should be administered in conjunction with the surgical consultant. Broad-spectrum gram-negative and anaerobic coverage is indicated (see Medications).
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.
Urgent Versus Emergent Appendectomy
A retrospective study suggested that the risk of appendiceal rupture is minimal in patients with less than 24-36 hours of untreated symptoms,[45] and another retrospective study suggested that appendectomy within 12-24 hours of presentation is not associated with an increase in hospital length of stay, operative time, advanced stages of appendicitis, or complications compared with appendectomy performed within 12 hours of presentation.[46]
Additional studies are needed to demonstrate whether initiation of antibiotic therapy followed by urgent appendectomy is as effective as emergent appendectomy for patients with unperforated appendicitis.
Go to Appendectomy and Pediatric Appendectomy for more information on these topics.
Emergent Versus Interval Surgery for Perforated Appendicitis
Historically, immediate (emergent) appendectomy was recommended for all patients with appendicitis, whether perforated or unperforated. More recent clinical experience suggests that patients with perforated appendicitis with mild symptoms and localized abscess or phlegmon on abdominopelvic computed tomography (CT) scans can be initially treated with IV antibiotics and percutaneous or transrectal drainage of any localized abscess. If the patient's symptoms, WBC count, and fever satisfactorily resolve, therapy can be changed to oral antibiotics and the patient can be discharged home. Then, delayed (interval) appendectomy can be performed 4-8 weeks later.
The above approach is successful in the vast majority of patients with perforated appendicitis and localized symptoms. Some have suggested that interval appendectomy is not necessary, unless the patient presents with recurrent symptoms. Further studies are needed to clarify not only whether routine interval appendectomy is indicated but also to identify the optimal treatment strategy in patients with perforated appendicitis
Go to Appendectomy and Pediatric Appendectomy for more information on these topics.
Laparoscopic Appendectomy
Initially performed in 1987, laparoscopic appendectomy has been performed in thousands of patients and is successful in 90-94% of attempts. It has also been demonstrated that laparoscopic appendectomy is successful in approximately 90% of cases of perforated appendicitis. However, this procedure is contraindicated in patients with significant intra-abdominal adhesions.
According to the 2010 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline, the indications for laparoscopic appendectomy are identical to those for open appendectomy.[47]
The 2010 SAGES guideline lists the following conditions as suitable for laparoscopic appendectomy:[47]
- Uncomplicated appendicitis
- Appendicitis in pediatric patients
- Suspected appendicitis in pregnant women
According to the SAGES guideline, laparoscopic appendectomy may be the preferred approach in the following cases:[47]
- Perforated appendicitis
- Appendicitis in elderly patients
- Appendicitis in obese patients
The SAGES guideline states that the laparoscopic approach should be preferred in women of childbearing age with presumed appendicitis.[47]
Diagnostic laparoscopy may be useful in selected cases (eg, infants, elderly patients, female patients) to confirm the diagnosis of appendicitis. This procedure has been suggested for pregnant patients in the first trimester with suspected appendicitis. If findings are positive, such procedures should be followed by definitive surgical treatment at the time of laparoscopy. Although negative appendectomy does not appear to adversely affect maternal or fetal health, diagnostic delay with perforation does increase fetal and maternal morbidity. Therefore, aggressive evaluation of the appendix is warranted in this group.
According to the SAGES guideline, if findings are negative (normal appendix) on laparoscopic approach, removal should be considered based on the patient’s clinical situation.[47]
Advantages of laparoscopic appendectomy include increased cosmetic satisfaction and a decrease in the postoperative wound-infection rate. Some studies show that laparoscopic appendectomy shortens the hospital stay and convalescent period compared with open appendectomy.
Disadvantages of laparoscopic appendectomy are increased cost and an operating time approximately 20 minutes longer than that of an open appendectomy; however, the latter may resolve with increasing experience with laparoscopic technique. The SAGES guideline recommends practicing a consistent operative method to reduce cost, operating time, and complications.[47]
Go to Appendectomy and Pediatric Appendectomy for more information on these topics.
Complications
Complications of appendicitis may include wound infection, dehiscence, bowel obstruction, abdominal/pelvic abscess, and, rarely, death. Stump appendicitis also occurs rarely; however, at least 36 reported cases of appendicitis in the surgical stump after previous appendectomy exist.[48]
Consultations
In cases of suspected appendicitis, consult a general surgeon. The surgeon's goals are to evaluate a relatively small population of patients referred for suspected appendicitis and to minimize the negative appendectomy rate without increasing the incidence of perforation.
Karamanakos SN, Sdralis E, Panagiotopoulos S, Kehagias I. Laparoscopy in the emergency setting: a retrospective review of 540 patients with acute abdominal pain. Surg Laparosc Endosc Percutan Tech. Apr 2010;20(2):119-24. [Medline].
Niwa H, Hiramatsu T. A rare presentation of appendiceal diverticulitis associated with pelvic pseudocyst. World J Gastroenterol. Feb 28 2008;14(8):1293-5. [Medline]. [Full Text].
Yeh B. Evidence-based emergency medicine/rational clinical examination abstract. Does this adult patient have appendicitis?. Ann Emerg Med. Sep 2008;52(3):301-3. [Medline].
Place RC. Acute urinary retention in a 9-year-old child: an atypical presentation of acute appendicitis. J Emerg Med. Aug 2006;31(2):173-5. [Medline].
Oto A, Ernst RD, Mileski WJ, Nishino TK, Le O, Wolfe GC, et al. Localization of appendix with MDCT and influence of findings on choice of appendectomy incision. AJR Am J Roentgenol. Oct 2006;187(4):987-90. [Medline].
Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med. Jan 2010;55(1):71-116. [Medline].
National Guideline Clearinghouse (NGC). Guideline summary: Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. National Guideline Clearinghouse (NGC), Rockville (MD). Available at http://www.guideline.gov. Accessed 2011 Feb 24.
Markle GB 4th. Heel-drop jarring test for appendicitis. Arch Surg. Feb 1985;120(2):243. [Medline].
Sedlak M, Wagner OJ, Wild B, Papagrigoriades S, Exadaktylos AK. Is there still a role for rectal examination in suspected appendicitis in adults?. Am J Emerg Med. Mar 2008;26(3):359-60. [Medline].
Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. May 1986;15(5):557-64. [Medline].
[Best Evidence] Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric cohort. Ann Emerg Med. Jun 2007;49(6):778-84, 784.e1. [Medline].
Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric cohort. Ann Emerg Med. Jun 2007;49(6):778-84, 784.e1. [Medline].
Migraine S, Atri M, Bret PM, Lough JO, Hinchey JE. Spontaneously resolving acute appendicitis: clinical and sonographic documentation. Radiology. Oct 1997;205(1):55-8. [Medline].
Cobben LP, de Van Otterloo AM, Puylaert JB. Spontaneously resolving appendicitis: frequency and natural history in 60 patients. Radiology. May 2000;215(2):349-52. [Medline].
Dueholm S, Bagi P, Bud M. Laboratory aid in the diagnosis of acute appendicitis. A blinded, prospective trial concerning diagnostic value of leukocyte count, neutrophil differential count, and C-reactive protein. Dis Colon Rectum. Oct 1989;32(10):855-9. [Medline].
Thimsen DA, Tong GK, Gruenberg JC. Prospective evaluation of C-reactive protein in patients suspected to have acute appendicitis. Am Surg. Jul 1989;55(7):466-8. [Medline].
de Carvalho BR, Diogo-Filho A, Fernandes C, Barra CB. [Leukocyte count, C reactive protein, alpha-1 acid glycoprotein and erythrocyte sedimentation rate in acute appendicitis]. Arq Gastroenterol. Jan-Mar 2003;40(1):25-30. [Medline].
Albu E, Miller BM, Choi Y, et al. Diagnostic value of C-reactive protein in acute appendicitis. Dis Colon Rectum. Jan 1994;37(1):49-51. [Medline].
Gurleyik E, Gurleyik G, Unalmiser S. Accuracy of serum C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon's clinical impression. Dis Colon Rectum. Dec 1995;38(12):1270-4. [Medline].
Shakhatreh HS. The accuracy of C-reactive protein in the diagnosis of acute appendicitis compared with that of clinical diagnosis. Med Arh. 2000;54(2):109-10. [Medline].
Asfar S, Safar H, Khoursheed M, Dashti H, al-Bader A. Would measurement of C-reactive protein reduce the rate of negative exploration for acute appendicitis?. J R Coll Surg Edinb. Feb 2000;45(1):21-4. [Medline].
Erkasap S, Ates E, Ustuner Z, Sahin A, Yilmaz S, Yasar B, et al. Diagnostic value of interleukin-6 and C-reactive protein in acute appendicitis. Swiss Surg. 2000;6(4):169-72. [Medline].
Gronroos JM, Gronroos P. Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis. Br J Surg. Apr 1999;86(4):501-4. [Medline].
Ortega-Deballon P, Ruiz de Adana-Belbel JC, Hernandez-Matias A, Garcia-Septiem J, Moreno-Azcoita M. Usefulness of laboratory data in the management of right iliac fossa pain in adults. Dis Colon Rectum. Jul 2008;51(7):1093-9. [Medline].
Gronroos JM. Is there a role for leukocyte and CRP measurements in the diagnosis of acute appendicitis in the elderly?. Maturitas. Mar 15 1999;31(3):255-8. [Medline].
Yang HR, Wang YC, Chung PK, et al. Role of leukocyte count, neutrophil percentage, and C-reactive protein in the diagnosis of acute appendicitis in the elderly. Am Surg. Apr 2005;71(4):344-7. [Medline].
Gronroos JM. Do normal leucocyte count and C-reactive protein value exclude acute appendicitis in children?. Acta Paediatr. Jun 2001;90(6):649-51. [Medline].
Stefanutti G, Ghirardo V, Gamba P. Inflammatory markers for acute appendicitis in children: are they helpful?. J Pediatr Surg. May 2007;42(5):773-6. [Medline].
Mohammed AA, Daghman NA, Aboud SM, Oshibi HO. The diagnostic value of C-reactive protein, white blood cell count and neutrophil percentage in childhood appendicitis. Saudi Med J. Sep 2004;25(9):1212-5. [Medline].
Yang HR, Wang YC, Chung PK, Chen WK, Jeng LB, Chen RJ. Laboratory tests in patients with acute appendicitis. ANZ J Surg. Jan-Feb 2006;76(1-2):71-4. [Medline].
Tundidor Bermudez AM, Amado Dieguez JA, Montes de Oca Mastrapa JL. [Urological manifestations of acute appendicitis]. Arch Esp Urol. Apr 2005;58(3):207-12. [Medline].
Bolandparvaz S, Vasei M, Owji AA, Ata-Ee N, Amin A, Daneshbod Y, et al. Urinary 5-hydroxy indole acetic acid as a test for early diagnosis of acute appendicitis. Clin Biochem. Nov 2004;37(11):985-9. [Medline].
Rao PM, Rhea JT, Rattner DW, et al. Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates. Ann Surg. Mar 1999;229(3):344-9. [Medline].
McGory ML, Zingmond DS, Nanayakkara D, Maggard MA, Ko CY. Negative appendectomy rate: influence of CT scans. Am Surg. Oct 2005;71(10):803-8. [Medline].
Harswick C, Uyenishi AA, Kordick MF, Chan SB. Clinical guidelines, computed tomography scan, and negative appendectomies: a case series. Am J Emerg Med. Jan 2006;24(1):68-72. [Medline].
Frei SP, Bond WF, Bazuro RK, Richardson DM, Sierzega GM, Reed JF. Appendicitis outcomes with increasing computed tomographic scanning. Am J Emerg Med. Jan 2008;26(1):39-44. [Medline].
Pickhardt PJ, Lawrence EM, Pooler BD, Bruce RJ. Diagnostic performance of multidetector computed tomography for suspected acute appendicitis. Ann Intern Med. Jun 21 2011;154(12):789-96. [Medline].
Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. Nov 29 2007;357(22):2277-84. [Medline].
Zilbert NR, Stamell EF, Ezon I, Schlager A, Ginsburg HB, Nadler EP. Management and outcomes for children with acute appendicitis differ by hospital type: areas for improvement at public hospitals. Clin Pediatr (Phila). Jun 2009;48(5):499-504. [Medline].
[Best Evidence] Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology. Oct 2006;241(1):83-94. [Medline].
Barloon TJ, Brown BP, Abu-Yousef MM, Warnock N, Berbaum KS. Sonography of acute appendicitis in pregnancy. Abdom Imaging. Mar-Apr 1995;20(2):149-51. [Medline].
Cobben LP, Groot I, Haans L, Blickman JG, Puylaert J. MRI for clinically suspected appendicitis during pregnancy. AJR Am J Roentgenol. Sep 2004;183(3):671-5. [Medline].
Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. Jan 19 2011;1:CD005660. [Medline].
Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg. Feb 1995;82(2):166-9. [Medline].
Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg. Mar 2006;202(3):401-6. [Medline].
Abou-Nukta F, Bakhos C, Arroyo K, Koo Y, Martin J, Reinhold R, et al. Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg. May 2006;141(5):504-6; discussion 506-7. [Medline].
[Guideline] Korndorffer JR Jr, Fellinger E, Reed W. SAGES guideline for laparoscopic appendectomy. Surg Endosc. Apr 2010;24(4):757-61. [Medline]. [Full Text].
Liang MK, Lo HG, Marks JL. Stump appendicitis: a comprehensive review of literature. Am Surg. Feb 2006;72(2):162-6. [Medline].
| Characteristic | Score |
| M = Migration of pain to the RLQ | 1 |
| A = Anorexia | 1 |
| N = Nausea and vomiting | 1 |
| T = Tenderness in RLQ | 2 |
| R = Rebound pain | 1 |
| E = Elevated temperature | 1 |
| L = Leukocytosis | 2 |
| S = Shift of WBCs to the left | 1 |
| Total | 10 |
| Source: Alvarado.[10] | |
| RLQ = right lower quadrant; WBCs = white blood cells | |
| WBC (× 10,000) | Likelihood Ratio (95% CI) |
| 4-7 | 0.10 (0-0.39) |
| 7-9 | 0.52 (0-1.57) |
| 9-11 | 0.29 (0-0.62) |
| 11-13 | 2.8 (1.2-4.4) |
| 13-15 | 1.7 (0-3.6) |
| 15-17 | 2.8 (0-6.0) |
| 17-19 | 3.5 (0-10) |
| 19-22 | ∞ |
| Source: Dueholm et al.[15] | |
| CI = confidence interval; WBC = white blood cell. | |
Print
