Approach Considerations
Appendectomy remains the only curative treatment of appendicitis, although nonoperative management is increasingly recognized as being safe and effective for uncomplicated cases of acute appendicitis. [55, 56]
In general, however, management of patients with an appendiceal mass can usually be divided into the following 3 treatment categories:
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Patients with a phlegmon or a small abscess: After intravenous (IV) antibiotic therapy, an interval appendectomy can be performed 4-6 weeks later.
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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.
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Patients with a multicompartmental abscess: These patients require early surgical drainage.
Antibiotics have an important role in the nonsurgical treatment of patients with acute appendicitis. [56] 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 Medication).
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 intravenous (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. [57] 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. [11] Factors associated with prescription of any analgesia and opioids are older age and payment source; in addition, use of computed tomography (CT) scanning was associated with prescription of analgesics. [57]
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 have described the success of intravenous (IV) antibiotics in treating acute appendicitis in patients without access to surgical intervention (eg, submariners, individuals on ships at sea). [56] However, clinical trials have shown success of nonoperative management of uncomplicated appendicitis in not only the adult population but also pediatric patients. [56]
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. [58]
The Appendicitis Acuta (APPAC) trial, which compared antibiotic therapy with appendectomy in the treatment of 530 patients with uncomplicated acute appendicitis confirmed by computed tomography (CT), was not able to demonstrate noninferiority of antimicrobial management versus surgery. [59]
Bonadio et al reported that of 203 children with perforated appendicitis, those who underwent early appendectomy (n = 122) had significantly better outcomes than those who received medical management (n = 81). [60] The early appendectomy group had shorter hospitalization stays, received fewer parenteral antibiotics, underwent fewer radiologic studies and other invasive procedures (percutaneous drainage, central venous catherization), and had fewer inpatient febrile episodes, as well as had fewer postadmission intraabominal complications and/or fewer unscheduled postdischarge readmissions. [60]
More recently, a 2022 systematic review and meta-analysis found no significant difference in treatment success and major adverse effects between patients treated operatively versus those treated nonoperatively for uncomplicated acute appendicitis. [55] However, those who received nonoperative management had a significantly longer length of hospital stay as well as a higher rate of recurrent appendicitis.
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 Medication).
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, [61] 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. [62]
Fair et al used data from the American College of Surgeons National Surgical Quality Improvement Project to evaluate 30-day morbidity and mortality of intervention (laparoscopic and open appendectomy) at different time periods (adjusted for preoperative risk factors) and found similar outcomes between when appendectomy was performed within 24 hours and when it was performed between 24-48 hours. [63] However, a delay of operative intervention longer than 48 hours was associated with doubling of complication rates.
In a separate study, Boomer et al reported that delaying appendectomy (16 hours from presentation in the emergency department or 12 hours from inpatient admission) in children did not result in higher rates of surgical site infections. [64]
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. [65]
The 2010 SAGES guideline lists the following conditions as suitable for laparoscopic appendectomy [65] :
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Uncomplicated appendicitis
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Appendicitis in pediatric patients
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Suspected appendicitis in pregnant women
According to the SAGES guideline, laparoscopic appendectomy may be the preferred approach in the following cases [65] :
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Perforated appendicitis
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Appendicitis in elderly patients
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Appendicitis in obese patients
The SAGES guideline states that the laparoscopic approach should be preferred in women of childbearing age with presumed appendicitis. [65]
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.
In a systematic review and meta-analysis of 11 studies on laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy, Wilasrusmee et al found that laparoscopic appendicectomy in pregnant women was associated with a significantly greater risk of fetal loss. [66] 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. [65]
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. [65]
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. [67]
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.
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CT scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.
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Sagittal graded compression transabdominal sonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.
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Transverse graded compression transabdominal sonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection.
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Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled WBCs in the right lower quadrant consistent with acute appendicitis.
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Perforated appendicitis.
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Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.
Tables
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. [18] |
|
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. [23] |
|
CI = confidence interval; WBC = white blood cell. |
|
