Approach

The usual standard of care for the management of uncomplicated appendicitis continues to be operative.

There is emerging evidence to suggest that a nonoperative, antibiotic-only approach may be feasible in select patient populations. The evidence supporting nonoperative management of appendicitis continues to be conflicting, and further research is warranted. There is more evidence to support a nonoperative approach in children than in adults.[61][62][63][64][65][66][67][68]

Uncomplicated presentation

Once the diagnosis of acute appendicitis is made, patients should be given nothing by mouth.

Intravenous fluids, such as lactated Ringer solution, should be started. Use of prophylactic intravenous antibiotics postoperatively is controversial; however, the use of a broad-spectrum antibiotic such as cefoxitin (one dose preoperatively and 2 doses postoperatively) is recommended for uncomplicated appendicitis to reduce the risk of wound infection.[69] Prompt appendectomy remains the treatment of choice in international guidelines and should be recommended in most cases.

An antibiotic-only approach may be reasonable for select groups, where patients understand the risk of recurrence appendicitis.[68][66]

Complicated presentation

Complications of acute appendicitis occur in 4% to 6% of patients and include gangrene with subsequent perforation or intra-abdominal abscess.[14]

Initial management includes keeping the patient nothing by mouth and starting intravenous fluids. Patients who are in shock should be given a bolus of intravenous fluid, such as lactated Ringer solution, in order to maintain a stable pulse rate and BP.[70][71]

Intravenous antibiotics (e.g., cefoxitin or piperacillin/tazobactam) should be started immediately and continued until the patient becomes afebrile and the leukocytosis is corrected. For more severe infections, a carbapenem antibiotic may be used as a single agent. Combination antibiotic regimens may also be used based on local sensitivities and protocols.[14]

In patients with acute peritonitis, appendectomy should be performed without delay. Patients presenting with right lower quadrant abscess should be managed with intravenous antibiotics and drainage either by interventional radiology (computed tomography-guided drainage) or by operative drainage. If there is clinical improvement and the signs and symptoms are completely resolved, interval appendectomy may be unnecessary.[72][73][74]

Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved.[75] There is evidence to suggest that laparoscopic appendectomy may be a feasible first-line option over conservative treatment for appendiceal phlegmon/abscess in adults and children; however, one systematic review was unable to find evidence for either benefit or harm from early appendectomy (laparoscopic or open) versus conservative treatment.[76][77] Unplanned interim analysis of 60 patients included in one small, randomized controlled trial (subsequently terminated), suggested that patients >40 years of age with periappendiceal abscess may be at increased risk for appendiceal tumor.[78] Until further information becomes available from future studies, routine interval appendectomy should be preferred in these patients.[78][79]

Surgical options

There are 2 operative options for appendectomy: open and laparoscopic. Most procedures are now undertaken laparoscopically.

In adults, the choice of appendectomy generally depends upon the experience of the surgeon. Studies have shown laparoscopic appendectomy to have better cosmetic results, shorter length of hospital stay, reduced postoperative pain, and reduced risk of wound infection, compared with open appendectomy. [ Cochrane Clinical Answers logo ] [80] Laparoscopic appendectomy is recommended for uncomplicated appendicitis, as well as complicated and perforated appendicitis.[81][82] It is also considered the safest approach in obese patients.[83] 

In children, laparoscopic appendectomy decreases the incidence of overall postoperative complications, including wound infection and duration of total hospital stay.[84][85][80] However, another study has shown no significant difference.[86]


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The surgical approach in pregnant women is controversial. Meta-analyses report significantly greater risk of fetal loss with a laparoscopic approach, but length of hospital stay and overall complications may be lower than for open surgery.[88][89]

Antibiotic-only therapy

Antibiotics alone for the treatment of uncomplicated appendicitis can be successful in selected patients who wish to avoid surgery, and who accept the risk of up to 39% recurrence. In such cases, it is recommended that the diagnosis of uncomplicated appendicitis is confirmed by imaging, and that patient expectations are managed via a shared decision-making process.[29][90][66][68]

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