Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
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.
Appendectomy should be performed without delay, as early appendectomy reduces the chances of perforation and intra-abdominal abscess.
[Figure caption and citation for the preceding image starts]: Acute appendicitis - intraoperative specimen.Nasim Ahmed, MBBS, FACS; used with permission [Citation ends].
There are 2 operative options for appendectomy: open and laparoscopic. 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, when compared with open appendectomy.
[ 
]
[80]
Laparoscopic appendectomy is recommended for uncomplicated appendicitis.[81] It is also considered the safest approach in obese patients.[83] 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]
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 significent difference.[86]
Peripheral venous cannulation: animated demonstration
Practical suturing techniques: animated demonstrationsPatients with higher APACHE (Acute Physiology and Chronic Health Evaluation) scores seem to be at higher risk of development of postoperative complications.[ APACHE II scoring system ]
Treatment recommended for SOME patients in selected patient group
Primary options
cefoxitin: 1-2 g intravenously as a single dose before surgery, followed by 1-2 g every 8 hours for 2 doses postsurgery
Given for 24 hours for uncomplicated appendicitis.
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 be confirmed by imaging, and that patient expectations be managed via a shared decision-making process.[29][90][66][68]
Primary options
cefoxitin: 1-2 g intravenously every 8 hours
OR
piperacillin/tazobactam: 3.375 g intravenously every 6 hours
MoreOR
meropenem: 1 g intravenously every 8 hours
These patients have evidence of perforation, mass, or abscess.
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 blood pressure.[70][71] Following on, maintenance intravenous fluids should be given until the condition of the patient improves and an oral diet can be tolerated.
Intravenous antibiotics (e.g., cefoxitin or piperacillin/tazobactam) should be started immediately. 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]
Antibiotics should be continued until the patient becomes afebrile and leukocytosis is corrected.
Patients with higher APACHE (Acute Physiology and Chronic Health Evaluation) scores seem to be at higher risk of development of postoperative complication.[ APACHE II scoring system ]
perforation
Treatment recommended for ALL patients in selected patient group
There are 2 operative options for appendectomy: open and laparoscopic. 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, when compared with open appendectomy.
[ ]
[80]
Laparoscopic appendectomy is recommended for complicated and perforated appendicitis.[82] It is also considered the safest approach in obese patients.[83] 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]
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]
Peripheral venous cannulation: animated demonstrationPractical suturing techniques: animated demonstrationsabscess
Treatment recommended for ALL patients in selected patient group
Abscess usually occurs as a progression of the disease process, particularly after perforation.
Presents with tender right lower quadrant mass, swinging fever, and leukocytosis. Ultrasonography or computed tomography (CT) scan will show the abscess.
Initial treatment includes intravenous antibiotics and CT-guided or operative drainage of the abscess.
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 one randomized controlled trial (subsequently terminated) suggested that patients >40 years of age with periappendiceal abscess may be at increased risk for appendiceal tumor.[78] Routine interval appendectomy should be preferred in these patients.[78][79]
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