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.
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]
[82]
Laparoscopic appendectomy is recommended for uncomplicated appendicitis.[83] It is also considered the safest approach in obese patients.[85]
In pregnant patients, laparoscopic appendectomy should be preferred to open appendectomy when surgery is indicated and where expertize of laparoscopy is available. It is safe in terms of risk of fetal loss and preterm delivery. Compared to open surgery during pregnancy, laparoscopic appendectomy is associated with shorter length of hospital stay and lower incidence of surgical site infection. Laparoscopy is technically safe and feasible during pregnancy.[10][91]
In children, nonoperative management is feasible, safe, and effective as initial treatment unless an appendicolith is present.[10] However, in the US the usual standard of care for the management of uncomplicated appendicitis in children continues to be operative.
Laparoscopic appendectomy decreases the incidence of overall postoperative complications, including wound infection and duration of total hospital stay.[86][87][82][88][89][94]
Peripheral venous cannulation: animated demonstration
Practical suturing techniques: animated demonstrationsSome patients with uncomplicated appendicitis may be discharged safely after laparoscopic appendectomy without hospitalization, provided that an ambulatory pathway with well-defined ERAS (Enhanced Recovery After Surgery) protocols and patient information/consent are locally established.[10] ERAS implementation after laparoscopic appendectomy carries similar rates of morbidity and readmissions compared with conventional care.[93] Its potential benefits include earlier recovery after surgery and lower hospital and social costs.[10]
Patients 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: 2 g intravenously as a single dose 30-60 minutes before surgery
A single preoperative dose of broad-spectrum antibiotic such as cefoxitin should be given to patients with uncomplicated appendicitis undergoing appendectomy. Postoperative antibiotics are not indicated for these patients.[10]
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.[95][92][71][73]
An antibiotic-only approach is not recommended if an appendicolith is present since nonoperative management carries a significant failure rate.[10][74]
A conservative approach should be avoided in pregnant patients.[10]
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.[75][76] 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.[16]
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.[82]
[ ]
Laparoscopic appendectomy is recommended for complicated and perforated appendicitis.[84] It is also considered the safest approach in obese patients.[85] In pregnant patients, laparoscopic appendectomy should be preferred to open appendectomy when surgery is indicated and where expertize of laparoscopy is available. It is technically feasible and is safe in terms of risk of fetal loss and preterm delivery. Compared to open surgery during pregnancy, laparoscopic appendectomy is associated with shorter length of hospital stay and lower incidence of surgical site infection.[10][91]
In children, laparoscopic appendectomy decreases the incidence of overall postoperative complications, including wound infection and duration of total hospital stay.[86][87][82][88][89][94]
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.[10][77][78][79][80] Interval appendectomy is associated with a non-negligible rate of morbidity.[79] Any patient ages ≥40 years who has conservative management without interval appendectomy should also undergo screening with colonoscopy and interval full-dose contrast-enhanced CT scan since the incidence of appendicular neoplasms is high.[10]
Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved.[10][11][96] Adoption of a wait-and-see approach, reserving appendectomy for patients with recurrent symptoms, is the most cost-effective strategy compared with routine interval appendectomy.[10]
For patients with phlegmon or abscess, management remains subject to debate. Latest evidence suggests that laparoscopic appendectomy is associated with fewer readmissions and fewer additional interventions than conservative management, provided advanced laparoscopic expertize is available. However, nonoperative management with antibiotics and, if available, percutaneous image-guided drainage is a reasonable alternative if the patient is stable and laparoscopic appendectomy is unavailable, although there is a lack of evidence for its use on a routine basis.[10]
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