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.
Laparoscopic appendectomy is recommended for uncomplicated appendicitis. [37] It is also considered the safest approach in obese patients. [64] However, open appendectomy is considered to be the safest approach in pregnant women. [65]
Intra-abdominal abscesses have previously been noted to be more common in adult patients who undergo laparoscopic appendectomy, [70] but other factors such as the level of contamination, possible stump leak, use of preoperative antibiotic, and the patient's own immune response to infection may be involved. However, one study suggests that intra-abdominal abscess is less frequent in patients undergoing laparoscopic surgery. [37]
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 The APACHE score is commonly used to establish illness severity in the ICU and predict the risk of death. In this context, there is a high risk of death if the score is 25 or above.
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.
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 BP. [56] [57] 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. [10]
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
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.
Laparoscopic appendectomy is recommended for complicated and perforated appendicitis. [63] It is also considered the safest approach in obese patients. [64] However, open appendectomy is considered to be the safest approach in pregnant women. [65]
In children, laparoscopic appendectomy decreases the incidence of overall postoperative complications, including wound infection and duration of total hospital stay, but does not reduce the postoperative pain compared with open appendectomy. [66] [67] However, another study has shown no significant difference. [68]
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 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, then there is no need for interval appendectomy. [58] [59] [60] Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved. [61]
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