治疗流程
请注意药品名称和品牌、药品处方或地区之间的配方/用药途径和剂量可能有所不同。治疗建议针对患者特定群体提出： 查看免责声明
无并发症的急性阑尾炎
阑尾切除术 + 支持治疗
急性阑尾炎的诊断一经确立，患者即应禁食禁水。
应当开始静脉输液，例如给予乳酸林格氏液。
不应延误实施阑尾切除术，越早进行，则穿孔和腹腔内脓肿的发生率越低。[Figure caption and citation for the preceding image starts]: 急性阑尾炎：术中标本Nasim Ahmed, MBBS, FACS；经许可后使用 [Citation ends].
有两种阑尾切除术术式：开腹和腹腔镜。对于成人，阑尾切除术式的选择主要依赖于外科医生的经验。
多项研究显示，与开腹阑尾切除术相比，腹腔镜下阑尾切除术的伤口更美观，住院时长更短，术后疼痛更轻，并且伤口感染的风险降低。
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For adults and adolescents with suspected appendicitis, how does laparoscopic appendectomy compare with conventional appendectomy?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2373/full展示答案[80]Jaschinski T, Mosch CG, Eikermann M, et al. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2018 Nov 28;(11):CD001546.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517145
http://www.ncbi.nlm.nih.gov/pubmed/30484855?tool=bestpractice.com
对于单纯性阑尾炎，推荐进行腹腔镜下阑尾切除术。[81]Wei HB, Huang JL, Zheng ZH, et al. Laparoscopic versus open appendectomy: a prospective randomized comparison. Surg Endosc. 2010 Feb;24(2):266-9. http://www.ncbi.nlm.nih.gov/pubmed/19517167?tool=bestpractice.com 对于肥胖患者，腹腔镜下阑尾切除术被认为是最安全的方法。[83]Woodham BL, Cox MR, Eslick GD. Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis. Surg Endosc. 2012 Sep;26(9):2566-70. http://www.ncbi.nlm.nih.gov/pubmed/22437955?tool=bestpractice.com 对于孕妇的手术方法存在争议。荟萃分析显示，腹腔镜手术的胎儿丢失风险显著升高，但住院时间和并发症总体发生率可能低于开放性手术。[88]Wilasrusmee C, Sukrat B, McEvoy M, et al. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. 2012 Nov;99(11):1470-8. http://onlinelibrary.wiley.com/doi/10.1002/bjs.8889/full http://www.ncbi.nlm.nih.gov/pubmed/23001791?tool=bestpractice.com [89]Prodromidou A, Machairas N, Kostakis ID, et al. Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2018 Jun;225:40-50. http://www.ncbi.nlm.nih.gov/pubmed/29656140?tool=bestpractice.com
对于儿童，与开腹阑尾切除术相比，腹腔镜阑尾切除术可降低术后并发症（包括伤口感染）的总发生率，缩短总住院时长。[84]Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg. 2005 Sep;242(3):439-48; discussion 448-50. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16135930 http://www.ncbi.nlm.nih.gov/pubmed/16135930?tool=bestpractice.com [85]Billingham MJ, Basterfield SJ. Pediatric surgical technique: laparoscopic or open approach? A systematic review and meta-analysis. Eur J Pediatr Surg. 2010 Mar;20(2):73-7. http://www.ncbi.nlm.nih.gov/pubmed/19882502?tool=bestpractice.com [80]Jaschinski T, Mosch CG, Eikermann M, et al. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2018 Nov 28;(11):CD001546. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517145 http://www.ncbi.nlm.nih.gov/pubmed/30484855?tool=bestpractice.com 然而，另一项研究显示两者并无显著差异。[86]Lintula H, Kokki H, Vanamo K, et al. Laparoscopy in children with complicated appendicitis. J Pediatr Surg. 2002 Sep;37(9):1317-20. http://www.ncbi.nlm.nih.gov/pubmed/12194123?tool=bestpractice.com
急性生理学及慢性健康状况评估评分（APACHE 评分）更高的患者发生术后并发症的风险较高。 [ 急性生理学与慢性健康状况评分系统 II (APACHE II) ]
静脉抗生素治疗
针对特定患者群中部分患者治疗的附加建议
对于单纯性阑尾炎，给药 24 小时。
第一选择
头孢西丁: 术前 1-2 g，单次静脉输注，术后每 8 小时用 1-2 g，用 2 次
仅抗生素治疗
对于希望避免手术，并对高达 39％ 复发风险可接受的特定患者，可给予单纯抗生素治疗单纯性阑尾炎。在这种情况下，建议通过影像学检查确诊单纯性阑尾炎，并通过共同决策过程管理患者期望值。[30]Di Saverio S, Birindelli A, Kelly MD, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg. 2016 Jul 18;11:34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949879 http://www.ncbi.nlm.nih.gov/pubmed/27437029?tool=bestpractice.com [90]Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2017 Jul 10;12:29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5504840 http://www.ncbi.nlm.nih.gov/pubmed/28702076?tool=bestpractice.com [66]Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Sep 25;320(12):1259-65. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233612 http://www.ncbi.nlm.nih.gov/pubmed/30264120?tool=bestpractice.com [68]Sakran JV, Mylonas KS, Gryparis A, et al. Operation versus antibiotics--The "appendicitis conundrum" continues: A meta-analysis. J Trauma Acute Care Surg. 2017 Jun;82(6):1129-37. http://www.ncbi.nlm.nih.gov/pubmed/28338596?tool=bestpractice.com
身体不适且伴有穿孔或脓肿
静脉使用抗生素治疗 + 支持治疗
患者有穿孔、肿块或脓肿的证据。
初始处理包括禁食、禁水以及开始静脉输液。如果患者处于休克状态，应当给予快速静脉推注液体，例如乳酸林格氏液，以维持脉率和血压稳定。[70]National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. May 2017 [internet publication]. https://www.nice.org.uk/guidance/cg174 [71]Lobo DN, Awad S. Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury? Kidney Int. 2014 Dec;86(6):1096-105. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255073 http://www.ncbi.nlm.nih.gov/pubmed/24717302?tool=bestpractice.com 紧接着，应维持静脉输液，直到患者病情改善，能耐受经口进食。
应该立即开始静脉使用抗生素（例如头孢西丁、替卡西林/克拉维酸或哌拉西林/他唑巴坦）。对于更严重的感染，可以单用碳青霉烯类抗生素。根据当地细菌敏感性和诊疗方案，可能使用抗生素联合治疗方案。[15]Brunicardi FC, Andersen DK, Billiar TR, et al, eds. Schwartz's principles of surgery. 8th ed. New York, NY: McGraw-Hill; 2005.
抗生素应持续使用到患者退热以及白细胞恢复正常。
急性生理学及慢性健康状况评估评分（APACHE 评分）更高的患者发生术后并发症的风险较高。 [ 急性生理学与慢性健康状况评分系统 II (APACHE II) ]
阑尾切除术
针对特定患者群中所有患者的治疗建议
有两种阑尾切除术术式：开腹和腹腔镜。对于成人，阑尾切除术式的选择主要依赖于外科医生的经验。
多项研究显示，与开腹阑尾切除术相比，腹腔镜下阑尾切除术的伤口更美观，住院时长更短，术后疼痛更轻，并且伤口感染的风险降低。
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For adults and adolescents with suspected appendicitis, how does laparoscopic appendectomy compare with conventional appendectomy?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2373/full展示答案[80]Jaschinski T, Mosch CG, Eikermann M, et al. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2018 Nov 28;(11):CD001546.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517145
http://www.ncbi.nlm.nih.gov/pubmed/30484855?tool=bestpractice.com
对于有并发症和穿孔的阑尾炎，推荐进行腹腔镜下阑尾切除术。[82]Yau KK, Siu WT, Tang CN, et al. Laparoscopic versus open appendectomy for complicated appendicitis. J Am Coll Surg. 2007 Jul;205(1):60-5. http://www.ncbi.nlm.nih.gov/pubmed/17617333?tool=bestpractice.com 对于肥胖患者，腹腔镜下阑尾切除术被认为是最安全的方法。[83]Woodham BL, Cox MR, Eslick GD. Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis. Surg Endosc. 2012 Sep;26(9):2566-70. http://www.ncbi.nlm.nih.gov/pubmed/22437955?tool=bestpractice.com 对于孕妇的手术方法存在争议。荟萃分析显示，腹腔镜手术的胎儿丢失风险显著升高，但住院时间和并发症总体发生率可能低于开放性手术。[88]Wilasrusmee C, Sukrat B, McEvoy M, et al. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. 2012 Nov;99(11):1470-8. http://onlinelibrary.wiley.com/doi/10.1002/bjs.8889/full http://www.ncbi.nlm.nih.gov/pubmed/23001791?tool=bestpractice.com [89]Prodromidou A, Machairas N, Kostakis ID, et al. Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2018 Jun;225:40-50. http://www.ncbi.nlm.nih.gov/pubmed/29656140?tool=bestpractice.com
对于儿童，与开腹阑尾切除术相比，腹腔镜阑尾切除术可降低术后并发症（包括伤口感染）的总发生率，缩短总住院时长。[84]Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg. 2005 Sep;242(3):439-48; discussion 448-50. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16135930 http://www.ncbi.nlm.nih.gov/pubmed/16135930?tool=bestpractice.com [85]Billingham MJ, Basterfield SJ. Pediatric surgical technique: laparoscopic or open approach? A systematic review and meta-analysis. Eur J Pediatr Surg. 2010 Mar;20(2):73-7. http://www.ncbi.nlm.nih.gov/pubmed/19882502?tool=bestpractice.com [80]Jaschinski T, Mosch CG, Eikermann M, et al. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2018 Nov 28;(11):CD001546. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517145 http://www.ncbi.nlm.nih.gov/pubmed/30484855?tool=bestpractice.com 然而，另一项研究显示两者并无明显差异。[86]Lintula H, Kokki H, Vanamo K, et al. Laparoscopy in children with complicated appendicitis. J Pediatr Surg. 2002 Sep;37(9):1317-20. http://www.ncbi.nlm.nih.gov/pubmed/12194123?tool=bestpractice.com
引流 ± 延期阑尾切除术
针对特定患者群中所有患者的治疗建议
脓肿通常随疾病进展而发生，尤其是在穿孔发生之后。
表现为右下腹包块压痛、弛张热、白细胞增多。超声和计算机体层成像（computed tomography, CT）扫描可显示脓肿。
初始治疗包括静脉使用抗生素和 CT 引导下或手术引流脓肿。
如果临床情况改善，体征和症状完全消退，则无需进行延期阑尾切除术。[72]Mason RJ. Surgery for appendicitis: is it necessary? Surg Infect (Larchmt). 2008 Aug;9(4):481-8. http://www.ncbi.nlm.nih.gov/pubmed/18687030?tool=bestpractice.com [73]Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass - is it necessary? Surgeon. 2007;5:45-50. http://www.ncbi.nlm.nih.gov/pubmed/17313128?tool=bestpractice.com [74]Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg. 2007 Nov;246(5):741-8. http://www.ncbi.nlm.nih.gov/pubmed/17968164?tool=bestpractice.com 如果症状没有完全消退，延期阑尾切除术应在 6 周后进行。[75]Garba ES, Ahmed A. Management of appendiceal mass. Ann Afr Med. 2008 Dec;7(4):200-4. http://www.annalsafrmed.org/article.asp?issn=1596-3519;year=2008;volume=7;issue=4;spage=200;epage=204;aulast=Garba http://www.ncbi.nlm.nih.gov/pubmed/19623924?tool=bestpractice.com
有证据显示，对于成人和儿童阑尾蜂窝织炎/脓肿，相对于保守治疗，腹腔镜下阑尾切除术可能是一种可行的一线治疗选择；然而，一项系统评价却无法找到证据，证明早期阑尾切除术（腹腔镜或开放手术）相对于保守治疗更为获益亦或更为有害。[76]Mentula P, Sammalkorpi H, Leppäniemi A. Laparoscopic surgery or conservative treatment for appendiceal abscess in adults? A randomized controlled trial. Ann Surg. 2015;262:237-42. http://www.ncbi.nlm.nih.gov/pubmed/25775072?tool=bestpractice.com [77]Cheng Y, Xiong X, Lu J, et al. Early versus delayed appendicectomy for appendiceal phlegmon or abscess. Cochrane Database Syst Rev. 2017 Jun 2;(6):CD011670. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481778 http://www.ncbi.nlm.nih.gov/pubmed/28574593?tool=bestpractice.com
一项小型随机对照试验（随后终止）中 60 例患者的非计划性期中分析表明， >40 岁且出现阑尾周围脓肿的患者，阑尾肿瘤风险可能将增加。[78]Mällinen J, Rautio T, Grönroos J, et al. Risk of appendiceal neoplasm in periappendicular abscess in patients treated with interval appendectomy vs follow-up with magnetic resonance imaging: 1-year outcomes of the peri-appendicitis Acuta randomized clinical trial. JAMA Surg. 2019 Mar 1;154(3):200-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439633 http://www.ncbi.nlm.nih.gov/pubmed/30484824?tool=bestpractice.com 这些患者应常规行延期阑尾切除术。[78]Mällinen J, Rautio T, Grönroos J, et al. Risk of appendiceal neoplasm in periappendicular abscess in patients treated with interval appendectomy vs follow-up with magnetic resonance imaging: 1-year outcomes of the peri-appendicitis Acuta randomized clinical trial. JAMA Surg. 2019 Mar 1;154(3):200-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439633 http://www.ncbi.nlm.nih.gov/pubmed/30484824?tool=bestpractice.com [79]Kristo G, Itani KMF. Settling the controversy-appendectomy as the criterion for appendicitis diagnosis. JAMA Surg. 2019 Mar 1;154(3):207-8. http://www.ncbi.nlm.nih.gov/pubmed/30484826?tool=bestpractice.com
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