Treatment

• Bowel rest (NPO)

• Intravenous fluids

• Electrolyte repletion as needed

• IV analgesics

• IV antiemetics as needed

• Antipyretic therapy

• Indication: all patients with acute appendicitis

• Required coverage: against gram-negative and anaerobic organisms

• Preoperative antibiotics for uncomplicated appendicitis: Administer one of the following agents as prophylaxis against surgical site infection (can be discontinued after surgery or within 24 hours)

  • A cephalosporin with anaerobic coverage: Cefoxitin OR Cefotetan

  • Combination therapy with a first-generation cephalosporin (e.g., cefazolin ) PLUS metronidazole

  • In patients allergic to penicillin/cephalosporin, administer clindamycin OR metronidazole PLUS one of the following:

    • High dose gentamicin

    • Ciprofloxacin

• Nonoperative management for appendicitis (with or without interval appendectomy)

  
  

  • Duration for early uncomplicated appendicitis (not yet standardized): Consider initial parenteral antibiotics for at least 2–3 days then switch to oral antibiotics for 7 days.

  • Duration for complicated appendicitis (appendiceal mass or appendiceal abscess): 3–5 day

Appendectomy within 24 hours of diagnosis is the current standard of care for acute uncomplicated appendicitis.

• Definition: surgical removal of the appendix, usually within 24 hours of the diagnosis

• Emergency appendectomy

  • Timing: less than 8 hours after diagnosis

  • Indications: systemic manifestations resulting from complicated appendicitis (e.g., sepsis, generalized peritonitis)

• Relative contraindications

  • Appendiceal mass

  • Appendicular abscess

• Approach

  • Laparoscopic appendectomy

  • Open appendectomy (via a transabdominal incision in the RLQ)

Surgery for acute uncomplicated appendicitis can safely be delayed for up to 24 hours from diagnosis.

Initial operative treatment of appendiceal abscesses or appendiceal phlegmons is associated with a high risk of complications

Typically performed after a trial of nonoperative management for appendicitis.

• Definition: appendectomy performed 6–8 weeks following the resolution of an acute episode of appendiceal mass or appendiceal abscess to minimize surgical complications

• Indications: currently not routinely recommended

  • Consider for persistent or recurrent symptoms of appendicitis in a patient with an appendiceal mass or appendiceal abscess treated conservatively.

  • Consider in patients > 40 years of age if there is concern for an underlying appendiceal tumor

Nonoperative management (NOM; conservative management) is typically preferred for patients at high risk of surgical morbidity if operated on immediately. It is sometimes followed by an interval appendectomy. NOM can also be offered to select patients with early uncomplicated appendicitis in consultation with an experienced surgeon, however, this remains an area of ongoing research.

• Inflammatory appendiceal mass

• Appendiceal abscess

• Patient refusal of surgery

• High surgical risk due to comorbidities

• History of previous surgical/anesthesia complications

• Consider in select patients with early uncomplicated appendicitis

• Septic shock

• Generalized peritonitis

• Inability to percutaneously drain an appendiceal abscess

• Appendiceal fecalith

• Empiric parenteral antibiotic therapy for 2–3 days

• Supportive care (see above)

• Periappendiceal abscess > 4 cm: image-guided percutaneous drainage; send aspirate for cultures

• Monitor vitals and serial abdominal examinations every 6–12 hours.

  • Insignificant improvement/worsening of symptoms : urgent surgical intervention

  • Symptomatic improvement within 24–48 hours

    • Slow introduction of enteral nutrition

    • Switch to oral antibiotics for 7-day course. [33][38]

• Schedule interval colonoscopy in patients > 40 years of age following NOM of acute appendicitis to rule out early colonic malignancy