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Management/Acute Appendicitis


Case

A 27-year-old male presents to the emergency department complaining of abdominal pain for the past 13 h. He describes the pain as gradual in onset and initially centered around the umbilicus that progressively intensified to become constant, severe, and predominantly right-sided. He also reports nausea and anorexia and had one normal bowel movement prior to coming to the emergency department which did not alleviate the pain. He denies fevers, urinary symptoms, diarrhea, bloody stools, or previous similar episodes. Upon evaluation, his temperature is 100.2°F and the rest of the vital signs are within normal limits. Abdominal evaluation is remarkable for tap tenderness over McBurney point with localized right lower quadrant tenderness on light palpation associated with guarding and rebound tenderness. The pain is reproduced upon flexion at the right hip. The remainder of his physical examination is unremarkable. Blood chemistry, liver function test, and urinalysis are within normal limits. His white blood cell count is elevated to 18.8 103/mm3 with 85% polymorphonuclear cells. Abdominal computed tomography scan with intravenous and rectal contrast was performed which demonstrates a dilated and non-filling appendix measuring 1.2 cm in diameter with wall thickening and surrounding fat stranding. Broad-spectrum antibiotics were administered intravenously and the patient was brought to the operating room for planned laparoscopic appendectomy.

Management

Acute Appendicitis

The standard of care consists of prompt appendectomy. Delays in surgical treatment due to delayed presentation or in-hospital delays are associated with more advanced pathology and higher morbidity, Patients should be resuscitated with fluids and receive perioperative intravenous antibiotic prophylaxis, which reduces the risk of wound infection and intra-abdominal abscess formation. A single dose of a second-generation cephalosporin (cefoxitin or cefotetan) is adequate to cover common Gram-negative (Pseudomonas, Esche-richia coli), Gram-positive (Enterococcus, Streptococcus) and anaerobic (Bacteroides) organisms. Alternatively, a first-generation cephalosporin can be given in combination with metronidazole.

Surgical options include open andlaparoscopic appendectomy. Evidence from several randomized trials have demonstrated substantial benefits of the laparoscopic approach over open appendectomy, including reduced postoperative pain, length of hospital stay, recovery time, and wound infection rates. On the other hand, the laparoscopic approach is associated with longer operative time and higher cost. Although most studies demonstrate no difference in morbidity following open versus laparoscopic appendectomy, a large meta-analysis concluded that laparoscopic appendectomy was associated with a higher rate of intra-abdominal abscess relative to open appendectomy ,

Perforated Appendicitis

Based on pooled data from a recent meta-analysis, 3.8% of patients (CI 2.6-4.9) with acute appendicitis present with a phlegmon or localized abscess. Typically, these patients present after several days of symptoms. The most common organisms involved in perforated appendicitis are Escherichia coli, Peptostreptococcus, Bacillus fragilis, and Pseudomonas. Several antibiotic combinations can achieve broad-spectrum coverage against those pathogens including: (i) triple coverage with ampicillin, ami-noglycoside, and metronidazole or clindamycin; (ii) monotherapy with a broad-spectrum agent such as piperacillin/tazobactam ; and (iii) combination therapy with a third-generation cephalosporin (cefotax-ime or ceftriaxone) combined with metronidazole. Duration of antibiotic treatment should be tailored to clinical response but is usually transitioned to monotherapy within 5 to 7 days. In one study in pediatric patients, antibiotics were discontinued when patients were afebrile for 24 h and had normalized their white blood cell count with less than 3% bands with a minimal risk of recurrent intra-abdominal abscess, Perforated appendicitis can be managed non-operatively or with immediate appendectomy depending on the clinical presentation, time course, and computed tomography scan findings. Immediate appendectomy can be technically challenging, depending on the degree of inflammation and is associated with higher risk of laparotomy and ileocecal resection than in non-perforated appendicitis. Alternatively, patients can be managed conservatively with broad-spectrum antibiotics, bowel rest, and percutaneous drainage of any periappendiceal abscess, with subsequent observation or interval appendectomy following resolution of the acute episode. Neither approach has been demonstrated to be superior, and the choice largely depends on the clinical presentation and the surgeon’s experience. Patients with generalized peritonitis should undergo immediate surgery, whereas patients with an appendiceal mass from a walled-off phlegmon or periappendiceal abscess might benefit from initial non-operative management. Several studies have found that immediate appendectomy is feasible with morbidity and length of stay comparable to conservative management. In the majority of studies, however, conservative management with or without percutaneous drainage was associated with lower morbidity, and reduced length of stay relative to immediate appendectomy. Based on pooled data from a meta-analysis, failure of conservative management occurs in 7% of patients (CI 4-10.5). With respect to operative management, perforated appendicitis is not a contraindication to laparoscopic appendectomy. In experienced hands and when technically feasible, laparoscopic appendectomy appears to significantly reduce the incidence of intra-abdominal abscess formation relative to an open approach.

Interval Appendectomy

Interval appendectomy was traditionally recommended following resolution of perforated appendicitis successfully managed non-operatively. Interval appendectomy is typically performed 8 to 10 weeks following resolution of the episode, the rationale being that acute appendicitis recurs in 5-40% of patients. Another argument in favor of interval appendectomy is that other pathology might be missed, such as cecal malignancy or Crohn disease. The same meta-analysis found malignancy present in 1.2% of patients (CI 0.6-1.7) following non-operative treatment of perforated appendicitis, with the majority detected in patients 40 years and older , There is growing debate regarding the need for interval appendectomy as multiple studies have demonstrated long-term recurrence rates as low as 5%, at follow-up as long as 4 years. Therefore, after ruling out malignancy in patients 40 years or older in age with an interval colonoscopy or barium enema following resolution of the acute episode, patients may be observed with interval appendectomy reserved for those with recurrent symptoms.

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