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Non-Operative Management for Acute Appendicitis

October 20, 2021

Written by Gabby Leonard

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In shared decision making between patient and provider, it is reasonable to consider nonoperative treatment of acute uncomplicated appendicitis (lack of appendicolith, abscess, tumor, perforation, sepsis, hemodynamic instability, age <45) as a safe first-line alternative to appendectomy.

Why does this matter?
Acute appendicitis is the most common cause of emergency abdominal surgery, with an average lifetime risk of 7-8% peaking between ages 10-19 years old. In the case of untreated appendicitis, rupture, sepsis and death may occur. Traditionally, up to 80% of acute uncomplicated appendicitis has been treated with urgent appendectomy. Advantages and disadvantages of appendectomy versus antibiotic therapy alone should be considered, including work/family responsibility, schedule flexibility, travel plans, expenses, and patient comfort with intervention.

Can we avoid operative intervention?
Three large multicenter trials have evaluated operative versus non-op management of acute uncomplicated appendicitis: absence of appendicolith, abscess, tumor, phlegmon or perforation, or hemodynamic instability; and symptom onset <48 hours, appendiceal diameter <11mm, and WBC count <18,000.

  1. APPAC trial: 530 adults evaluated at 5-year outcomes. 95% of adults who got antibiotics alone improved during hospitalization; 27% eventually underwent appendectomy within 1 year. There was a similar 5-year incidence of complications in patients who had urgent vs delayed appendectomy, with no increased risk of perforation. Patients who were treated non-operatively with antibiotics had lower median days of being unable to work or participate in normal activity when compared to patients who received appendectomy (7 vs 19 days).

  2. CODA: 1552 adults with 90-day outcomes. Patients with appendicolith had higher rate of appendectomy within 90 days than patients without (41% vs 25%) as well as higher complications when treated with antibiotics only vs urgent appendectomy (14% vs 3%). Patients with acute uncomplicated appendicitis treated with antibiotics versus urgent appendectomy had fewer mean days of disability at 90 days (5 vs 8).

  3. MWPSC: 1068 children at 1 year outcome. Initial response rate to antibiotics was 86%; 33% of these had appendectomy within 1 year. There were fewer median days that patients were unable to participate in normal work/activity in the antibiotic group vs appendectomy group (4 vs 7 days).

Antibiotics to cover aerobic gram negative and anaerobic bacteria (such as ertapenem or ceftriaxone with metronidazole) should be given to patients for both operative and non-operative intervention. Patients treated nonoperatively should continue antibiotics with metronidazole + third or fourth generation cephalosporin or fluoroquinolone for 7-10 days. Patient should be instructed on strict return precautions and should have further clinical evaluation within 24-48 hours. Indications for emergent appendectomy include, but are not limited to, diffuse peritonitis or sepsis and lack of improvement at 48 hours. Risk factors for delayed response to antibiotic treatment include presence of appendicolith on CT, extraluminal fluid or air, age >45 years old, fever, symptoms > 48 hours, and initial elevated inflammatory markers. In the absence of any complicating factors, a trial of non-operative management with antibiotics could be considered.

Treatment of Acute Uncomplicated Appendicitis. N Engl J Med. 2021 Sep 16;385(12):1116-1123. doi: 10.1056/NEJMcp2107675.

What are your thoughts?