With numerous recent studies demonstrating that antibiotics work as well as surgery for most uncomplicated appendicitis cases, the non-surgical approach can now be considered a routine option, according to a review article in JAMA.
The finding, led by Dr Theodore Pappas, professor in the Department of Surgery at Duke University School of Medicine, cites the consensus of evidence that antibiotics successfully treat up to 70% of appendicitis cases.
Surgery, usually done laparoscopically, remains the definitive option for otherwise healthy patients with a severely inflamed appendix or other factors that increase the risk of rupture.
“Acute appendicitis is the most common abdominal surgical emergency in the world, striking about one in 1,000 adults,” Pappas said. “Until recently, the only treatment option was surgery, so having a non-surgical approach for many of these cases has significant impact for both patients and the healthcare system.”
Pappas said the criteria for determining the best treatment approach is nuanced, but not excessively difficult. Appendicitis cases, marked by abdominal pain that often migrates to the lower right side, nausea and vomiting, and low-grade fever, are confirmed with ultrasound and/or CT scans.
If the scans depict no complications, most patients could receive antibiotics instead of undergoing an appendectomy. Antibiotics could also be a first-line therapy for patients who have severe symptoms, but who are older or have medical conditions that add risks to surgeries.
“We think it's going to be 60% to 70% of patients who are good candidates for consideration of antibiotics,” Pappas said. “A lot of people note that patient preferences can be brought into the decision, so it is important to provide the literature and educate the public.”
He said antibiotics were not always a complete cure. In about 40% of cases, patients who recover from a bout of appendicitis after receiving antibiotics have another episode and eventually need their appendix surgically removed.
“It’s important to take into account every case and its unique context as we consider patient preferences,” he added. “If someone presents with an appendicitis and they’re attending their brother’s wedding the next day, antibiotics may be a good option. If they have appendicitis and they are planning to head to rural Alaska next year, they might want to consider an appendectomy, given that the condition could recur.”
Study details
Diagnosis and Management of Acute Appendicitis in Adults.
Dimitrios Moris, Erik Karl Paulson, Theodore Pappas
Published in JAMA on 14 December 2021
Abstract
Importance
Acute appendicitis is the most common abdominal surgical emergency in the world, with an annual incidence of 96.5 to 100 cases per 100 000 adults.
Observations
The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging. Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever. The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms. Laparoscopic appendectomy remains the most common treatment. However, increasing evidence suggests that broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, successfully treats uncomplicated acute appendicitis in approximately 70% of patients.
Specific imaging findings on computed tomography (CT), such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, defined as the conglomeration of feces in the appendiceal lumen, identify patients for whom an antibiotics-first management strategy is more likely to fail. CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach. Therefore, surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy.
In unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended, and surgery may be considered if antibiotic treatment fails. In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered.
Conclusions and Relevance
Acute appendicitis affects 96.5 to 100 people per 100 000 adults per year worldwide. Appendectomy remains first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis.
JAMA review – Diagnosis and Management of Acute Appendicitis in Adults (Open access)
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