The goal of therapy of acute appendicitis is early diagnosis and prompt operative intervention. However, this goal is not always easily accomplished since many patients do not seek medical attention in a timely manner and the diagnosis of appendicitis can be difficult . Many surgeons use an aggressive approach, accepting a certain number of negative appendectomies, traditionally 15 percent, although the use of imaging studies appears to have reduced the negative appendectomy rate to less than 10 percent .
The management of appendicitis in adults will be reviewed here. The diagnosis and differential diagnosis of appendicitis, appendicitis in pregnancy, and the diagnosis and differential diagnosis of abdominal pain in general are discussed separately. (See "Acute appendicitis in adults: Clinical manifestations and diagnosis" and "Acute appendicitis in pregnancy" and "Diagnostic approach to abdominal pain in adults" and "Differential diagnosis of abdominal pain in adults".)
OUTCOMES WITH MEDICAL THERAPY
The great majority of patients with acute appendicitis are treated surgically and an appendectomy remains the gold standard of care. As illustrated in the following randomized trials, some patients respond to medical therapy with antibiotics alone but are at appreciable risk for recurrent disease:
- A trial of 243 patients (mean age 33 years) with uncomplicated appendicitis documented by a preoperative CT scan were randomly assigned to medical therapy alone with amoxicillin plus clavulanic acid for 8 to 15 days or appendectomy . Among patients in the appendectomy arm, 20 percent had complicated appendicitis at the time of surgery. Thus, a preoperative CT showing uncomplicated appendicitis does not exclude complicated disease.
The occurrence of postoperative peritonitis within 30 days of beginning treatment was the primary endpoint. The pertinent outcome findings included:
- Postoperative peritonitis was significantly more frequent in patients treated with amoxicillin plus clavulanic acid compared with appendectomy (8 versus 2 percent).
- Fourteen patients (12 percent) treated with antibiotics underwent an appendectomy within 30 days of treatment.
- An additional 30 patients underwent an appendectomy within the year following antibiotic therapy, 26 of whom had confirmed acute appendicitis.