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Management of acute appendicitis in adults

INTRODUCTION

The goal of management 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 [1]. Many surgeons use an aggressive approach, accepting a certain number of negative appendectomies, traditionally 15 percent, although the use of advanced abdominal imaging appears to have reduced the negative appendectomy rate to less than 10 percent [2].  

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 differential diagnosis" and "Acute appendicitis in pregnancy" and "Diagnostic approach to abdominal pain in adults" and "Differential diagnosis of abdominal pain in adults".)

ROLE OF NONOPERATIVE MANAGEMENT

Appendectomy remains the standard of care for most patients with uncomplicated acute appendicitis. An alternative strategy is antibiotic therapy, supportive care, and observation, with appendectomy reserved for those who do not respond to this treatment or those who develop complicated appendicitis. Some theorize that perforated and nonperforated appendicitis could have different patterns and pathological processes. There may be a subset of patients who will respond to nonoperative management and for whom the risk of recurrent acute appendicitis are less than the potential risks associated with appendectomy. However, given that the subset of patients least likely to fail initial nonoperative management (37 percent in the meta-analysis below) has not been definitively determined, we continue to recommend appendectomy as the initial treatment for those with acute appendicitis, complicated or uncomplicated, for the following reasons:

Appendectomy can generally be performed with low morbidity and very low mortality.

Preoperative abdominal CT interpreted as uncomplicated appendicitis cannot exclude the possibility of complicated disease. In one trial, among patients in the appendectomy arm, 20 percent had complicated appendicitis identified at the time of surgery [3].

                                      

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Literature review current through: Nov 2014. | This topic last updated: Oct 27, 2014.
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