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Management of acute appendicitis in adults

Authors
Douglas Smink, MD, MPH
David I Soybel, MD
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

Acute appendicitis is the most common abdominal surgical emergency in the world, with a lifetime risk of 8.6 percent in males and 6.9 percent in females [1]. For over a century, open appendectomy was the only standard treatment for appendicitis. Contemporary management of appendicitis is more sophisticated and nuanced: laparoscopic appendectomy has surpassed open appendectomy in usage, some patients with perforated appendicitis may benefit from initial antibiotic therapy followed by interval appendectomy, and several European trials have even suggested that it is feasible to treat uncomplicated appendicitis nonoperatively with antibiotics alone.

The management of appendicitis in adults will be reviewed here. Appendicitis in children and pregnant women is discussed separately:

(See "Acute appendicitis in children: Management".)

(See "Acute appendicitis in pregnancy".)

The clinical manifestations and diagnostic evaluation of appendicitis in adults are also discussed elsewhere.

                                       
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Literature review current through: Nov 2017. | This topic last updated: Dec 05, 2017.
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References
Top
  1. Körner H, Söndenaa K, Söreide JA, et al. Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 1997; 21:313.
  2. Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 2013; 8:3.
  3. Di Saverio S, Birindelli A, Kelly MD, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016; 11:34.
  4. Gorter RR, Eker HH, Gorter-Stam MA, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc 2016; 30:4668.
  5. Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011; 377:1573.
  6. Hansson J, Körner U, Khorram-Manesh A, et al. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 2009; 96:473.
  7. Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995; 82:166.
  8. Styrud J, Eriksson S, Nilsson I, et al. Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial. World J Surg 2006; 30:1033.
  9. Turhan AN, Kapan S, Kütükçü E, et al. Comparison of operative and non operative management of acute appendicitis. Ulus Travma Acil Cerrahi Derg 2009; 15:459.
  10. Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA 2015; 313:2340.
  11. Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev 2011; :CD008359.
  12. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ 2012; 344:e2156.
  13. Antibiotic therapy for acute appendicitis in adults. Fewer immediate complications than with surgery, but more subsequent failures. Prescrire Int 2014; 23:158.
  14. Sallinen V, Akl EA, You JJ, et al. Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg 2016; 103:656.
  15. Harnoss JC, Zelienka I, Probst P, et al. Antibiotics Versus Surgical Therapy for Uncomplicated Appendicitis: Systematic Review and Meta-analysis of Controlled Trials (PROSPERO 2015: CRD42015016882). Ann Surg 2017; 265:889.
  16. Ehlers AP, Talan DA, Moran GJ, et al. Evidence for an Antibiotics-First Strategy for Uncomplicated Appendicitis in Adults: A Systematic Review and Gap Analysis. J Am Coll Surg 2016; 222:309.
  17. Podda M, Cillara N, Di Saverio S, et al. Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics. Surgeon 2017; 15:303.
  18. Park HC, Kim MJ, Lee BH. Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis. Br J Surg 2017; 104:1785.
  19. Singh JP, Mariadason JG. Role of the faecolith in modern-day appendicitis. Ann R Coll Surg Engl 2013; 95:48.
  20. Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet 1990; 171:185.
  21. Marudanayagam R, Williams GT, Rees BI. Review of the pathological results of 2660 appendicectomy specimens. J Gastroenterol 2006; 41:745.
  22. Kırkıl C, Yiğit MV, Aygen E. Long-term results of nonoperative treatment for uncomplicated acute appendicitis. Turk J Gastroenterol 2014; 25:393.
  23. McCutcheon BA, Chang DC, Marcus LP, et al. Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis. J Am Coll Surg 2014; 218:905.
  24. Carpenter SG, Chapital AB, Merritt MV, Johnson DJ. Increased risk of neoplasm in appendicitis treated with interval appendectomy: single-institution experience and literature review. Am Surg 2012; 78:339.
  25. Chandrasegaram MD, Rothwell LA, An EI, Miller RJ. Pathologies of the appendix: a 10-year review of 4670 appendicectomy specimens. ANZ J Surg 2012; 82:844.
  26. Chhabra KR, Sacks GD, Dimick JB. Surgical Decision Making: Challenging Dogma and Incorporating Patient Preferences. JAMA 2017; 317:357.
  27. Di Saverio S, Sibilio A, Giorgini E, et al. The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg 2014; 260:109.
  28. Baird DLH, Simillis C, Kontovounisios C, et al. Acute appendicitis. BMJ 2017; 357:j1703.
  29. United Kingdom National Surgical Research Collaborative, Bhangu A. Safety of short, in-hospital delays before surgery for acute appendicitis: multicentre cohort study, systematic review, and meta-analysis. Ann Surg 2014; 259:894.
  30. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev 2005; :CD001439.
  31. Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect (Larchmt) 2008; 9:579.
  32. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
  33. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.
  34. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
  35. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152:784.
  36. Pearcy C, Almahmoud K, Jackson T, et al. Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy. Am J Surg 2017; 214:1012.
  37. Sporn E, Petroski GF, Mancini GJ, et al. Laparoscopic appendectomy--is it worth the cost? Trend analysis in the US from 2000 to 2005. J Am Coll Surg 2009; 208:179.
  38. Nguyen NT, Zainabadi K, Mavandadi S, et al. Trends in utilization and outcomes of laparoscopic versus open appendectomy. Am J Surg 2004; 188:813.
  39. Brügger L, Rosella L, Candinas D, Güller U. Improving outcomes after laparoscopic appendectomy: a population-based, 12-year trend analysis of 7446 patients. Ann Surg 2011; 253:309.
  40. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010; :CD001546.
  41. Andersson RE. Short-term complications and long-term morbidity of laparoscopic and open appendicectomy in a national cohort. Br J Surg 2014; 101:1135.
  42. Jaschinski T, Mosch C, Eikermann M, Neugebauer EA. Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC Gastroenterol 2015; 15:48.
  43. Markar SR, Penna M, Harris A. Laparoscopic approach to appendectomy reduces the incidence of short- and long-term post-operative bowel obstruction: systematic review and pooled analysis. J Gastrointest Surg 2014; 18:1683.
  44. Moberg AC, Ahlberg G, Leijonmarck CE, et al. Diagnostic laparoscopy in 1043 patients with suspected acute appendicitis. Eur J Surg 1998; 164:833.
  45. Enochsson L, Hellberg A, Rudberg C, et al. Laparoscopic vs open appendectomy in overweight patients. Surg Endosc 2001; 15:387.
  46. Golub R, Siddiqui F, Pohl D. Laparoscopic versus open appendectomy: a metaanalysis. J Am Coll Surg 1998; 186:545.
  47. Mason RJ, Moazzez A, Moroney JR, Katkhouda N. Laparoscopic vs open appendectomy in obese patients: outcomes using the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012; 215:88.
  48. Semm K. Endoscopic appendectomy. Endoscopy 1983; 15:59.
  49. Faiz O, Clark J, Brown T, et al. Traditional and laparoscopic appendectomy in adults: outcomes in English NHS hospitals between 1996 and 2006. Ann Surg 2008; 248:800.
  50. Frutos MD, Abrisqueta J, Lujan J, et al. Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy. Ann Surg 2013; 257:413.
  51. Kim JH, Kim HY, Park SK, et al. Single-incision Laparoscopic Appendectomy Versus Conventional Laparoscopic Appendectomy: Experiences From 1208 Cases of Single-incision Laparoscopic Appendectomy. Experiences From 1208 Cases of Single-incision Laparoscopic Appendectomy. Ann Surg 2015; 262:1054.
  52. Deng L, Xiong J, Xia Q. Single-incision versus conventional three-incision laparoscopic appendectomy: A meta-analysis of randomized controlled trials. J Evid Based Med 2017; 10:196.
  53. Lee JS, Hong TH. Comparison of various methods of mesoappendix dissection in laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A 2014; 24:28.
  54. Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000; 66:739.
  55. Sajid MS, Rimple J, Cheek E, Baig MK. Use of endo-GIA versus endo-loop for securing the appendicular stump in laparoscopic appendicectomy: a systematic review. Surg Laparosc Endosc Percutan Tech 2009; 19:11.
  56. Mannu GS, Sudul MK, Bettencourt-Silva JH, et al. Closure methods of the appendix stump for complications during laparoscopic appendectomy. Cochrane Database Syst Rev 2017; 11:CD006437.
  57. Mayir B, Ensari CÖ, Bilecik T, et al. Methods for closure of appendix stump during laparoscopic appendectomy procedure. Ulus Cerrahi Derg 2015; 31:229.
  58. McBurney C. II. The Indications for Early Laparotomy in Appendicitis. Ann Surg 1891; 13:233.
  59. Arnbjörnsson E. Invagination of the appendiceal stump for the reduction of peritoneal bacterial contamination. Curr Surg 1985; 42:184.
  60. Watters DA, Walker MA, Abernethy BC. The appendix stump: should it be invaginated? Ann R Coll Surg Engl 1984; 66:92.
  61. Engström L, Fenyö G. Appendicectomy: assessment of stump invagination versus simple ligation: a prospective, randomized trial. Br J Surg 1985; 72:971.
  62. Street D, Bodai BI, Owens LJ, et al. Simple ligation vs stump inversion in appendectomy. Arch Surg 1988; 123:689.
  63. Poole GV. Management of the difficult appendiceal stump: how I do it. Am Surg 1993; 59:624.
  64. Lavonius MI, Liesjärvi S, Niskanen RO, et al. Simple ligation vs stump inversion in appendicectomy. Ann Chir Gynaecol 1996; 85:222.
  65. van der Graaf Y, Obertop H. [Simple ligation better than invagination of the appendix stump; a prospective randomized study]. Ned Tijdschr Geneeskd 1992; 136:1525.
  66. Frazee RC, Abernathy SW, Isbell CL, et al. Outpatient Laparoscopic Appendectomy: Is It Time to End the Discussion? J Am Coll Surg 2016; 222:473.
  67. Frazee RC, Abernathy SW, Davis M, et al. Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis. J Trauma Acute Care Surg 2014; 76:79.
  68. Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg 1992; 158:37.
  69. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995; 221:278.
  70. Cheng Y, Xiong X, Lu J, et al. Early versus delayed appendicectomy for appendiceal phlegmon or abscess. Cochrane Database Syst Rev 2017; 6:CD011670.
  71. Oliak D, Yamini D, Udani VM, et al. Initial nonoperative management for periappendiceal abscess. Dis Colon Rectum 2001; 44:936.
  72. Mentula P, Sammalkorpi H, Leppäniemi A. Laparoscopic Surgery or Conservative Treatment for Appendiceal Abscess in Adults? A Randomized Controlled Trial. Ann Surg 2015; 262:237.
  73. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 2010; 147:818.
  74. Gee D, Babineau TJ. The optimal management of adult patients presenting with appendiceal abscess: "conservative" vs immediate operative management. Curr Surg 2004; 61:524.
  75. Siewert B, Raptopoulos V. CT of the acute abdomen: findings and impact on diagnosis and treatment. AJR Am J Roentgenol 1994; 163:1317.
  76. Brown CV, Abrishami M, Muller M, Velmahos GC. Appendiceal abscess: immediate operation or percutaneous drainage? Am Surg 2003; 69:829.
  77. Fagenholz PJ, Peev MP, Thabet A, et al. Abscess due to perforated appendicitis: factors associated with successful percutaneous drainage. Am J Surg 2016; 212:794.
  78. Darwazeh G, Cunningham SC, Kowdley GC. A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See? Am Surg 2016; 82:11.
  79. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg 2007; 246:741.
  80. Kaminski A, Liu IL, Applebaum H, et al. Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis. Arch Surg 2005; 140:897.
  81. Wright GP, Mater ME, Carroll JT, et al. Is there truly an oncologic indication for interval appendectomy? Am J Surg 2015; 209:442.
  82. Teixeira FJR Jr, Couto Netto SDD, Akaishi EH, et al. Acute appendicitis, inflammatory appendiceal mass and the risk of a hidden malignant tumor: a systematic review of the literature. World J Emerg Surg 2017; 12:12.
  83. Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass--is it necessary? Surgeon 2007; 5:45.
  84. Lin HF, Lai HS, Lai IR. Laparoscopic treatment of perforated appendicitis. World J Gastroenterol 2014; 20:14338.
  85. Yu MC, Feng YJ, Wang W, et al. Is laparoscopic appendectomy feasible for complicated appendicitis ?A systematic review and meta-analysis. Int J Surg 2017; 40:187.
  86. Moore CB, Smith RS, Herbertson R, Toevs C. Does use of intraoperative irrigation with open or laparoscopic appendectomy reduce post-operative intra-abdominal abscess? Am Surg 2011; 77:78.
  87. St Peter SD, Adibe OO, Iqbal CW, et al. Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: a prospective randomized trial. Ann Surg 2012; 256:581.
  88. Sun F, Wang H, Zhang F, et al. Copious Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Complicated Appendicitis in Adults. J Invest Surg 2017; :1.
  89. Greenall MJ, Evans M, Pollock AV. Should you drain a perforated appendix? Br J Surg 1978; 65:880.
  90. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses. Ann Surg 2004; 240:1074.
  91. Cheng Y, Zhou S, Zhou R, et al. Abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis. Cochrane Database Syst Rev 2015; :CD010168.
  92. Lemieur TP, Rodriguez JL, Jacobs DM, et al. Wound management in perforated appendicitis. Am Surg 1999; 65:439.
  93. Cohn SM, Giannotti G, Ong AW, et al. Prospective randomized trial of two wound management strategies for dirty abdominal wounds. Ann Surg 2001; 233:409.
  94. Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized clinical trials comparing primary vs delayed primary skin closure in contaminated and dirty abdominal incisions. JAMA Surg 2013; 148:779.
  95. Siribumrungwong B, Noorit P, Wilasrusmee C, Thakkinstian A. A systematic review and meta-analysis of randomised controlled trials of delayed primary wound closure in contaminated abdominal wounds. World J Emerg Surg 2014; 9:49.
  96. Brasel KJ, Borgstrom DC, Weigelt JA. Cost-utility analysis of contaminated appendectomy wounds. J Am Coll Surg 1997; 184:23.
  97. Bhangu A, Søreide K, Di Saverio S, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386:1278.
  98. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA 2001; 286:1748.
  99. SCOAP Collaborative, Cuschieri J, Florence M, et al. Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 2008; 248:557.
  100. National Surgical Research Collaborative. Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. Br J Surg 2013; 100:1240.
  101. Güller U, Rosella L, McCall J, et al. Negative appendicectomy and perforation rates in patients undergoing laparoscopic surgery for suspected appendicitis. Br J Surg 2011; 98:589.
  102. Phillips AW, Jones AE, Sargen K. Should the macroscopically normal appendix be removed during laparoscopy for acute right iliac fossa pain when no other explanatory pathology is found? Surg Laparosc Endosc Percutan Tech 2009; 19:392.
  103. Strong S, Blencowe N, Bhangu A, National Surgical Research Collaborative. How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study. Int J Surg 2015; 15:107.
  104. Grimes C, Chin D, Bailey C, et al. Appendiceal faecaliths are associated with right iliac fossa pain. Ann R Coll Surg Engl 2010; 92:61.
  105. Mussack T, Schmidbauer S, Nerlich A, et al. [Chronic appendicitis as an independent clinical entity]. Chirurg 2002; 73:710.
  106. Leardi S, Delmonaco S, Ventura T, et al. [Recurrent abdominal pain and "chronic appendicitis"]. Minerva Chir 2000; 55:39.
  107. Olsen J, Skovdal J, Qvist N, Bisgaard T. Treatment of appendiceal mass--a qualitative systematic review. Dan Med J 2014; 61:A4881.
  108. Tannoury J, Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013; 19:3942.
  109. Charfi S, Sellami A, Affes A, et al. Histopathological findings in appendectomy specimens: a study of 24,697 cases. Int J Colorectal Dis 2014; 29:1009.
  110. Rymer B, Forsythe RO, Husada G. Mucocoele and mucinous tumours of the appendix: A review of the literature. Int J Surg 2015; 18:132.
  111. Watters JM, Blakslee JM, March RJ, Redmond ML. The influence of age on the severity of peritonitis. Can J Surg 1996; 39:142.
  112. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132:910.
  113. Horattas MC, Guyton DP, Wu D. A reappraisal of appendicitis in the elderly. Am J Surg 1990; 160:291.
  114. Paajanen H, Kettunen J, Kostiainen S. Emergency appendectomies in patients over 80 years. Am Surg 1994; 60:950.
  115. Hui TT, Major KM, Avital I, et al. Outcome of elderly patients with appendicitis: effect of computed tomography and laparoscopy. Arch Surg 2002; 137:995.
  116. Harrell AG, Lincourt AE, Novitsky YW, et al. Advantages of laparoscopic appendectomy in the elderly. Am Surg 2006; 72:474.
  117. Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 2004; 239:43.
  118. Flum DR, Steinberg SD, Sarkis AY, Wallack MK. Appendicitis in patients with acquired immunodeficiency syndrome. J Am Coll Surg 1997; 184:481.
  119. Bova R, Meagher A. Appendicitis in HIV-positive patients. Aust N Z J Surg 1998; 68:337.
  120. Whitney TM, Macho JR, Russell TR, et al. Appendicitis in acquired immunodeficiency syndrome. Am J Surg 1992; 164:467.
  121. Ciarrocchi A, Amicucci G. Laparoscopic versus open appendectomy in obese patients: A meta-analysis of prospective and retrospective studies. J Minim Access Surg 2014; 10:4.
  122. Fleming FJ, Kim MJ, Messing S, et al. Balancing the risk of postoperative surgical infections: a multivariate analysis of factors associated with laparoscopic appendectomy from the NSQIP database. Ann Surg 2010; 252:895.
  123. Kanona H, Al Samaraee A, Nice C, Bhattacharya V. Stump appendicitis: a review. Int J Surg 2012; 10:425.