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Internal Medicine

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A 25-year-old patient in excellent health was in a rural area five days ago when he developed right lower quadrant pain. A local emergency room diagnosed acute appendicitis by abdominal CT scan (appendiceal dilation and edema but no perforation) but elected to treat him with a 10-day course of amoxicillin-clavulanic acid since no surgeon was available.

The patient comes to you for advice since the Emergency Room team told him that follow up was mandatory.

Your radiologist reviews the film and confirms the diagnosis was in fact a non-perforated appendicitis.

WBC has fallen from 18000/mm3 with a neutrophilic predominance when the patient was first seen in the rural ER to 6000/mm3 with a normal differential in your office.

He is no longer symptomatic on day 5 of antibiotics.


Which of the following is the most appropriate management at this time?

  • Change therapy to ampicillin-sulbactam intravenously

  • Refer to surgery for emergent appendectomy

  • Complete the course of amoxicillin-clavulanic acid

  • Repeat CT scan


H S

The gold standard therapy for non-perforated appendicitis is surgical excision, which can be done laparoscopically or by open procedure. (Nonperforated appendicitis is defined as acute appendicitis that presents without clinical or radiographic signs of perforation, specifically inflammatory mass or abscess). The surgical approach has many advantages e.g., confirms the diagnosis, identifies any perforation or peritonitis that was missed on imaging, and avoids the possibility of recurrent appendicitis.

The attitude towards medical management is changing for children, and this is affecting management of adults.

There is extensive literature on the use of medical therapy after CT confirmed appendicitis. 90% respond to medical management and 10% require rescue surgery, often due to persistent pain. However, 10-30% of patients have recurrent appendicitis, sometimes within two weeks of stopping antibiotics, but sometimes occurring as long as a year later. Thus, medical therapy can be an effective measure for non-perforated appendicitis in low risk patients.

High risk patients would include the elderly, the immunosuppressed, or patients with substantial comorbidities, although the exact definition of these groups in this context can be vague.

A perforated appendix always requires antibiotics and drainage. There are multiple factors that determine whether drainage should be surgical or by interventional radiology, and whether the surgery should be immediate, should follow a period of IV antimicrobial therapy or whether non-operative management (i.e., no removal of the appendix following the initial drainage) is appropriate.

You should know that medical therapy is a reasonable option for non-perforated appendicitis, understanding that CT with contrast often fails to recognize perforations, and that recurrent appendicitis is common following medical management.  

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