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Acute Appendicitis

I. Purpose

Acute appendicitis is one of the most common reasons for presentation to the Emergency General Surgery service. This document outlines the management considerations for patients presenting with acute appendicitis.

II. Guideline

A. Initial Evaluation

  • Laboratory tests

    • Complete blood count (CBC)
    • Basic metabolic panel (BMP)

  • Imaging

    • CT abdomen/pelvis with IV contrast

B. Management

1. Antibiotic Therapy

Recommended durations:

  • Perforated appendicitis with source control: 4-day postoperative course
  • Nonoperative management: 10-day course
  • Appendectomy performed (uncomplicated): Stop antibiotics postoperatively

Regimens:

  • Without shock

    • First-line: Ceftriaxone + Metronidazole
    • Severe penicillin allergy: Levofloxacin + Metronidazole

  • With sepsis or risk for multidrug resistance

    • First-line: Piperacillin–Tazobactam
    • Severe penicillin allergy: Vancomycin + Cefepime + Metronidazole

2. Additional Management Steps

  • Place patient NPO pending operative plan
  • Obtain Emergency General Surgery consultation and admit to service
  • Proceed with laparoscopic appendectomy if operative management is chosen

3. Considerations for Nonoperative Management

  • Patient preference for nonoperative approach
  • Severe inflammation, phlegmon, or perforation on CT requiring ileocecectomy
  • High operative or perioperative risk
  • Appendicolith on CT (associated with higher recurrence risk)
  • Pregnancy: failure of nonoperative management may result in fetal demise
  • Age >40 with perforation: consider interval appendectomy due to malignancy risk

4. Follow-Up

  • Operative patients: 7–14 day follow-up (telemedicine or in-person) with pathology review
  • All patients: Consider colonoscopy referral if colorectal cancer risk factors are present

III. References

  1. de Almeida Leite RM, et al. Nonoperative vs Operative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-analysis. JAMA Surg. 2022;157(9):828–834.

  2. Rushing A, et al. Management of Acute Appendicitis in Adults: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;87(1):214–224.

  3. Di Saverio S, et al. Diagnosis and Treatment of Acute Appendicitis: 2020 Update of the WSES Jerusalem Guidelines. World J Emerg Surg. 2020;15(1):27. DOI: 10.1186/s13017-020-00306-3

IV. Author

Michael C. Smith, MD
December 18, 2023