Medical Management of

Appendicitis - 2013
Dr. Robert Mustard
St. Michaels Hospital
April 19, 2013
MEDICAL MANAGEMENT OF ACUTE APPENDICITIS - 2013
A 30 year old woman with a one day history of right lower quadrant pain. Now
resolving. Wishes to go home. On examination:

- afebrile
- RLQ tenderness on deep palpation
- WBC 8.5
- CT simple acute appendicitis, no fecalith

What would you recommend?

1) discharge home

2) discharge home with oral antibiotics

3) admit, give antibiotics, if continues to improve, discharge

4) appendectomy
MEDICAL MANAGEMENT OF ACUTE APPENDICITIS - 2013
Do all cases of appendicitis eventually perforate?

Am. J. Epidemiology 129, 905-918, 1989
Br. M. Journal 308, 107-110, 1994.
Incidence
Simple and perforated appendicitis are likely two separate diagnoses.
Non-perforating
Perforated
0 15 75
Age
MEDICAL MANAGEMENT OF ACUTE APPENDICITIS - 2013
Impact of the CT Scanner

Rao et al. Effects of Computed Tomography of the Appendix
on Treatment of Patients and Use of Hospital Resources.
NEJM 1998; 338: 141-146.

Krajewski et al. Impact of Computed Tomography of the
Abdomen On Clinical Outcomes in Patients with Right Lower
Quadrant Pain: A Meta-analysis.
CJS 54; 1, 43-53, 2011.

Result: Increase in the radiological diagnosis of
acute appendicitis.






MEDICAL MANAGEMENT OF ACUTE APPENDICITIS - 2013
Who needs surgery?




Incidence
Severity
MEDICAL MANAGEMENT OF ACUTE APPENDICITIS - 2013
Antibiotic Treatment for Appendicitis

Wilm et al: Appendectomy versus Antibiotic Treatment for Acute Appendicitis.
Cochrane Review 2011.

Kao et al: Antibiotics versus Appendectomy for Uncomplicated Acute
Appendicitis.
JAMC 216:3, 501-505, 2013.
(CAGS Evidence-based Reviews of Surgery).

Appendectomy remains the standard treatment for acute appendicitis.

Current evidence provides support for the feasibility and safety of antibiotic
therapy in patients with uncomplicated acute appendicitis.





MEDICAL MANAGEMENT OF ACUTE APPENDICITIS - 2013
Indicators for Appendectomy
1) Clinical or CT findings suggestive of perforation
2) Fecalith on CT
(Acta Surg Scand. 149: 789-791, 1983)

3) Not an optimal patient
4) Unable to discharge patient from Emergency Room
MEDICAL MANAGEMENT OF ACUTE APPENDICITIS - 2013
Timing of Surgery

Perforated appendicitis or sick patient ASAP (within 6 hours)

Simple acute appendicitis as soon as is convenient

Abou-Nulata et al. Effects of delaying appendectomy for
acute appendicitis.
Arch Surg 141: (5): 504-6, 2006.