A practical guide to appendicitis evaluation and treatment

A look at the imaging options

Advanced imaging technology can affirm or refute a diagnosis of appendicitis and reduce the negative appendectomy rate, previously reported to be 15%.¹⁵ Ultrasonography (US), abdominal CT, and magnetic resonance imaging (MRI) are the most commonly used modalities. Point-of-care ultrasound ­(POCUS) is an option to start the diagnostic evaluation, given its relative ease of access, rapidity, and lack of radiation. However, a stand-alone POCUS at this time should not be the only imaging tool to rule out appendicitis.^16-18 Its accuracy depends on operator skill and is limited by patient-specific factors such as obesity.^16-19 If results are equivocal or the diagnosis otherwise remains unclear, arrange for different imaging.^16-18

Abdominal CT has sensitivity and specificity rates between 76% and 100% and 83% and 100%, respectively.^15,20,21 Ultrasonography has sensitivity and specificity rates of 71% to 94% and 81% to 98%, respectively.^15,20,21 Formal US is reliable to confirm appendicitis, but less so to rule out appendicitis. Special considerations for imagining in pregnant patients and children are discussed in a bit.

Timing of surgical consultation

Surgical consultation is paramount once the diagnosis of appendicitis is probable. Imaging is best obtained prior to surgical consultation to streamline evaluation and enhance decision- making. Typically, patients will be categorized as complicated or uncomplicated based on the presence or absence of perforation, a gangrenous appendix, an intra-abdominal abscess (IAA), or purulent peritonitis. Active continuous surgical involvement (­co-management or assumption of care) is recommended in all cases of appendicitis, especially if nonoperative management is selected, given that some cases must convert to immediate operative treatment or may be selected for delayed future (interval) appendectomy.²²

Management

Uncomplicated appendicitis

Prompt appendectomy has been the gold standard of care for uncomplicated acute appendicitis for 60 years. However, several studies have investigated an antibiotic-based strategy rather than surgical treatment for uncomplicated appendicitis.

Antibiotics vs appendectomy. In 2020, the CODA Collaborative published a randomized trial comparing a 10-day course of antibiotics with appendectomy in patients with uncomplicated appendicitis. In this multicenter study based in the United States, 1552 patients 18 years of age or older were randomized to receive antibiotics or undergo appendectomy (95% performed laparoscopically). The antibiotic treatment consisted of at least 24 hours of IV antibiotics, with or without admission to the hospital. Antibiotic choice was individualized according to guidelines for intra-abdominal infection published by the Infectious Diseases Society of America, with the most common IV medications being ertapenem, cefoxitin, or metronidazole plus one of the following: ceftriaxone, cefazolin, or levofloxacin. For the remaining 10 days, oral metronidazole plus ciprofloxacin or cefdinir were used.²²

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