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Diagnosis and Management of Acute Appendicitis in AdultsA Review

Educational Objective
To review the clinical management of suspected acute appendicitis in adults.
1 Credit CME

Importance  Acute appendicitis is the most common abdominal surgical emergency in the world, with an annual incidence of 96.5 to 100 cases per 100 000 adults.

Observations  The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging. Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever. The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms. Laparoscopic appendectomy remains the most common treatment. However, increasing evidence suggests that broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, successfully treats uncomplicated acute appendicitis in approximately 70% of patients. Specific imaging findings on computed tomography (CT), such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, defined as the conglomeration of feces in the appendiceal lumen, identify patients for whom an antibiotics-first management strategy is more likely to fail. CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach. Therefore, surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy. In unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended, and surgery may be considered if antibiotic treatment fails. In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered.

Conclusions and Relevance  Acute appendicitis affects 96.5 to 100 people per 100 000 adults per year worldwide. Appendectomy remains first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis.

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Article Information

Corresponding Author: Theodore N. Pappas, MD, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 (theodore.pappas@duke.edu).

Accepted for Publication: October 28, 2021.

Author Contributions: Drs Moris and Pappas had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Moris.

Drafting of the manuscript: Moris, Paulson.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Pappas.

Supervision: Pappas.

Other: Paulson.

Conflict of Interest Disclosures: Dr Pappas reported serving as a paid consultant for Transenterix Corp. No other disclosures were reported.

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