Acute appendicitis is the most common diagnosis in young patients admitted to hospital for acute abdominal pain, with a lifetime prevalence of about 7%. Since in 1883 Grooves performed the first appendectomy, surgery has been the most accepted treatment of choice. Over the past twenty years, there has been a renewed interest on the conservative management of uncomplicated acute appendicitis. What are, in your personal opinion, the most effective criteria to identify a subgroup of patients with uncomplicated acute appendicitis for whom antibiotic treatment can be highly effective ?
- Difficult to a set criteria. Depends on clinical progress of the patient. Assess regularly 6-12 hrs .
In children we usually evaluate laboratory test (CRP + WBC + Fibrinogen elevation) associated to abdominal US (plus obviuosly clinical findings..). If only clinical positivity is present, without fever, and slightly lab test elevation, I suggest re-evaluation after 48 hours, but without antibiotics.
Sorry! I will not tell you what you want but it is totally a waste of time. If I was in the Ethics Com. I would not let this study done in the laparoscopy era. If I was doing the litigation, treating an appendicitis patient with antibiotics if turns up with any complication, I would call it "malpractice". Whatever antibiotic you prescribe, even in low incidence, inevitable perforations and other septic complications will ensue. Nothing can be more effective than timely surgery. Treatment of appendicitis with and similar approaches will bring the end of antibiotics that unnecessary consumption is the most important reason of resistance!
Hello. First of all I agree with the previos answers and Grooves didnt perform the firdt appendectomy. Second the progression from uncomplicated to complicated is umprediictable and it is very variable.it has been confirmed that conservativo treatment could fail in 30% , with longer hospital stay and total cost, it is no lonher an interesting, safe or feasible option en apendicitis treatment
Hello again. In our Service we apply, by a couple of years, conservative treatment of complicated appendicitis with US documented abscesses. If broad -spectrum antibiotics ev during the first 24h hours, do not decrease fever, laboratory tests and pain, we operate. I admit that only 30% of children, avoid surgery. Anyway laparoscopic appendectomy is only delayed by 4-5 months (appendectomy is really easy at that time..).
There is not total security about the stage of the appendicitis, even with the most advanced diagnostics techniques. I work in a hospital of a country with limited resources and our mains techniques for appendicitis’ diagnosis are M & H: mind & hands. By the other hand, since some years ago, when the non surgical treatment was proposed, several reports showed that between 25 – 30% of patients non surgical managed, will need an operation in the next 24 hours. But, how many of these patients really had appendicitis and not mesenteric adenitis, for example? It’s hard to be sure if you “can’t see” inside the abdomen. I’m agree with Dr. Engin Olcucuoglu: “Acute abdomen is acute abdomen and needs surgery”. In our service, if we suspected appendicitis, the patient will go to the surgical unit.
Best regards ...
i've have been managing uncomplicated appendicitis conservatively for nearly 2 years, a local guideline was set up. we are collecting a data on that, based on my observation; the sooner you start the antibiotics in relation to onset of abdominal pain, greater success rate. of course we only observe for 24 hours, if no improvement we operate. earlier series have demonstrated male gender and presence of fecolith on scan are the predictors for fail conservative management. we have noticed that also. so far we have no significant morbidity related with current approach with success rate of around 80%. tq
Surgery is the best treatment for accute appendicitis but in some patients medical treatment could be a good option above all depending comorbidity of patients
The most important problem is to decide if it's a complicated appendicitis or not. Alvarado score, AIR score,US scan can be of great help in the decision making process, but there is an additional difficulty to do NOM vs surgery. In our region, patients are terrified of peritonitis, so proposing an antibiotic treatment as an alternative to an appendectomy clashes with the skepticism and folk beliefs deeply rooted in our area. Furthermore, perform an appendectomy in case of uncomplicated appendicitis with patient discharge in 2nd post-operative day, it seems to me not a serious sin.
http://www.oumedicine.com/docs/ad-surgery-workfiles/williams_history-of-appendicitis-with-anecdotes-illustrating-its-importance.pdf
Dear collegues, thank you all for your contributions.
I think this argument is still a matter of debate.
We performed a meta-analysis and I attached here our results. I leave you the conclusions (based on our findings).
Five studies comparing AT and ST qualified for inclusion in this meta-analysis with a total of 1.351 patients: 632 in the AT group and 719 in the ST group.
The meta-analysis of studies comparing treatment efficacy based on one year follow-up after AT (75.9%) and ST (98.3%) showed a higher rate of efficacy in the ST group (P
In my opinion, the resurgence of the conservative treatment of acute appendicitis - which used to be the state of the art 200 yrs ago- is a matter where evidence and experience clash. Common sense dictates a surgical treatment for most cases of acute appendicitis, whatever scientific evidence there is to support a nonoperative treatment.
Which healthy young wants to take antibiotics and wait for a complication to happen or happen not and moreover risk a relapse just to avoid a laparoscopic appendectomy which will make him leave the hospital, cured, one day later ? No patient with an ounce of common sense. Let us not rewrite history.
We operate on all cases of acute appendictits if there is no appendicular mass or another specific reason to choose for a non-operative treatment.
There are many studies that confirm upt to 30% or relapse after antibiotic therapy during 1-3 years follow up.
The recurrence is the first problem.
The second problem is: is there additional technical difficulty in performing (laparoscopic) appendectomy in second episode of appendicitis and theoretically higher possibility of postoperative complications.
The third problem is the population with let's say endometriosis. My opinion is that appendectomy is better option to eliminate the diagnostic problems with subsequent right lower quadrant pain.
Dear Goran
I totally agree with you, especially with regards to the second problem you exposed. Unfortunately, none of the trials published in the literature focused on the issue: is there additional technical difficulty in performing laparoscopic appendectomy for a second episode of appendicitis?
With regards to the possibility of higher rates of post-operative complications after failure of the antibiotic-first approach, the meta-analysis we performed stated that there's not this kind of risk.
Thanks for your comments
the best treatment for Acute appendicitis is appendicectomy . Occasionally some patients with appendicitis present in the resolving phase and then non operative treatment can be considered. This is a clinical decision
It is always "all" or "non" fashioned debate on surgical issues, which is not right. The correct answer is always existed between two ends of "all" or "non". The most important issue is to find out this point and to know its criteria.
Although it is easy to perform an appendectomy, but we should also learn that appendectomy is not always right.
Whether conservative treatment or appendectomy for acute appendicitis is a debate raging all over the world in last two decades. The standard treatment of acute appendicitis is appendectomy which gives rise to 100% cure with minimal complications, if done properly. There is always a dilemma regarding 100% confirmed diagnosis of acute appendicitis. It is essentially a clinical diagnosis where Alvarado's score is highly suggestive. No particular investigation confirms the diagnosis and US scan is very helpful in the diagnosis. So, there is always a chance of misdiagnosis and consequently, an unwanted surgery. In this context, conservative treatment has a definite role where there is a doubt in confirming acute appendicitis. The main pitfall of conservative treatment is high recurrence rate; not to forget about the concurrent complications. I totally agree with Dr. Goran regarding the difficulty of performing Lap appendectomy in a recurrent case due to intense adhesion and sometimes confronted with sloughed-off tiny appendix. Many times you have to convert it into open appendectomy with longer hospital stay and sometimes with added complications of surgery. My opinion is to perform appendectomy if you are sure of acute appendicitis as it gives a 100% cure and conservative treatment should be reserved when appendectomy is not feasible logistically (not so uncommon in some third world countries due to lack of proper surgical care in rural areas) or if we are unsure about is progression into an appendicular lump which generally occurs if patients come late for the treatment (again not so uncommon in some third world countries).
Until that time arrives when we can diagnose 1. the etiology of appendicitis with certainty then 2. selectively classify it as medically curable then and only then we may defer surgery. Appendectomy is the gold standard because the morbidity is negligible in capable hands and you do not gamble with a patients well being. By pathophysiology, inflammation of the appendix from whatever etiology will generate obstruction of the lumen. Spontaneously the monodirectional peristalsis of the appendix will try to drain hence propel the obstructing etiology. If successful the appendicitis will subside. If it is inflammatory and the (e.g.) abscess drains into the lumen the appendicitis will subside. If it is not successful it will still look for a drainage exit. With an obstruction of the lumen, the inflammation will spread murally, reach the peritoneal surface and eventually perforate. In the initial phase when there is mural inflammation there may only be mesenteric symptoms like anorexia, nausea, epigastric discomfort. Is there anyone out there who can diagnose appendicitis at this time? Hardly! When the appendix is trying to expel the obstruction there will be colicky abdominal pain. Early on the WBC , US, and CT Scan will be negative ( but who will request a CT at this time?). When the inflammation is spreading murally (depending upon whether early or late) the WBC may start to elevate (except those with relative Addison's like the aged). The US is negative but the CT nay show thickened appendiceal wall. If the inflammation continues and the serosa is reached there may be peritoneal irritation and the rebound tenderness will become apparent. US may be positive only if there is substantially detectable periappendiceal phlegmon. If perforation does not occur the appendicitis can still resolve if the obstruction of the lumen is overcome by drainage or expulsion . So, the challenge to appendectomy lies with the diagnostician's ability to define a medical or surgical appendicitis and to decide when to or not to operate after a meaningful H&P.I have operated on patients with toothpicks, fishbone, carcinoid, intussuscepted appendix, cecal bascule, appendiceal polyp, etc,etc... Antibiotics would have been a joke. .So, to all of you with the pragmatic consequence who opt for appendectomy, " a feather in each of your caps".
My opinion written here on Resesearchgate are published as a 'Your View' in the British Journal of Surgery as a comment on the article by Sallinen et al.
http://www.bjs.co.uk/details/yourviews/9193551/Metaanalysis-of-antibiotics-versus-appendicectomy-for-nonperforated-acute-append.html
Who can diagnose Acute appendicitis with certainty? More importantly what is the etiology of the presumed appendicitis? Infection? Obstruction? What? If you can be very certain that the cause of the appendicitis is infection, then by all means try antibiotics, but, if you are not certain then it is best to perform appendectomy!
In my opinion it is a dangerous decision to discharge a young patient with antibiotic therapy for uncomplicated acute appendicitis. May be next day the patient will be far away from a hospital, with a generalized peritonitis or in a place where a laparoscopic appendectomy cannot be performed.
So, I think that laparoscopic appendectomy with one or two days hospital stay will solve forever the acute appendicitis, with no further medical presentations for this problem.
Treatment of a Diagnosed case of Acute appendicitis should be appendicectomy