Acute Appendicitis management

Definition

Acute appendicitis is inflammation of the vermiform appendix, usually resulting from luminal obstruction by a fecalith, lymphoid hyperplasia, foreign body, or, rarely, neoplasm. It is the most common surgical cause of acute abdominal pain and requires prompt diagnosis and management to prevent perforation and other complications.

Clinical Presentation

Symptoms

• Sudden onset abdominal pain, initially peri-umbilical and later migrating to the right iliac fossa

• Loss of appetite (anorexia)

• Nausea and vomiting, usually following the onset of pain

• Low-grade fever

• Constipation or occasionally diarrhea

• Abdominal bloating

Signs

• Right iliac fossa tenderness (McBurney’s point tenderness)

• Rebound tenderness

• Guarding and abdominal rigidity

• Localized peritonism

• Rovsing’s sign

• Psoas sign (retrocecal appendix)

• Obturator sign (pelvic appendix)

• Tachycardia

• Severe persistent abdominal pain

Special Populations

Children

• May present with diffuse abdominal pain, irritability, vomiting, and fever.

• Higher risk of perforation due to delayed diagnosis.

Elderly Patients

• Symptoms may be subtle with minimal fever or leukocytosis.

• Higher risk of perforation and mortality.

Pregnancy

• Pain may be displaced superiorly as gestation advances.

• Ultrasound is preferred initially; MRI may be considered when diagnosis remains uncertain.

Investigations

Laboratory Investigations

• Full Blood Picture (FBP)

• C-reactive protein (CRP) if available

• Urinalysis

• Pregnancy test in females of reproductive age

• Liver Function Tests (LFTs)

• Serum lipase/amylase (to exclude pancreatitis)

• Serum electrolytes, urea and creatinine

Imaging

• Abdominal Ultrasound (preferred initial imaging in children and pregnancy)

• Contrast-enhanced CT abdomen and pelvis (most accurate imaging modality in adults)

• MRI abdomen (if indicated during pregnancy)

Complications

• Appendiceal perforation

• Generalized peritonitis

• Appendicular abscess

• Appendicular mass (phlegmon)

• Sepsis

• Intestinal obstruction

• Septic shock

Non-Pharmacological Management

Initial Stabilization

• Nil per os (NPO)

• Intravenous fluid resuscitation

• Monitor vital signs

• Nasogastric tube if severe vomiting or bowel obstruction suspected

Definitive Treatment

• Appendectomy (laparoscopic or open) is the treatment of choice.

• Early surgical consultation is mandatory.

Appendicular Mass

• Conservative management (Ochsner-Sherren regimen) may be considered in selected stable patients.

• Interval appendectomy may be considered after resolution.

Appendicular Abscess

• Image-guided percutaneous drainage where available.

• Surgical drainage if percutaneous drainage is not feasible.

Pharmacological Management

Antibiotic Therapy (Pre-operative and Complicated Disease)

B: Ceftriaxone (IV) 1–2 g 24-hourly

AND

B: Metronidazole (IV) 500 mg 8-hourly

Continue for 24 hours after uncomplicated appendectomy or 4–7 days in perforated/complicated appendicitis according to clinical response.

Alternative Regimens (Complicated Appendicitis)

S: Piperacillin + Tazobactam (IV) 4.5 g 6–8 hourly

OR

S: Meropenem (IV) 1 g 8-hourly (severe sepsis or resistant organisms)

Analgesia

A: Paracetamol (IV/PO) 1 g 6-hourly when required

OR

A: Diclofenac (IM/PO) 75 mg 12-hourly when required (if no contraindication)

OR

A: Morphine (IV) titrated as required for severe pain

Referral

Refer urgently to a surgical unit for:

• Suspected acute appendicitis

• Signs of perforation or generalized peritonitis

• Appendicular abscess or mass

• Diagnostic uncertainty requiring advanced imaging or specialist assessment

Patient Education

• Seek medical attention immediately for worsening abdominal pain, persistent vomiting, or fever.

• Delay in treatment increases the risk of perforation and serious complications.

• Early appendectomy generally results in complete recovery with low complication rates.

Key Point

Acute appendicitis is a surgical emergency. Antibiotics are adjunctive therapy; definitive treatment is usually appendectomy.