Surgery
Published October 18, 2025 | Version v1
Journal article Open

Conservative treatment for acute appendicitis

Authors/Creators

  • 1. University Hospital Saint Anna

Description

INTRODUCTION: The exact clinical diagnosis of acute appendicitis is often a challenge, requiring a synthesis of the clinical picture and data from laboratory and imaging studies. At the same time, the presumed pathological phase of the inflammation can significantly determine the treatment strategy and tactics. There are two primary forms of the disease: uncomplicated and complicated. Complicated appendicitis refers to all patients with a gangrenous appendix, with or without perforation, and with evidence of peritonitis, an abscess, or a peri appendicular phlegmon.
DISCUSSION: There are significant differences among national, European, and intercontinental consensus guidelines regarding the diagnosis and treatment of acute appendicitis. Appendectomy is the "Gold Standard" of treatment and when there presents advanced laparoscopic expertise the laparoscopic appendectomy is recommended. Conservative treatment with antibiotics is a subject of increasing interest as an alternative to the standard operative surgical approach. Recent studies conclude that most patients with uncomplicated appendicitis can be initially treated conservatively. In complicated forms with a peri appendicular abscess or phlegmon, some authors again advocate for a non-operative initial approach, while others recommend aggressive operative management. A subject of debate in these cases remains the necessity of interval appendectomy after eventual success of the non-operative treatment. There is a lack of definitive consensus on the optimal antibiotic regimen and the duration of treatment. Additional aspects of the conservative treatment are the pre-operative therapyq as well as the post-operative one, particularly in complicated cases.
CONCLUSIONS: The main factors in taking the decision for conservative approach are three: In-depth discussion with the patient, adequate patient selection, and dynamic observation of the development of the disease.  Conservative treatment with antibiotics is a viable method for selected patients with uncomplicated acute appendicitis. Initial conservative treatment for peri appendicular abscess is the preferred choice of treatment. Appendectomy remains the gold standard in the treatment of acute appendicitis due to its higher long-term effectiveness. Additional studies and evaluation of long-term outcomes in conservative treatment are needed to optimize patient selection criteria and the antibiotics regimen.

Abstract (Bulgarian)

ВЪВЕДЕНИЕ: Екзактната клинична диагноза на острия апендицит често е предизвикателство, което налага обобщаването на клиничната картина и данните от лабораторните и образните изследвания. В същото време предполагаемата патолого-анатомична фаза на развитие на възпалението в значителна степен може да определи лечебната стратегия и тактика. Съществуват две клинични форми на заболяването- неусложнена и усложнена.  Усложненият апендицит включва случаите при които е налице гангренозно възпаление, с или без данни за периапендикуларен флегмон, перфорация, перитонит или абсцес. 
ДИСКУСИЯ: Съществуват значителни различия за поведението при острия апендицит между националните, европейските и интерконтиненталните консенсуси. Апендектомията е „Златен стандарт“ на лечение, а когато е налична напреднала лапароскопска експертиза е препоръчителна лапароскопската апендектомия. Консервативното лечение чрез антибиотици е обект на нарастващ интерес като алтернатива на стандартния оперативен подход. Последните проучвания показват, че голяма част от пациентите с неусложнен апендицит могат първоначално да бъдат лекувани консервативно. При усложнените форми на остър апендицит някои автори отново се застъпват за начален неоперативен подход, докато други препоръчват агресивно оперативно поведение. Обект на дебат в тези случаи остава и необходимостта от интервална апендектомия след евентуален успех от неоперативното лечение. Липсва категоричен консенсус за оптимална антибиотична схема и продължителността на лечението. Допълнителни аспекти на консервативното лечение са предоперативната терапия, както и следоперативната такава, особено при усложнените форми.
ИЗВОДИ: Основните фактори за вземането на решение за консервативен подход са три:  Задълбочена дискусия с пациента, адекватна селекция и динамично наблюдение на развитието на заболяването. Консервативното лечение чрез антибиотици е приложим метод за лечение при селектирани пациенти с некомплициран остър апендицит. Първоначалното консервативно лечение при уложнените форми е препоръчителен подход. Апендектомията е златен стандарт с висока и дългосрочна ефективност при лечението на острия апендицит. Необходими са допълнителни проучвания и оценка на дългосрочните резултати от консервативното лечение за да се оптимизират критериите за селекция на пациентите и антибиотичните схеми. 

Files

surgery-v89i3-5.pdf

Files (285.9 kB)

Name Size Download all
md5:28923251069cbc72bc189af4bfed6800
285.9 kB Preview Download

Additional details

Additional titles

Translated title (Bulgarian)
Консервативно лечение при остър апендицит

Identifiers

ISSN
3033-151X
URL
https://bgss.eu/index.php/surgery/article/view/56

Dates

Issued
2025-10-19

References

  • 1.Andersson R, Hugander A, Thulin A, Nyström PO, Olaison G. Indications for operation in suspected appendicitis and incidence of perforation. BMJ. 1994;308:107–110. doi: 10.1136/bmj.308.6921.107.
  • 2.Basoli A, Zarba Meli E, Salvio A, Crovaro M, Scopelliti G, Mazzocchi P, Lomanto D, Fiocca F, Speranza V. Trends in the incidence of acute appendicitis in Italy during the past 30 years. Minerva Chir. 1993;48:127–132.
  • 3.Elangovan S, Knapp DP, Kallail KJ. Incidence of acute appendicitis confirmed by histopathologic diagnosis. Kans Med. 1997;98:10–13.
  • 4.Ilves I, Fagerström A, Herzig KH, Juvonen P, Miettinen P, Paajanen H. Seasonal variations of acute appendicitis and nonspecific abdominal pain in Finland. World J Gastroenterol. 2014;20:4037–4042. doi: 10.3748/wjg.v20.i14.4037.
  • 5.Viniol A, Keunecke C, Biroga T, Stadje R, Dornieden K, Bösner S, Donner-Banzhoff N, Haasenritter J, Becker A. Studies of the symptom abdominal pain—a systematic review and meta-analysis. Fam Pract. 2014;31:517–529. doi: 10.1093/fampra/cmu036.
  • 6.Wei PL, Chen CS, Keller JJ, Lin HC. Monthly variation in acute appendicitis incidence: a 10-year nationwide population-based study. J Surg Res. 2012;178:670–676. doi: 10.1016/j.jss.2012.06.034.
  • 7.Livingston EH, Woodward WA, Sarosi GA, et al. Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg. 2007;245:886–92.
  • 8.Jaschinski T, Mosch C, Eikermann M, et al. Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC Gastroenterol. 2015;15:48.
  • 9. Yu M-C, Feng Y, Wang W, et al. Is laparoscopic appendectomy analysis. Int J Surg. 2017;40:187–97.
  • 10. Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg. 2009;96:473–481. doi: 10.1002/bjs.6482.
  • 11. Eriksson S, Granstrom L. Randomized clinical trial of appendectomy versus antibiotic therapy for acute appendicitis. Br J Surg. 1995;82:166–169. doi: 10.1002/bjs.1800820207.
  • 12.Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, Rex L, Badume I, Granstrom L. Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicentre randomized controlled trial. World J Surg. 2006;30:1033–1037. doi: 10.1007/s00268-005-0304-6.
  • 13. Malik AA, Bari S. Conservative management of acute appendicitis. J Gastrointest Surg. 2009;13:966–970. doi: 10.1007/s11605-009-0835-5.
  • 14.Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, Karoui M, Alves A, Dousset B, Valleus P, Falissard B, Franco D. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis. An open label, non-inferiority, randomised controlled trial. Lancet. 2011;377:1573–1579. doi: 10.1016/S0140-6736(11)60410-8.
  • 15.Wilms IMHA, de Hoog DENM, de Visser DC, Janzing HMJ. Appendectomy versus antibiotic treatment for acute appendicitis (review) Cochrane Database Syst Rev. 2011 doi: 10.1002/14651858.CD008359.pub2.
  • 16.Svensson JF, Hall NJ, Eaton S, Pierro A, Wester T. A review of conservative treatment of acute appendicitis. Eur J Pediatr Surg. 2012;22:185–194. doi: 10.1055/s-0032-1320014.
  • 17.Mason RJ, Moazzez A, Sohn H, Katkhouda N. Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis. Surg Infect (Larchmt) 2012;13:74–84. doi: 10.1089/sur.2011.058.
  • 18.Kirby A, Hobson RP, Burke D, Cleveland V, Ford G, West RM. Appendicectomy for suspected uncomplicated appendicitis is associated with fewer complications than conservative antibiotic management: a meta-analysis of post-intervention complications. J Infect. 2015;70:105–110. doi: 10.1016/j.jinf.2014.08.009.
  • 19.Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta analysis of randomised controlled trials. BMJ. 2012 doi: 10.1136/bmj.e2156.
  • 20.Ansaloni L, Catena F, Coccolini F, Ercolani G, Gazzotti F, Pasqualini E, Pinna AD. Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials. Dig Surg. 2011;28:210–221. doi: 10.1159/000324595.
  • 21.Liu K, Fogg L. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis. Surgery. 2011;150:673–683. doi: 10.1016/j.surg.2011.08.018.
  • 22.Podda M, Gerardi C, Cillara N, et al. Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: a systematic review and meta-analysis. Ann Surg. 2019;270:1028–40.
  • 23.Sallinen V, Akl EA, You JJ, et al. Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg. 2016;103:656–67.
  • 24.Huston JM, Kao LS, Chang PK, et al. Antibiotics vs. appendectomy for acute uncomplicated appendicitis in adults: review of the evidence and future directions. Surg Infect. 2017;18:527–35.
  • 25.Harnoss JC, Zelienka I, Probst P, et al. Antibiotics versus surgical therapy for uncomplicated appendicitis: systematic review and meta-analysis of controlled trials (PROSPERO 2015). Ann Surg. 2017;265:889–900.
  • 26.Hansson J, Khorram-Manesh A, Alwindawe A, et al. A model to select patients who may benefit from antibiotic therapy as the first line treatment of acute appendicitis at high probability. J Gastrointest Surg. 2014;18:961–7.
  • 27.Loftus TJ, Brakenridge SC, Croft CA, et al. Successful nonoperative management of uncomplicated appendicitis: predictors and outcomes. J Surg Res. 2018;222:212–218.e2.
  • 28.Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320:1259.
  • 29.Singh JP, Mariadason JG. Role of the faecolith in modern-day appendicitis. Ann R Coll Surg Engl. 2013;95:48–51.
  • 30.Mällinen J, Vaarala S, Mäkinen M, et al. Appendicolith appendicitis is clinically complicated acute appendicitis—is it histopathologically different from uncomplicated acute appendicitis. Int J Colorectal Dis. 2019;34:1393–400.
  • 31. Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020 Apr 15;15(1):27. doi: 10.1186/s13017-020-00306-3. PMID: 32295644; PMCID: PMC7386163.
  • 32. Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2017;12:29.
  • 33. Haijanen J, Sippola S, et al. on behalf of the APPAC study group, Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial). BMC Surg. 2018;18:117.
  • 34.Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg. 2007;246:741–8.4
  • 35. Simillis C, Symeonides P, Shorthouse AJ, et al. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery. 2010;147:818–29.
  • 36. Helling TS, Soltys DF, Seals S. Operative versus non-operative management in the care of patients with complicated appendicitis. Am J Surg. 2017;214:1195–200.
  • 37. Kim JK, Ryoo S, Oh HK, Kim JS, Shin R, Choe EK, Jeong SY, Park KJ. Management of appendicitis presenting with abscess or mass. J Korean Soc Coloproctol. 2010;26:413–419. doi: 10.3393/jksc.2010.26.6.413.
  • 38.Deelder JD, Richir MC, Schoorl T, Schreurs WH. How to treat an appendiceal inflammatory mass: operatively or nonoperatively? J Gastrointest Surg. 2014;18:641–645. doi: 10.1007/s11605-014-2460-1.
  • 39. Gorter RR, Eker HH, Gorter-Stam MA, Abis GS, Acharya A, Ankersmit M, Antoniou SA, Arolfo S, Babic B, Boni L, Bruntink M, van Dam DA, Defoort B, Deijen CL, DeLacy FB, Go PM, Harmsen AM, van den Helder RS, Iordache F, Ket JC, Muysoms FE, Ozmen MM, Papoulas M, Rhodes M, Straatman J, Tenhagen M, Turrado V, Vereczkei A, Vilallonga R, Deelder JD, Bonjer J. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016 Nov;30(11):4668-4690. doi: 10.1007/s00464-016-5245-7. Epub 2016 Sep 22. PMID: 27660247; PMCID: PMC5082605.
  • 40.Hall NJ, Jones CE, Eaton S, Stanton MP, Burge DM. Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J Pediatr Surg. 2011;46:767–771. doi: 10.1016/j.jpedsurg.2011.01.019.
  • 41. Darwazeh G, Cunningham SC, Kowdley GC. A systematic review of perforated appendicitis and phlegmon: interval appendectomy or wait-and-see? Am Surg. 2016;82:11–5.
  • 42. Rushing A, Bugaev N, Jones C, et al. Management of acute appendicitis in adults: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;87:214–24.
  • 43.Hall NJ, Eaton S, Stanton MP, et al. Active observation versus interval appendicectomy after successful non-operative treatment of an appendix mass in children (CHINA study): an open-label, randomised controlled trial. Lancet Gastroenterol Hepatol. 2017;2:253–60.
  • 44. Renteria O, Shahid Z, Huerta S. Outcomes of appendectomy in elderly veteran patients. Surgery. 2018;164:460–5.
  • 45. de Jonge J, Bolmers MDM, Musters GD, et al. Predictors for interval appendectomy in non-operatively treated complicated appendicitis. Int J Colorectal Dis. 2019;34:1325–32.
  • 46.Coakley B, Sussman E, Wolfson T, Bhagavath A, Choi J, Ranasinghe N, Lynn E, Divino C. Postoperative antibiotics correlate with worse outcomes after appendectomy for nonperforated appendicitis. J Am Coll Surg. 2011;213:778–783. doi: 10.1016/j.jamcollsurg.2011.08.018.
  • 47.van Rossem CC, Schreinemacher M, Treskes K, Hogezand RM, Geloven AAW. Duration of antibiotic treatment after appendicectomy for acute complicated appendicitis. Br J Surg. 2014;101:715–719. doi: 10.1002/bjs.9481.
  • 48.Pinto DJ, Sanderson PJ. Rational use of antibiotic therapy after appendicectomy. Br J Surg. 1980;280:275–277. doi: 10.1136/bmj.280.6210.275.
  • 49.Ambrose NS, Donovan IA, Wise R, Lowe P. Metronidazole and ticarcillin in the prevention of sepsis after appendicectomy. Am J Surg. 1983;146:346–348. doi: 10.1016/0002-9610(83)90413-0.
  • 50.Campbell WB. Prophylaxis of infection after appendicectomy: a survey of current surgical practice. BMJ. 1980;281:1597–1600. doi: 10.1136/bmj.281.6255.1597.
  • 51.Buckels JA, Brookstein R, Bonser R, Bullen B, Alexander-Williams J. A comparison of the prophylactic value of cefotetan and metronidazole appendectomy. World J Surg. 1985;9:814–818. doi: 10.1007/BF01655202.
  • 52.Nadler E, Reblock KK, Ford HR, Gaines BA. Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children. Surg Infect (Larchmt) 2003;4:327–333. doi: 10.1089/109629603322761382.
  • 53.Yu TC, Hamill JKM, Evans SM, Price NR, Morreau PN, Upadhyay VA, Ferguson RS, Best EJ, Hill AG. Duration of postoperative intravenous antibiotics in childhood complicated appendicitis: a propensity score-matched comparison study. Eur J Pediatr Surg. 2013;24:341–349. doi: 10.1055/s-0033-1349055.
  • 54.Lau WY, Fan ST, Yiu TF, Wong SH. Prophylaxis of post-appendicectomy sepsis by metronidazole and ampicillin: a randomized, prospective and double-blind trial. Br J Surg. 1983;70:155–157. doi: 10.1002/bjs.1800700306.
  • 55.Lau DHW, Yau KKK, Chung CC, Leung FCS, Tai YP, Li MKW. Comparison of needlescopic appendectomy versus conventional laparoscopic appendectomy: a randomized controlled trial. Surg Laparosc Endosc Percutan Techn. 2005;15:75–79. doi: 10.1097/01.sle.0000160290.78288.f4.