Treatment: Primary
Early, acute, non-perforated appendicitis is treated with emergent appendectomy, which may be performed via laparoscopy. Antibiotics do not alter the natural history of early acute appendicitis, and have no role in its primary treatment.
A perforated appendicitis with adjacent free pelvic fluid, a periappendiceal phlegmon (i.e., an indurated soft tissue mass without drainable pus), or a relatively small periappendiceal abscess may be conservatively managed with antibiotic therapy followed by appendectomy at a later time through a non-infected surgical field (11). A localized abscess or phlegmon not improving with antibiotic therapy within 12 to 24 hours should be treated with appendectomy and intraoperative abscess drainage (5 ).
A large or well-defined localized periappendiceal abscess may be treated with percutaneous imaging-guided drainage and intravenous antibiotics, with elective appendectomy performed 6 - 8 weeks later (12,31,32). A deep pelvic abscess may be transrectally drained under ultrasound guidance(33).
With percutaneous abscess drainage and intravenous antibiotic therapy, the patient is expected to demonstrate clinical improvement within 12 to 24 hours, indicated by lower fever spikes, decrease in leukocytosis, and improvement in abdominal tenderness. If the patient fails to show these signs of improvement, a repeat CT examination should be considered to evaluate for residual, undrained abscesses. Otherwise, an exploratory laparotomy and appendectomy is indicated.
Within the surgical literature, there is controversy regarding the appropriate timing of appendectomy in patients with periappendiceal inflammatory masses or abscesses. Opponents of elective appendectomy after percutaneous drainage and intravenous antibiotic therapy argue that the inflammatory changes involving the cecum and surrounding bowel can result in greater difficulty and time required for the procedure as well as increased risk of blood loss and bowel injury (5). Surgeons supporting elective appendectomy after the above described treatment regimen disagree. The superiority of either method of treatment has not been convincingly demonstrated in the surgical literature (5).
Generalized peritonitis requires intravenous hydration and correction of electrolyte disturbances as well as antibiotic therapy prior to exploratory laparotomy and appendectomy (34).
In neonates, Hirschsprung's disease can be the cause of appendicitis. In this age group, rectal biopsy with frozen section analysis should be performed intraoperatively at the time of appendectomy. Colostomy at the level of ganglion cell transition can be performed at that time if the biopsy proves positive (5).
Treatment: Postoperative Complications
Abscesses may also occur within the pelvis, subphrenic, or subhepatic spaces. These may be treated with percutaneous imaging-guided drainage procedures and broad-spectrum antibiotics.
Prolonged paralytic ileus often follows generalized peritonitis and may be aggravated by premature attempts at oral feeding.
Intestinal obstruction occurring within the first 30 postoperative days is treated with non-operative management. Intestinal obstruction occurring after the first 30 postoperative days may require surgery.
Fallopian tube obstruction with associated impaired fertility may require subsequent tuboplasty.