A pleasant, intelligent, fit 75-year- old lady presented with acute ruptured appendicitis to Caro- linas Medical Center USA in March of 2012. She was not taken to the OR, but admitted and given appropriate IV antibiotics for a week in the hospital, followed by an additional ten days of PO antibiotics, much like a case of moderate diverticulitis. She recovered successfully and even reported hiking, horseback riding and traveling as usual.
Six months later, on the 23rd of September, 2012, she presented to Aiken Regional Medical Center Emergency Department with acute appendicitis clinically, visualized by CT and confirmed in the operating suite.
This woman presented with the chief com- plaint of right lower quadrant abdominal pain for 24 hours. Pain was epigastric and mi- gratory the day before she decided to be driven by her husband to the hospital; and oddly subjective fever at onset of pain, resolved that first night. The next morning pain increased, “worse than when my appendix ruptured six months ago,” and localized to McBurney’s point. Walking exacerbated the pain. There was no back pain, nor genitourinary symptoms. She was anorexic but had no vomiting diarrhea nor complaint of constipation.
Past history revealed medical hypothyroidism, hypertension, lipidemia, prior hip surgery, and a D&C. She has no cardiopulmonary nor cerebrovascular nor malignancy or diabetes historically.
Meds were levothyroxine, a beta-blocker with hctz, pravastatin & an OTC multivitamin. There are NKDA.
Physical Exam: Stoic, cautious ambulation, RLQ abdominal tenderness with positive Rovsing’s sign. CT without contrast was ordered prior to labs, and she was kept NPO.
Radiology Imaging: “Significant inflammatory changes surround the cecum with the appendix swollen measuring up to 12 mm consistent with acute appendicitis ... with significant periappendiceal stranding... No complication such as abscess fluid collection or free air perforation.”
Surgical Findings: “Laparoscopic appendectomy... General endotracheal... There was thickening of the small bowel and cecum ... with densely adherent appendix lying up against the ileum.”
Post Operative Course: She was discharged the following day, and is doing well at home now on post op day #2. And she is doing well post-operatively long-term.
Pathology Report: Acute Appendicitis
This patient being our first encounter with non-operative medical therapy for appendicitis in the United States, our South Carolina community hospital medical staff was fascinated enough to submit this case for discussion of the history and pros and cons of nonoperative vs. traditional conservative surgery or acute appendicitis.
As a deputy ambassador representing the American College of Emergency Physicians International Section, and volunteering Medical Officer on the Operation Mobilization Ship Logos Hope in the Philippines earlier this year, I was privileged o meet the Chief of Surgery responsible for training residents at Saint Lukes Medical Center in Manilla. This was the first time I learned of non-operative treatment for acute appendicitis. I was informed that his practice of prolonged IV and PO antibiotics instead of surgery was based on French surgical literature.
The French Ministry of Health, Programme Hospitalier de Recherche clinique, published a Lancet article which states, “researchers have suggested that antibiotics could cure acute appendicitis. We assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendicectomy for treatment of patients with uncomplicated acute appendicitis.” Adults between the ages of 18 and 68 with uncomplicated acute appendicitis – as accessed by CT – were enrolled in six university hospitals in France. Of essentially 240 patients, approximately 120 were randomized to receive amoxicillin-clavulanate 3 grams daily (Unasyn for 8-15 days). The other 120 were allocated to undergo prompt appendectomy.
Of 120 patients treated with Unasyn nonoperatively, 44 (one third) were taken to the operating room for appendectomy within the first year, 14 (about 10%) of these within the first month (1).
In another randomized clinical trial, this time published in the British Journal of Surgery, 202 patients were allocated to 24 hours IV antibiotics followed by ten days PO home antibiotics. Only half (52%) completed medical treatment; the other half had surgery. Of nonoperative patients, 14% (15/106) developed acute appendicitis within sixteen months (2).
In an American study by Kaminski et al, 32,938 cases of appendicitis, all hospitalized, were assessed. Seven percent were abscessed, 18% had peritonitis, and 75% had uncomplicated appendicitis. Emergency appendectomy was done in 31,926, or 97% of patients.
Three percent, or 1012 people, did not go to surgery, but were treated medically. Of these, 148 (15%) had interval appendectomy and another 39 people needed appendectomy within 4 years (3).
According to a meta-analysis on Antibiotic therapy versus appendectomy for acute appendicitis published in the World Journal of Surgery in 2010, “Antibiotic treatment has been shown to be effective in treating selected patients with acute appendicitis, and three randomized controlled trials (RCTs) have compared the efficacy of antibiotic therapy alone with that of surgery for acute appendicitis. The purpose of this meta-analysis of RCTs was to assess the outcomes with these two therapeutic modalities” in adults over 18 years old. Children and patients suspected of perforation or peritonitis preoperatively were excluded in these 3 RCTs.
Of 350 patients treated with antibiotics only 200 remained asymptomatic after one year without re-hospitalization or surgery. 150 people received operative appendectomy or were re-admitted. Of these 150 patients, 38 who were re-hospitalized resolved their appendicitis with a second round of antibiotics without surgery and112 underwent appendectomy (4).
While the authors of this meta-analysis did not personally experiment with nonoperative medical treatment for their patients with appendicitis, their conclusion was “This meta-analysis suggests that although antibiotics may be used as primary treatment for selected patients with suspected uncomplicated appendicitis, this is unlikely to supersede appendectomy at present. Selection bias and crossover to surgery in the Randomized Controlled Trials suggest that appendectomy is still the gold standard therapy for acute appendicitis.”
Up To Date in August 2012 references 78 articles on the subject of acute appendicitis in adults. Only four of these 78 articles studied nonoperative treatment, and three of these (sited above) were done outside the United States. Neither of the articles intentionally included nonsurgical medical therapy of perforated appendicitis.
Uncomplicated appendicitis is distinct from perforated appendix. In the above French study 18% (21 of 119) of patients with simple appendicitis by CT images were found to be perforated at surgery.
During internship I was taught that with an adult’s inflamed appendix, 48% rupture in 48 hours. Swenson’s Text of Pediatric Surgery reported 85% of children with appendicitis were already perforated at the time of diagnosis. Abscess or phlegmon with appendiceal mass, and free (vs localized) peritonitis are further distinctions. This perhaps was a factor in the decision not to operate on our patient, when she originally presented. Delayed or nonoperative therapy of walled off abscess or phlegmon of the perforated appendix is supported by literature.
In a Swedish study of nonsurgical treatment of appendiceal abscess, abscess occurrence was reported in 4% of 61 studies of case series of appendicitis. 20% required drainage.Risk of recurrent appendicitis in patients treated nonsurgically was 7% (5).
Up To Date concludes that “The great majority of patients with acute appendicitis are treated surgically and an appendectomy remains the gold standard of care. As illustrated in the following randomized trials, some patients respond to medical therapy with antibiotics alone but are at appreciable risk for recurrent disease.”
John C. McDonald MD, former Chair of Surgery at Louisiana State University in Shreveport, made a comment appropriate to this discussion, and relevant to our patient. “Sometimes doctors use the term conservative inappropriately. Conservative therapy is not synonymous with non-surgical. There are times when conservative care is to operate.”
Carcinoid and other tumors of the appendix are not discussed.
Appendiceal obstruction by parasites is not included in this discussion.
Appendicitis in third trimester pregnancy also is not discussed.
Endometriosis of the visceral peritoneum of the appendix, for example in a young lady at Manilla Doctors’ Hospital in 2007, can be a rare cause of appendicitis.
Not all hospitals in Manilla treat appendicitis nonoperatively.
This article originally appeared in issue 10 of Emergency Physicians International