Medical Management of Appendicitis? Not so fast

Adapted from Saud Siddiqui's Grand Rounds Lecture

Leonid Rogozov removing his own appendix in 1961 during an Antarctic Expedition. 

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Some patients with acute appendicitis have been treated with medical management instead of surgical removal. Those with non-complicated appendicitis may be eligible for antibiotic therapy, however those treated with antibiotics have an increased rate of recurrence and peritonitis. Those treated with antibiotics who later require surgery have worse outcomes than those who were treated primarily with surgery. 

A JAMA article from June 16, 2015 showed poor outcomes among medically managed patients. Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for non-inferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the l-year follow-up period, and those who required appendectomy did not experience significant complications

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Who could potentially be treated medically? 

Most studies evaluating medical management of appendicitis excluded those with perforations, abscess, intraperitoneal fluid or appendicolithis, as well as those <15 or >60 years of age. 

Those not excluded per above and with uncomplicated appendicitis may be considered for medical management. 

Cochrane Review

A Cochrane review evaluated multiple RCTs to investigate whether antibiotic therapy was as effective as surgical removal in uncomplicated appendicitis. The Cochrane review used primary endpoints as cure within two weeks without major complications within one year. The review was unable to conclude whether antibiotic treatment is or not inferior to appendectomy, and because of the low quality of the trials, the review identified surgical treatment as the standard of care for acute appendicitis.