Because acute appendicitis requires immediate surgery to prevent perforation, the diagnosis is made from clinical findings. Physicians look for a variety of signs and symptoms, such as migratory right lower quadrant pain and tenderness, anorexia, nausea/vomiting, fever >37.5°C and leukocytosis. With a high clinical suspicion, imaging studies are not required.
With a high clinical suspicion of acute appendicitis, imaging studies are not required. Due to the benefits of early treatment patients displaying migratory right lower quadrant pain, anorexia, nausea/vomiting, fever > 37.5°C and leukocytosis can be taken to the operating room without imaging. While further imaging is not required, many physicians will request a CT scan before surgery.
In patients with suspected appendicitis, immediate appendectomy is warranted to prevent perforation and the spread of bacteria throughout the peritoneum. An open (laparotomy) or laparoscopic approach may be used.
Before surgery, patients should not ingest anything by mouth to prevent vomiting and aspiration. Therefore, patients should receive IV fluids to maintain hydration and volume status.
IV fluids are administered in patients prior to surgery to maintain hemodynamic stability.
In patients with non-perforated appendicitis, pre-treatment with one dose of antibiotics is sufficient for infection control. Antibiotics should cover gram-negative and anaerobic organisms, with cephalosporins or ampicillin/sulbactam in combination with metronidazole as common regimens. There is no need for postoperative antibiotics in cases without perforation.
Tertiary wound healing or intention, also known as delayed primary closure, is a technique where the surgical wound is left open after surgery for a couple of days, and then sutured closed when no signs of infection develop. Historically this has been the preferred technique over primary closure, where the wound is sutured closed immediately after surgery. However, more recent studies have refuted this, showing that primary closure may reduce hospital stays without increasing the risk of post-op infection. No definite technique appears to be preferred since studies have differed based on factors like antibiotic use and statistical significance. Overall, heavily contaminated wounds are likely to do better healing by tertiary intention, while more routine cases should take into consideration the current literature and risks/benefits reported.
Patients with a perforated appendix should receive antibiotics until they are no longer febrile. At first, broad spectrum antibiotics that cover gram-negative rods and anaerobes should be used. Antibiotics may be modified pending culture results.
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