Durham, NC—Visiting the pharmacy to treat uncomplicated appendicitis instead of seeking surgery is becoming much more common.
A review article in JAMA points out that many recent studies have demonstrated that antibiotics work as well as surgery for most uncomplicated appendicitis cases. This is so much the case, according to Duke University School of Medicine–led authors, that the nonsurgical approach can now be considered a routine option.
The consensus of evidence suggests that antibiotics can successfully treat up to 70% of appendicitis cases; however, surgery, usually done laparoscopically, remains the definitive option for otherwise healthy patients with a severely inflamed appendix or other factors that increase the risk of rupture, according to the authors.
"Acute appendicitis is the most common abdominal surgical emergency in the world, striking about one in 1,000 adults," explained Theodore Pappas, MD, professor in the Department of Surgery at Duke University School of Medicine. "Until recently, the only treatment option was surgery, so having a non-surgical approach for many of these cases has significant impact for both patients and the health care system."
While Dr. Pappas said the criteria for determining the best treatment approach can be complex, the decision usually is not that difficult to make. Ultrasound and/or CT scans are used to confirm appendicitis cases, usually signaled by abdominal pain that migrates to the lower right side, nausea and vomiting, and low-grade fever.
If the scans reveal no complications, the authors advise that most of the patients could receive antibiotics instead of undergoing an appendectomy. Antibiotics could also be used as first-line therapy for patients who have severe symptoms that are older or have medical conditions that add risks to surgeries.
"We think it's going to be 60% to 70% of patients who are good candidates for consideration of antibiotics," Dr. Pappas stated. "A lot of people note that patient preferences can be brought into the decision, so it is important to provide the literature and educate the public."
The authors recommend surgical management in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy.
Antibiotics are not always a complete cure, however. In about 40% of cases, patients who recover from appendicitis after receiving antibiotics experience another episode and eventually need surgery.
"It's important to take into account every case and its unique context as we consider patient preferences," Dr. Pappas stated. "If someone presents with an appendicitis and they're attending their brother's wedding the next day, antibiotics may be a good option. If they have appendicitis and they are planning to head to rural Alaska next year, they might want to consider an appendectomy, given that the condition could recur."
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