Appendicitis

Diagnosis and imaging. Classic acute appendicitis (pain migration to RLQ, McBurney's point tenderness, elevated WBC/CRP, short symptom duration) can proceed directly to laparoscopic appendectomy without imaging . Symptom duration >24–36 hours warrants ultrasound first; if non-diagnostic but concerning, proceed to CT; if diagnostic, CT is unnecessary [e314-c3, e314-c4]. CT at 4 days without secondary signs makes appendicitis unlikely . Clinical prediction models (Shira score: AUC 0.84, 3% failure rate) and standardized ultrasound reporting (equivocal reports 27%→9%, CT use 19%→9%) improve diagnostic accuracy [e4416-c2, e4416-c3, e4416-c4]. Perforation definition and outcomes. Strict perforation criteria—visible hole or fecalith in abdomen—are essential; inter-observer agreement without defined criteria is only 25–27% [e314-c16, e314-c18, e3934-c2]. Non-perforation abscess rate <5% with strict definition; perforation abscess rate consistently 15–20% [e3934-c5, e314-c30]. Four intraoperative findings predict complicated course: hole, abscess, fecal material, diffuse fibrinopurulent exudate beyond RLQ/pelvis [e4416-c9, e4416-c10]. Irrigation trials show conflicting results: large RCT (n=220) found no difference in 18–19% abscess rates with/without irrigation; smaller study with standardized high-volume irrigation (3–12L) showed 0% vs 19% abscess rate [e3934-c7, e3934-c9]. Meta-analysis found no difference . Antibiotic management. Ceftriaxone (50 mg/kg) + metronidazole (30 mg/kg) once daily is cost-effective, non-inferior to triple therapy, and facilitates home health transitions [e314-c7, e314-c8, e314-c9, e314-c11]. Non-perforated cases receive single preoperative dose only . For perforation, 5-day IV protocol with discharge if afebrile, normal WBC, tolerating diet; early discharge with oral Augmentin to complete 7 days shows no difference in abscess rate, with 40% discharged before day 5 [e314-c41, e314-c44, e314-c45]. One RCT (n=243) found two postoperative antibiotic doses reduced SSI from 6.6%→0.8% in simple appendicitis, though baseline rate seems high and abscess rates were not examined [e4416-c12, e4416-c13, e4416-c14]. Ceftriaxone+metronidazole showed 90% SSI reduction vs cefoxitin in large NSQIP cohort . Operative approach and recovery. Single-incision vs three-port laparoscopy (RCT n=360) showed no difference in wound infection (3.3% vs 1.7%), diet tolerance, LOS, or return to activity; single-incision had 5-minute longer OR time, more narcotics, greater difficulty, higher charges [e314-c22, e314-c23, e314-c24, e314-c25]. Same-day discharge for non-perforation (>100 patients, <6 hours postop) uses local anesthesia, no postoperative antibiotics [e314-c19, e314-c20]. Interval appendectomy at 8–10 weeks after non-operative abscess management is easier than early operation through inflammation; immediate vs interval appendectomy (n=40) showed no difference in total LOS, abscess rates, or charges, though immediate took longer (61 vs 42 min) [e314-c48, e314-c49, e314-c50, e314-c51, e314-c52, e314-c53]. Pain management. Wide variability exists in opioid prescribing (6–70% of surgeons prescribe, duration 1 day–1 month); patients receiving opioids presented to ED 3× more often [e1326-c6, e1326-c7, e1326-c8, e1326-c9]. Pre-post intervention eliminating opioids for non-perforation showed no increase in pain or medication requests [e4416-c15, e4416-c16]. 80% of adolescent recreational opioid use comes from leftover prescriptions . Non-operative management. Pilot RCT (n=50) showed 0% surgical failure vs 45% medical failure (defined as requiring appendectomy) [e4416-c5, e4416-c6]. Adult data suggest 50–60% could be managed non-operatively; pediatric trials ongoing [e314-c54, e314-c56, e314-c57]. Without interval appendectomy, ~10% recurrence at 1–1.5 years; 25–30 year follow-up needed to assess late recurrence risk from scarring/closed-loop obstruction [e314-c62, e314-c59, e314-c60]. Current data insufficient to justify routine non-operative approach when same-day surgery is feasible .