1. Home
  2. Appendicitis

Appendicitis

Acute Abdomen in the Modern Era

Author/s: 
Selwyn O Rogers Jr, Orlando C Kirton

Acute abdominal pain is one of the most common symptoms in patients presenting to the emergency department and accounts for 5 to 10% of all emergency department visits. Pathophysiological conditions that lead to surgical interventions in such patients are mainly gastrointestinal obstruction, hemorrhage, ischemia, and viscus perforation. Acute abdominal pain can be diffuse or localized (i.e., quadrant-based epigastric pain or pain in the right upper quadrant, left upper quadrant, right lower quadrant, or left lower quadrant)2,4,6 and is associated with but not limited to the following disease processes: perforated viscus, peptic ulcer disease, mesenteric ischemia, acute cholecystitis, appendicitis, diverticulitis, pancreatitis, and intraabdominal hemorrhage. The need for emergency general surgery is an independent risk factor for postoperative complications and death, indicating the severity of the condition. Therefore, timely diagnosis of acute abdominal emergencies is essential. From antiquity to modern times, medical students have been taught that the history and the physical examination are the central components in the evaluation of acute abdominal pain.

Keywords 
Abdomen acute abdomen diagnosis abdominal pain

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

Author/s: 
CODA Collaborative, Flum, David R., Davidson, Giana H., Monsell, Sarah E., Shapiro, Nathan I., Odom, Stephen R., Sanchez, Sabrina E., Drake, F.T., Fischkoff, Katherine, Johnson, Jeffrey, Patton, Joe H., Evans, Heather, Cuschieri, Joseph, Sabbatini, Amber K., Faine, Brett A., Skeete, Dionne A., Liang, Mike K., Sohn, Vance, McGrane, Karen", Matthew E., Chung, Bruce, Carter, Damien W., Ayoung-Chee, Patricia, Chiang, William, Rushing, Amy, Steinberg, Steven, Foster, Careen S., Schaetzel, Shaina M., Price, Thea P., Mandell, Kathrine A., Ferrigno, Lisa, Salzberg, Matthew, DeUgarte, Daniel A., Kaji, Amy H., Moran, Gregory J., Saltzman, Darin, Alam, Hasan B., Park, Pauline K., Kao, Lilian S., Thompson, Callie M., Self, Wesley H., Yu, Julianna T., Wiebusch, Abigail, Winchell, Robert J., Clark, Sunday, Krishnadasan, Anusha, Fannon, Erin, Lavallee, Danielle C., Comstock, Bryan A., Bizzell, Bonnie, Heagerty, Patrick J., Kessler, Larry G., Talan, David A.

BACKGROUND

Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis.

METHODS

We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life–5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith.

RESULTS

In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], −0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50).

CONCLUSIONS

For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.

Keywords 
antibiotics Appendicitis Appendectomy Antibiotic Therapy
Subscribe to Appendicitis