Management of acute uncomplicated appendicitis in adults: antibiotics versus appendicectomy

Abstract

Introduction: Acute appendicitis is the most prevalent abdominal surgical emergency in the United States. The diagnosis is based on clinical and laboratory and imaging findings. Appendectomy is the gold standard treatment of acute appendicitis, which carries a high cost and involves a high risk of surgical and anesthesia complications, that is the reason why, in recent studies the use of antibiotic therapy has been considered as a non-invasive medical management strategy for noncomplicated acute appendicitis. Objective: To describe the most sensitive diagnostic strategies, to differentiate complicated from non-complicated appendicitis, and to compare the effectiveness of medical management versus surgical management for noncomplicated acute appendicitis in adults, in terms of recurrence rate and complications associated with management.

Materials and methods: A qualitative descriptive study of bibliographic review of articles obtained from the databases of Pub Med, Google Scholar and Science Direct, using the descriptors "appendicitis" AND "diagnostic" AND "antibiotics". Ninety articles including clinical trials, case studies, literature reviews, and observational studies were obtained. Articles based on the pediatric population were excluded, articles selected were published between 2015 and 2020, in English and Spanish, and used at least two diagnostic tests, and compared antibiotic therapy vs. appendectomy. Finally, 26 articles were obtained as reference for this review. Results: The predominant diagnostic method is clinical, in association with the following positive signs: Mac Burney, Rovsing and Psoas sign. The diagnostic imaging methods, with the higher sensitivity include the computerized axial tomography and magnetic resonance imaging, the Score with the highest sensitivity and specificity is the RIPASA Score. The most widely used antibiotic regimen is intravenous ertapenem (1g/daily), for three days, followed by oral antibiotic therapy for seven days with levofloxacin (500 mg/daily) and metronidazole (500 mg/every eight hours). The use of antibiotics as management therapy of uncomplicated acute appendicitis is effective and safe; it has shown to be not inferior compared to surgical management; however, the results on a decrease in complications and therapeutic failure are controversial.  The ideal patient to undergo this therapy is one with a low risk for complications, so all patients with a clinical history of complicated appendicitis, or who are chronically using steroids or anticoagulants or those associated with comorbidities such as diabetes mellitus, acute coronary syndrome, heart, kidney or liver failure, should be excluded. The results should be interpreted with caution because of the lack of level 1 evidence studies.  Conclusions: In most of the studies analyzed, it is concluded that appendectomy remains the therapeutic method of choice; however conservative management is an alternative that is not inferior to invasive treatment and can be offered as an option.