Appendicitis: Management & Prognosis

00:01 So, we've gotten our lab work, we've gotten our imaging study, and we found that our patient has appendicitis.

00:08 What do we do for our patient who has appendicitis? So first and foremost we wanna do supportive care.

00:13 What is that mean essentially? We wanna keep our patient's NPO.

00:17 We don't want them to have anything to eat by mouth.

00:19 Because primarily, the end point here is gonna be that they’re gonna be getting an operation.

00:24 We wanna give IV fluids.

00:27 So for patients not able to eat or drink, we wanna make sure that they don't become dehydrated or volume deplete.

00:33 So we'll put in an IV, we'll give them IV fluids.

00:36 And we also wanna make sure we're controlling their pains, so patients can be very uncomfortable.

00:41 Historically, the thinking was, in the surgical community, that you didn't wanna give pain because that would potentially limit your ability to diagnose appendicitis.

00:50 That's been totally refuted and now we know that it’s very important to make sure that our patients are as comfortable as they can be and administering pain medication is the right choice.

01:00 When you're choosing your pain medication generally, we choose opioid pain medications in this situation and generally, we avoid non-steroidal medications because those can have effects on platelets and we wanna make sure that our patients if they are going to the operating room are able to clot their blood effectively.

01:17 The other thing you wanna do is you wanna control nausea symptoms or other associated symptoms the patients may have.

01:23 So you can go ahead and administer medications to help them with nausea.

01:27 Antibiotics is the next thing to think about.

01:31 So you wanna cover gram negative and anaerobic bacteria.

01:37 You can go ahead and treat with Ertapenem is often times the first medication that we reach for but there's other options as well.

01:45 So for non-perforated appendicitis, you can do Ciprofloxacin plus Flagyl, or Metronidzole, or you can also do Ampicillin-Sulbactam.

01:54 Now for perforated appendicitis, we wanna reach for our bigger guns, we wanna reach for our stronger antibiotics.

01:59 So Piperacillin-tazobactam or Cefepime would be options there.

02:04 And lastly, we wanna think about surgery.

02:07 A majority of these patients historically we get surgery.

02:11 So whenever you had appendicitis, the treatment would be, you call the surgeon and the patient gets an operation.

02:16 Now that's still is definitely at least in the United States, the standard of care and we'll talk a bit in a moment about how that may be changing.

02:23 There's definitely a movement towards laparoscopic procedures.

02:27 So doing the procedures using cameras to guide versus open surgical treatment which is what used to be done.

02:33 We know that laparoscopic surgery generally is less invasive, patients have faster recovery times and overall better outcomes.

02:40 So for the most part, most patients will be getting a laparoscopic appendectomy.

02:44 A procedure to remove their appendix.

02:47 So I mentioned that surgery is generally the main stay of treatment for these patients.

02:52 But there's good evidence that's coming out that potentially patients may not necessarily need surgery for appendicitis.

02:58 So the no surgery option is potentially a good choice for patients who have non-perforated low risk appendicitis.

03:05 So what is it mean that is low risk? It means that there's no high risk features.

03:10 So the high risk features are fecalith, abscess, tumor being present, any kind of fluid collection, or an appendiceal diameter of greater than 1.1 cm.

03:21 You know there's increase evidence that antibiotic management and in-patient observation may be an adequate treatment plan.

03:27 So for those patients who have no high risk features and have non-perforated appendicitis, this may be something up that's up and coming over the next number of years.

03:37 Currently, the standard of care in the US, is that patients for the most probably go to the operating room and get their appendix removed.

03:44 But it's possible that we may see patients just getting treated with antibiotics management.

03:49 Those patients who just get treated with antibiotic management, there are some studies or some evidence that show that over a course of time, they may develop appendicitis again or they may actually during that course of in-patient observation, require that they get their appendix out for various reasons.

04:07 But it's just a possible option, we know that when we do surgery for patients that the more surgery is a patient has on their abdomen, the more at risk they are for complications.

04:17 And while surgery for appendicitis is generally safe, down the line patients may develop a bowel obstruction or adhesions, so potentially limiting the amount of surgical procedures the patient has such as in appendicitis may be of benefit, so more to come on that in the future.

04:34 Now, another special case is perforated appendicitis.

04:37 So that's when the appendix ruptures.

04:38 For those patients, they also might need, might not need to go to the operating room to get their appendix remove emergently.

04:45 Sometimes for those patients, percutaneous drainage can take place first.

04:50 So what that basically means is that the patients goes to interventional radiology, and they have a drain placed in that fluid collection and that drain takes off some of the fluid.

05:00 Now, eventually, they may need surgical management.

05:03 But in that initial phase, percutaneous drainage may be appropriate.

05:07 So thinking about the prognosis.

05:11 Prognosis is generally very good for appendicitis.

05:13 If the imaging is negative or inconclusive, but the patient is still symptomatic, we wanna think about admission to the observation unit for serial abdominal examinations.

05:24 Because although our tests are very good especially CT scan has a very high sensitivity and specificity for appendicitis, we still know that there are maybe patients in whom we have false negative testing.

05:35 So in those patients that your still very concerned that they may still have the appendicitis even with negative testing, we can admit and do serial abdominal examinations and see how they're feeling, see if they develop a fever, see if they will potentially benefit from additional treatment down the line.

05:53 The other very important thing that you do if you are evaluating someone for appendicitis and their testing is negative, is you wanna make sure that you provide patient with return precautions to come back to the emergency department.

06:07 So if you discharge someone who came in with right-sided abdominal pain, and they wind up going home, again none of our test are perfect.

06:14 So you wanna tell them if you get a fever, if your pain changes in any way, if you're vomiting and not able to eat anything.

06:20 Those are indications to come back to the emergency department.

06:23 This is very, very key when we're evaluating patients with belly pain in the emergency department.

06:28 Then when we send people home when their testing is negative, we give them good instructions to return to the emergency department.