With few exceptions, the treatment of appendicitis is surgical (ie, appendectomy). The operation can be done open or laparoscopically. The results of clinical trials comparing the two methods show no clear-cut advantage of one method over the other, though patients treated laparoscopically return to work a few days earlier. A laparoscopic approach is desirable when the preoperative diagnosis is uncertain because the morbidity is less if the appendix is found to be uninflamed and an appendectomy is not done.
Prophylactic antibiotics are indicated preoperatively. A single-drug regimen, usually a cephalosporin, is as effective as more aggressive multiple-drug combinations. Routinely culturing abdominal fluid is of no practical value even when the appendix has perforated. The organisms obtained are the usual fecal flora.
In the past it was common to perform an incidental appendectomy in people under age 50 during the course of an abdominal operation for another illness—as long as the exposure was adequate and there were no specific contraindications. The declining lifetime risk of appendicitis now calls this practice into question. A related question concerns the appropriate course when a laparoscopy is performed for presumptive appendicitis and the appendix looks normal. The trend in this case is to leave the appendix intact—not to remove it prophylactically or on the assumption that the visual assessment may be inaccurate.
Chronic abdominal pain is a common problem, and when the complaints are confined to the right lower quadrant, the question of chronic appendicitis is usually raised. Patients with genuine chronicappendicitis experience pain that lasts for 3 weeks or more. The history usually includes an acute illness at some time in the past, compatible with acute appendicitis, which was managed nonoperatively. On examination, the appendix is chronically inflamed or fibrotic. The symptoms resolve with appendectomy.
Chronic intermittent pain in the right lower quadrant is most often caused by something other thanappendicitis, such as Crohn’s disease or renal disease. Barium x-rays are sometimes helpful, particularly in children. In many patients, the diagnosis is not obvious. Appendectomy relieves symptoms occasionally, but laparotomy for chronic abdominal pain is generally unproductive in the absence of objective findings (eg, localized tenderness, palpable mass, leukocytosis).