A lovely study out of The Lancet that tells us what we already know…is not as right as we thought it was. We’ve all seen the pediatric patient, usually female, that went to their pediatrician’s office with abdominal pain, had evidence of cystitis on a UA, and was prescribed amoxicillin or cephalexin. They got a little better, but they’re still having some nausea, some pain, and some loose stools. In your ED, the ultrasound is positive for free-fluid without visualization of the appendix, and a CT scan subsequently shows evidence for appendiceal rupture. But – as we’ll see here – most cases probably resolved before you saw them.
This is a prospective study randomizing patients to antibiotics versus early surgery, and the antibiotic group here actually had a lot more success than we imagine – since all we see/remember are those patients where we discovered the “latent” appendicitis, partially treated and festering after that initial course of antibiotics. Only 12% of their CT-proven uncomplicated appendicitis went on to have a appendectomy in the first 30 days, and 30% within a year. So, you could almost argue that with an 88% short-term cure rate with antibiotics and a 70% medium-term cure rate, antibiotics should be first-line therapy with observation for clinical worsening.
Definitive therapy has its advantages – you could almost equate the appendix to the gallbladder, and say that the 30% recurrence is almost certain to rise in subsequent years. But, is there an advantage to waiting to do an appendectomy on an elective basis? Are the adhesions that might develop more or less of an issue that the risks associated with emergent surgery? And, of course, in the female pelvis, any undertreated appendicitis represents a significant fertility risk. This study raises great questions about whether we should change our practice regarding our approach to appendicitis, and it might just be we find a role for being less aggressive with surgery.
“Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial.”
http://www.ncbi.nlm.nih.gov/pubmed/21550483