Acute Appendicitis! Surgery or Antibiotics?

Today we got a 10 year old girl complaining of severe lower abdominal pain and fever. Pain had started 4 days back. She was treated initially by a GP with oral antibiotics. But the pain failed to settle and actually worsened. Then she was correctly referred to us for further management.

On Examination she had severely tender abdomen. With the history and examination findings it was obvious that she had a ruptured appendix. So we went ahead with the surgery and she had exactly what we expected.

This is a picture of her appendix just before it was removed. As you can see it is severely inflamed and ruptured. There is a defect at the base of her appendix leading to leak of intestinal content into abdomen, causing severe infection inside her abdominal cavity. Dilemma comes as to if we could have avoided this had she been referred earlier.

Question comes as to if the GP had done the correct treatment by treating her with antibiotics. He can very well defend him self. There are many studies done over the years, showing comparable results in either management strategy. One such review is following article by New England Journal of Medicine.

David R. Flum, M.D., M.P.H. N Engl J Med 2015; 372:1937-1943May 14, 2015DOI: 10.1056/NEJMcp1215006

Appendicitis is a common problem and anyone of you could someday have it. It is important to know some background information when you are given the options of selecting antibiotic treatment or surgery.

If this patient was referred to us earlier, surgery could have done earlier and we could have avoided having to deal with a ruptured appendix and she could have left hospital the next day. But now she has to be in the hospital until the signs of intra abdominal infection settles.

As in this patient, if the antibiotic treatment doesn't settle the problem, it can get worse. Even if the patient recovers in the 1st instance, he or she can get appendicitis another time (recurrence). You can easily avoid all this trouble by simply opting to go ahead with surgery early in the course of the disease. As appendix is removed entirely by surgery, you can not get it another time.

Say you have an exam, wedding or some important meeting coming up in few month time and you are diagnosed with acute appendicitis, it's best to go ahead with surgery rather than taking a chance with antibiotics.