[size=20px]An ill-appearing ten-year old male presents with a five day history of abdominal pain that now localizes to his right lower quadrant. A computerized tomography scan demonstrates a dilated appendix with periappendiceal inflammation and free peritoneal fluid.

 

The optimal management of this patient with presumed perforated appendicitis is parenteral broad spectrum antibiotics

 

A alone.

 

B with subsequent interval appendectomy.

 

C with drainage of the peritoneal fluid by interventional radiology.

 

D with delayed appendectomy if his condition deteriorates.

 

E with immediate appendectomy.[/size]

E

(Untitled)

 

E

Correct Answer

E with immediate appendectomy.

 

Given the technical challenges of performing an appendectomy in the face of perforated appendicitis, a strategy combining parenteral antibiotics and subsequent interval appendectomy has gained in popularity. When a well formed periappendiceal abscess is identified, antibiotics, percutaneous drainage of the abscess and interval appendectomy has been found to deliver equivalent outcomes to immediate appendectomy, albeit at the cost of greater disruption to the patient’s quality of life.

 

This management is less clearly successful in patients with perforated appendicitis without abscess. Several studies indicate an advantage to patients with perforated appendicitis treated with immediate appendectomy rather than antibiotics and interval appendectomy. This decrease in success is due in part to the inability of computerized tomography (CT) to uniformly differentiate perforated from nonperforated appendicitis. Treatment failures using an initial nonoperative approach occur in as many as 10 to 20% of patients leading to increased morbidity and costs in those awaiting or undergoing interval appendectomy.

 

Following nonoperative treatment of perforated appendicitis the rate of recurrent appendicitis appears to be around ten percent. This rate is increased when an appendicolith is identified on CT.

 

Studies of patients who were initially managed nonoperatively with success suggest a cost benefit to subsequent conservative management without interval appendectomy.