Operative versus non-operative therapy for acute phlegmon of the appendix: Is it safer? A case report and review of the literature

Abstract

Introduction: There is no clear standardized approach to complicated appendicitis associated with abscess or phlegmon, with treatment varying from immediate appendectomy versus non-operative management with antibiotics and possible interval appendectomy. This case report reviews a presentation of complicated appendicitis failing non-operative therapy and reviews the literature on complicated appendicitis.

Presentation of case: A 19 year-old male presented with right lower quadrant pain, leukocytosis, and fever. He had been seen at an outside hospital, diagnosed with complicated appendicitis, treated non-operatively, and discharged on antibiotics. CT confirmed persistent complicated appendicitis; he was again treated non-operatively with resolution of symptoms. He was discharged but returned with recurrent pain/leukocytosis. The patient was determined to have failed non-operative management, underwent laparoscopic appendectomy. Post-operatively he improved was doing well in follow up.

Discussion: Historically, the therapy for acute appendicitis has been surgical. However, immediate surgical management of complicated appendicitis is often associated with increased complications. Non-operative management with antibiotics and interval appendectomy in cases of complicated appendicitis is an option. Literature shows that non-operative management of complicated appendicitis is not entirely innocuous. Non-operative management carries a significant failure rate. Patients that undergo immediate appendectomy may have a better health-related quality of life. Non-operative management of complicated appendicitis may lead to worse outcomes and higher healthcare costs.

Conclusion: Non-operative management of complicated appendicitis has significant failure rates, increased healthcare costs, and perhaps increased morbidity when compared to immediate surgical management. Immediate surgical management of complicated appendicitis remains the gold standard and should be used in most patients.

Keywords: Acute appendectomy; Acute appendicitis; Appendiceal abscess; Conservative management; Fistula; Perforated complicated appendicitis.