Appendicitis

Reducing Negative Appendectomy.

Appendicitis almost always guarantees an emergency trip to the hospital for an unexpected appendectomy (1). It is caused by the inflammation of the appendix when clogged by faeces, foreign material or cancer. In South Africa, a study showed that 17% of appendectomies were conducted unnecessarily (negative appendectomy), putting patients at risk surgical complications that could have been avoided. The perforation rate for appendicectomy patients was 36% (970/2 688), and mortality rate was 1% (2)

---

This article aims to recommend additional research into promising appendicitis management strategies, such as the following:

Recommendations to improve symptoms analysis

To improve symptoms assessment, the healthcare practitioner may consider using a scoring system based on whether the following criteria was met or not: abdominal pain, vomiting, right lower quadrant tenderness, fever, and polymorphonuclear leucocytosis. Appendicectomy should ideally be conducted when four or more criteria are met. In some studies, a negative appendectomy was reported in 6.5% in the intervention arm compared to 17% in the controlled group. Effective symptoms analysis reduces over treatment, minimises the incidence of appendicectomy related complications and further research is needed to integrate this procedure in clinical practice (3).

Recommendation for diagnosis procedure

Clinical diagnosis of appendicitis can often be challenging to assess because appendicitis often presents with atypical symptoms similar to other conditions. The gold standard for diagnosis is Magnetic Resonance Imaging (MRI), which offers radiation protection but is expensive and less accessible to the South African population. Diagnostic procedures that could be more effective include using ultrasound (US) as a first-line imaging modality; if the diagnosis is still unclear, then MRI is advised. Correlating US findings with readily available blood test such as an abnormal White Blood Cell (WBC) count and C-Reactive Protein (CRP) which tend to be higher in patients with appendicitis may reduce negative appendectomy rate (5).

Recommendation for Treatment

The generally accepted standard treatment for a confirmed appendicitis is an appendectomy, there's however a shift towards non-surgical treatment options. Antibiotics are now an accepted first-line treatment for most people with appendicitis as several randomised clinical trials confirm that antibiotic treatment is non-inferior to an appendectomy (6). Antibiotics potentially eliminate the risk of surgical complications, however the longer-term incidence of appendectomy following antibiotics is high. More research is needed on strategies to curb the appendicitis recurrence rate post antibiotics therapy. Although some clinicians and patients may determine that these longer-term rates of appendectomy make antibiotics a less desirable treatment than early appendectomy, substantial numbers of patients report a preference for antibiotics, even if appendectomy may ultimately be necessary(8).

Application of current evidence based medicine in clinical practice will reduce the occurrence of negative appendectomy. Further research is however necessary to improve the clinical diagnosis and treatment of appendicitis, and minimise the incidence of associated complications. To keep updated and maintain your clinical competence, access CPD course library on the Clinical Care Platform.

---

Reference List:

1. Begum J. Appendicitis [Internet]. WebMD. 2022 [cited 19 July 2022]. Available from:https://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis

2. YANG, E; KAHN, D and COOK, C.Acute appendicitis in South Africa: A systematic review.S. Afr. j. surg. [online]. 2015, vol.53, n.3-4, pp.1-8. ISSN 2078-5151. Available at Acute appendicitis in South Africa : a systematic review surgery | South African Journal of Surgery (journals.co.za)

3. Christian F, Christian GP. A simple scoring system to reduce the negative appendicectomy rate. Ann R Coll Surg Engl. 1992 Jul;74(4):281-5. PMID: 1416684; PMCID: PMC2497615. Available at A simple scoring system to reduce the negative appendicectomy rate - PubMed (nih.gov)

4. Mostbeck G, Adam E, Nielsen M, Claudon M, Clevert D, Nicolau C et al. How to diagnose acute appendicitis: ultrasound first. Insights into Imaging. 2016;7(2):255-263. Available at:How to diagnose acute appendicitis: ultrasound first - PMC (nih.gov)

5. Kartal K. How To Avoid Negative Appendectomies: Can Us Achieve This?. Turkish Journal of Trauma and Emergency Surgery. 2016;.available at How to avoid negative appendectomies: Can US achieve this? - PubMed (nih.gov)

6. The CODA Collaborative: Antibiotics versus Appendectomy for Acute Appendicitis — Longer-Term Outcomes. N Engl J Med 2021; 385:2395-2397, December 2021. Available from: https://www.nejm.org/doi/full/10.1056/NEJMc2116018

7. Donohue B. Antibiotics for appendicitis: Study findings finalized [Internet]. Newsroom.uw.edu. 2022 [cited 19 July 2022]. Available from: https://newsroom.uw.edu/news/antibiotics-appendicitis-study-findings-finalized

8. Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M et al. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259. Available at Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial - PubMed (nih.gov)