[Progressive insight into treatment of appendicitis: antibiotic use appears to be a safe step forward]

Since the late 19th century, standard treatment for acute appendicitis has been an appendectomy. Recently, two new developments have induced a new paradigm. More accurate diagnosis by imaging has since overruled the old adagium: 'When in doubt, take it out.' Secondly, new insights into the pathogenesis of appendicitis have negated the theory that simple appendicitis will inevitably progress into complicated appendicitis, with associated perforation and generalised peritonitis. Four randomised controlled trials in adults have demonstrated that antibiotic treatment in selected patients is safe and effective: in two-thirds of healthy and relatively young men, antibiotics cured the appendicitis. In 15%, an operation was indicated for failure to respond and 15% relapsed within one year. These promising results need to be confirmed in other populations such as children and women. Furthermore, the establishment of prognostic factors such as the presence of a faecolith is needed before the treatment of appendicitis can be removed from the surgeon's realm.