Appendicitis in the Neutropenic Patient: A Systematic Review

Neutropenia increases the complexity of surgical decision-making in cases of acute appendicitis. In this systematic review, we discuss medical vs surgical management and timing of appendectomy in the neutropenic adult patient. We queried databases utilizing the key words "neutropenia" and "appendicitis." The search identified 999 articles of which 481 articles were reviewed after duplicates were removed. Studies with pediatric patients, single case studies, and abdominal pain in neutropenic patients not caused by appendicitis were excluded. Seven studies remained in this review accounting for 130 patients, of which 28 were diagnosed with neutropenic appendicitis, and were included for final analysis. Four of the 7 articles were case reports, demonstrating the relative paucity of literature on this subject. Studies referred to the high risk of morbidity and mortality after surgical intervention in the neutropenic population, and attempting medical management first was common but not universal, reserving appendectomy for failure of medical management. Three studies suggested medical therapy as first-line management while 2 studies suggested surgical management and 2 studies did not distinguish a precedence. Both medical and surgical management have been successfully used in treating appendicitis in neutropenic patients. In most patients, medical management was attempted first (n = 16/28) vs immediate appendectomy (n = 7/28). Appendectomy was performed when medical management failed (n = 2/28) or after correction of neutropenia (n = 1/28). Timing or performance of appendectomy was unclear in 2 patients. With the increasing use of immunosuppressive medications, broad-spectrum antibiotics, and recent data from the CODA (Comparison of Outcomes of Antibiotic Drugs and Appendectomy) trial, medical management as a first-line treatment for most patients with neutropenia and appendicitis is warranted, and identifying a protocol for such patients would be of value.