Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review

For more than 100 years, physicians and patients considered appendicitis a surgical emergency requiring hospitalization for urgent removal of the obstructed and inflamed appendix to prevent rupture and sepsis. With the advent of modern imaging, uncomplicated appendicitis is identifiable, and later evidence showed that surgical delay does not increase the risk of appendiceal perforation. Perforation appears to be a separate disease, with uncomplicated appendicitis likely related to infection, which sometimes self-resolves. Most recently, studies compared nonoperative treatment of uncomplicated appendicitis with antibiotics and observation followed by selective surgery to urgent appendectomy, including 4 multicenter trials involving more than 2,000 adults and 2,000 children. The results led the American College of Surgeons to endorse nonoperative treatment of uncomplicated appendicitis as a safe alternative treatment. Furthermore, emergency department discharge and outpatient management appears feasible in as many as 90% of nonoperative treatment of uncomplicated appendicitis-treated patients. We review methods and results of these trials and evaluate implications for emergency care.