Complications
Patients may present with sepsis or shock, with localized peritonitis and guarding, generalized peritonitis (a tense, distended abdomen with guarding or rigidity and absent bowel sounds), or a palpable mass (due to a peri-appendiceal abscess caused by a perforation that is contained by the omentum).[2][7][37]
Emergency appendectomy (open or laparoscopic) should be performed in all cases.[142]
It is now recognized that perforation is not merely a progression of an appendicitis, but rather a completely different pathology.[7][13][143] In practice, it is currently not possible to predict early in the course of the condition which patients have uncomplicated (nonperforating) appendicitis and which have appendicitis that will progress to perforation.[13] In certain patient groups (patients >65 years, those with comorbidities, and those with a delay of more than 12 hours before surgery is performed) there is some evidence of increased risk of perforation. Surgical delay should be minimized in these groups.[144]
Large perforation of acutely inflamed appendix results in generalized peritonitis.
Presents with an acute abdomen (high fever, diffuse abdominal pain, generalized tenderness, and absent bowel sounds).[37]
If the diagnosis is suspected as acute appendicitis, appendectomy can be performed. If diagnosis is in doubt, exploratory laparotomy should be performed through midline incision, and the appendix, if inflamed, should be removed.
Usually seen in patients with a relatively long history of symptoms.
Presents with tender right lower quadrant mass. Ultrasonography or computed tomography scan will show a mass.
If the patient appears otherwise well, the initial management is conservative treatment with intravenous fluids and broad-spectrum antibiotics. If there is clinical improvement and the signs and symptoms are completely resolved, then there is no need for interval appendectomy.[106][107][108] Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved.[7]
Any patient ages >40 years who has conservative management without interval appendicectomy should also undergo investigations to rule out colon malignancy; these should include colonoscopy and interval full-dose contrast-enhanced computed tomography scan.[7]
Usually occurs as a progression of the disease process, particularly after perforation.
Presents with tender right lower quadrant mass, swinging fever, and leukocytosis.
Ultrasonography or computed tomography (CT) scan will show the abscess.
Initial treatment includes intravenous antibiotics and CT-guided drainage of abscess.
If there is clinical improvement and the signs and symptoms are completely resolved, then there is no need for interval appendicectomy.[106][107][108] Interval appendicectomy should be performed after 6 weeks if the symptoms are not completely resolved.[145] There is evidence to suggest that laparoscopic appendicectomy may be a feasible first-line option over conservative treatment for appendiceal abscess in adults; however, this is not recommended.[146]
Any patient ages >40 years who has conservative management without interval appendicectomy should also undergo investigations to rule out colon malignancy; these should include colonoscopy and interval full-dose contrast-enhanced CT scan.[7]
One retrospective cohort study of 150 patients with perforated appendicitis with abscess or peritonitis found a laparoscopic approach reduced the incidence of surgical site infection and repeat surgery and led to a shorter length of stay compared with open surgery.[147]
Decreased incidence if laparoscopic approach and prophylactic antibiotic used.[148]
[ 
]
[Evidence B]
The risk of appendiceal neoplasm in patients treated with nonoperative management of complicated appendicitis is 11%, increasing to 16% in patients ages 50 years and older and 43% in patients ages over 80.[110][113][114] Mucinous neoplasms are the most common form of appendiceal malignancy (43%), although the incidence of appendiceal carcinoid appendiceal tumors is rising, particularly in patients under 40 years of age.[113][149]
A rare complication which occurs in approximately 0.25% of patients following laparoscopic appendicectomy.[150] Presents with right lower quadrant pain, a median of 292 days following laparoscopic appendectomy.[150] Treatment is surgical, with the majority of patients (97%) undergoing repeat laparoscopic appendectomy.[150]
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