A 35-year-old female presents with right lower quadrant pain for 36 hours. CT abdomen shows a 12 mm appendix with periappendiceal fat stranding, a small periappendiceal abscess (3 cm), and no free perforation. Her Alvarado score is 7. Which management strategy has been validated by the APPAC trial?

• A Immediate laparoscopic appendicectomy in all cases with Alvarado ≥ 7
• B Interval appendicectomy after 6–8 weeks of antibiotic treatment for abscess
• C CT-guided drainage of abscess followed by immediate appendicectomy
• D IV antibiotics alone as definitive treatment for uncomplicated acute appendicitis (non-perforated) ✓

Explanation

The APPAC (Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis) trial demonstrated that IV antibiotics (ertapenem) alone successfully treated uncomplicated acute appendicitis (CT-confirmed, no appendicolith, no perforation) in about 73% of patients at 1 year, with appendectomy performed only for failures. This challenged the dogma that appendicitis always requires surgery. However, the recurrence rate is significant (~27% over 5 years), and the presence of an appendicolith increases failure rate. For cases with a periappendiceal abscess without free perforation, interval appendicectomy after 6–8 weeks of antibiotics is the alternative, but non-operative management with antibiotics is the APPAC trial's studied approach for uncomplicated appendicitis.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.