Appendicitis: Is surgery always needed?

Several studies have compared the effectiveness of treatment with surgery and treatment with antibiotics in adults and children. The study participants had uncomplicated appendicitis. In other words, only their appendix was affected, and it was only inflamed. There were no abscesses (pockets of pus) and there were no signs that the inflammation had spread to the abdomen.

The studies have shown the following:

• The problems went away for good in about 60 out of 100 people. They were then able to do without surgery.
• The infection didn't go away, or it came back later, in about 40 out of 100 people who were treated only with antibiotics. They needed surgery.

That means that the appendicitis went away in most people after being treated with antibiotics only, but also that it often came back.

The appendicitis does not come back after surgery because the appendix has then been removed.

Antibiotics can have various side effects. They often cause nausea or diarrhea, for instance. The exact side effects will depend on the specific product you are using.

The studies also compared how often complications occurred with each of the two treatments). The results were not clear: Some studies found that the treatments were about as safe as each other. Other studies found that people who only took antibiotics even had fewer complications than those who had surgery (perhaps because no anesthetics or cuts were needed). But treatment with antibiotics was less effective than surgery, and it carries an increased risk of getting appendicitis again – and then perhaps needing surgery after all.

Having antibiotics without surgery is mainly an option for people who have uncomplicated appendicitis – that is, when there are no signs that a pocket of pus has formed or that the inflammation is spreading. It may be especially suitable for younger people who have stable health and do not have a weakened immune system. Children who have appendicitis that is clearly uncomplicated are also first given antibiotics only.

To better rule out complicated cases, examinations are often needed – for instance, a CT scan of the abdomen. But because antibiotics are less likely to be effective over the long term, surgery is also often used to treat uncomplicated appendicitis.

Even if pockets of pus have already formed, antibiotics can be used as treatment and surgery is not done at first. Then a thin tube has to be inserted into the abdomen to allow the pus to drain.

Some studies have looked into whether antibiotics also help in people who have complicated appendicitis. They found that surgery was the more effective and safer treatment option in children whose appendix had already burst open. Surgery was also more effective over the long term in adults. So surgery within a short time is recommended for treating complicated appendicitis.

Some people with uncomplicated appendicitis also have a higher risk of antibiotics not being effective against the inflammation. They include:

• People over the age of 65 years,
• People with a weakened immune system (immunodeficiency)
• People who are very overweight
• People who have had a fecalith (stone made of feces) found in their bowel
• Pregnant women

Experts recommend that they have surgery instead, ideally within twelve hours of appendicitis being diagnosed.

Surgery needs to be performed quickly if there are signs that the inflammation is spreading.