Early Uncomplicated Appendicitis—Who Can We

Treat Nonoperatively?
MARK C. HORATTAS, M.D.,* ILEANA K. HORATTAS, B.S.,† ELYA M. VASILIOU, M.D.‡

From the Cleveland *Clinic Akron General, Akron, Ohio; †Northeast Ohio Medical University, Rootstown,
Ohio; and ‡Summa Akron City Hospital, Akron, Ohio

This study evaluated nonoperative treatment for mild appendicitis and reviewed selection criteria
to be used in introducing this option into clinical practice. A retrospective review of 73 consecutive
cases of appendicitis treated by a single surgeon from 2011 to 2013 was completed. Patients who
were diagnosed with mild appendicitis meeting the criteria of an APPENDICITIS scoring algo-
rithm proposed in this manuscript were considered for nonoperative management. An additional
17 patients with mild appendicitis were offered and successfully treated nonoperatively between
2014 and 2016 and reviewed. Of these original 73 patients, 37 had moderate to severe appendicitis
and directly underwent appendectomy. The remaining patients were diagnosed with mild ap-
pendicitis and considered eligible for nonoperative management. Of these, 14 patients were of-
fered nonoperative therapy. Thirteen responded successfully; one patient responded partially, but
later opted for surgery. In 2014, this scoring system and preliminary results were shared with the
other surgeons in our department. Nonoperative management was then selectively adopted by
a few of the surgeons from 2014 to 2016 with another 17 patients (APPENDICITIS score of 0 or 1)
being offered and successfully managed nonoperatively. Patients with mild or early appendicitis
can be successfully managed nonoperatively. A proposed APPENDICITIS scoring system may
provide a helpful mnemonic for successfully selecting patients for this option.

S in 1883, appendectomy has

INCE ITS INTRODUCTION
been the standard treatment for appendicitis.
Although surgical management for appendicitis was
1–3
introduced well before the discovery and availability
of antibiotics, treatment recommendations have changed
very little in the past century. Recently, some in-
vestigators have suggested using antibiotics as an alter-
native to surgery for the treatment of appendicitis. In
patients with early or mild appendicitis today, should an
initial trial of nonoperative management also be consid-
ered rather than only offering appendectomy?
European investigators have reported very good
outcomes using antibiotics alone compared with tradi-
tional surgical intervention for patients presenting with
appendicitis.4–7 Multiple prospective international stud-
ies have suggested that administration of antibiotics may
be the appropriate first line of treatment in acute
appendicitis.6–14 These recommendations have yet to
become widely accepted in the United States. Most of the
American surgeons still consider appendectomy to be the
only option for treating acute appendicitis.15–17 Indeed,
many maintain the mindset that delay in performing an
Address correspondence and reprint requests to Mark C. Horattas,
M.D. Clinic Akron General, 1 Akron General Avenue Akron, OH
44307. E-mail: mark.horattas@akrongeneral.org.
appendectomy may result in potentially life-threatening
perforation and sepsis.18
These studies also raise questions regarding which
patients with appendicitis should be selected for
nonoperative management and the relative likelihood of
response to nonoperative therapy as not all cases of
appendicitis are alike. Another challenge to introducing
a nonoperative approach for the management of ap-
pendicitis is standardizing messages to the patient from
all of those involved—from presentation to diagnosis to
treatment—allowing for consistent communication re-
garding operative versus nonoperative options. In many
instances, patients and/or caregivers may have con-
flicting preconceptions that immediate appendectomy
should be the only option, even for very mild appen-
dicitis. Therefore, nonoperative options may not even be
considered or offered to the patient.19, 20
Consideration of nonoperative therapy may become
even more important as the incidence of patients di-
agnosed with mild or early appendicitis appears to be
increasing in recent years. This trend is in part due to
the increasing use of CT in the evaluation of patients
presenting with abdominal pain to the emergency de-
partment (ED). Patients with appendicitis are often
diagnosed earlier in the disease process than they were
before the widespread use of routine CT scanning.19, 21, 22

174
No. 2 EARLY UNCOMPLICATED APPENDICITIS
Previously, some patients who presented with suspected
early appendicitis based on clinical, nonradiographic
findings alone may have recovered without surgical in-
tervention during their period of evaluation and initial
observation.19 This observation is supported by wide-
spread autopsy findings of resolved appendicitis ac-
knowledged as early as 1886 by the physician who coined
the term “appendicitis.”23 It is common for these same
patients to now be diagnosed with early appendicitis by
CT scan in the ED and routinely undergo surgery.
In this study, we propose and describe an APPENDICITIS
scoring system to address these challenges based on
many of the selection criteria that we used for our own
patients with mild appendicitis who were successfully
treated with a nonoperative approach. The proposed
scoring system is an attempt to offer a standardized
approach to help guide in the decision for including
nonoperative care as part of patient informed consent
based on objective findings. By grouping together
these exclusion criteria, we developed a memorable
acronym that facilitates interdepartmental and patient
communication and may help with introducing into
clinical practice the option of nonoperative manage-
ment for mild or early appendicitis.
Methods
A retrospective chart review was performed review-
ing all patients admitted with a diagnosis of appendicitis
treated consecutively by a single surgeon over the three-
year period from 2011 to 2013. The study received
approval by the hospital institutional review board.
Nonoperative management for mild appendicitis was
selectively used and the factors involved in the treat-
ment selection specific to each case were analyzed.
Patient follow-up data were then reviewed, ranging
three to four years after initial presentation.
Patients presenting with symptomatic mild appendi-
citis were selectively offered nonoperative management
as part of informed consent if they met the following
criteria: absence of appendicolith on CT scan (an
appendicolith was considered to be potentially associ-
ated with increased risk of complicated or recurrent
appendicitis); CT findings consistent with mild or early
appendicitis; absence of severe pain, tenderness, or
peritoneal signs on examination; and complete in-
formed patient consent with the patient opting for a trial
of initial nonoperative management. These were find-
ings similarly highlighted by Rao et al. and later by
Salminen’s group.24, 25 A mnemonic was designed by
grouping the criteria for patient selection to create an
easy-to-remember acronym for educating all involved
in caring for this patient population. The result was the
proposed APPENDICITIS scoring system, which was
used to aid surgery and ED residents and attendings in
? Horattas et al. 175
operationalizing nonoperative management. This scor-
ing system was developed based on criteria successfully
used in our experience and consistent with other pub-
lished recommendations.25
We found that many patients, physicians, and nurses
were unexpectedly opposed to the possibility of non-
operative treatment because of personal bias and pre-
conceptions. This scoring system was, therefore, introduced
to better identify patients meeting these criteria and to
help enable all caregivers interacting with these pa-
tients to present a cohesive and uniform message, be-
ginning with initial patient assessment in the ED.
Generally, patients with appendicitis who were offered
an initial trial of antibiotic treatment and observation had
none of the following findings (i.e. an “APPENDICITIS”
score 4 0):
A: Appendicolith or intraluminal opacity demon-
strated by CT scan. Such findings possibly in-
dicate an obstructive etiology and higher risks for
recurrence or progression to perforation.26
P: Pain (severe pain >7/10) and/or not easily
controllable with analgesics. Severe pain may be
associated with advanced appendicitis. Patients
are more inclined to proceed with immediate cu-
rative appendectomy for both symptom control
and cure.
P: Peritonitis or clinical findings suggestive of
advanced infection. Because the specific threshold
for requiring surgical intervention is not currently
clearly defined, it seemed appropriate to offer
surgery for any patient presenting with more than
mild appendicitis.
E: Examination with vital signs concerning for
advanced appendicitis or sepsis. Similar to the
presence of peritonitis, physical findings of ad-
vanced appendicitis and sepsis are likely better
treated surgically.
N: No improvement within 24 to 48 hours of
initiating antibiotic therapy as measured by pain,
leukocytosis, or examination findings. Some im-
provement is anticipated within one to two days to
warrant continued nonoperative treatment.
D: Dilatation of lumen beyond 11 mm. Dilatation
may indicate an obstructive etiology with poten-
tially increased risks of progression to perforation.
Although the appendiceal luminal diameter sug-
gestive of risk of progression to perforation is
probably variable between patients, a general
guideline of 11 mm was selected for the purpose
of this scoring system to avoid missing patients
who might be better managed with appendectomy.
I: Immunocompromised patient with increased
potential for complications. The response of this
subgroup of patients to nonoperative management
176 THE AMERICAN SURGEON
requires further study before routinely considering
this option for such cases.
C: CT findings with severe inflammation (perfo-
ration, extensive free fluid, severe fat stranding) or
nondiagnostic of acute appendicitis. Findings of
severe appendicitis indicate the need for surgical
intervention. However, severe inflammation as-
sociated with an appendiceal phlegmon may still
be an indication for antibiotic therapy alone. In
the cases lacking confirmation of appendicitis by
CT, diagnostic and therapeutic judgment de-
termines management and reconsideration of the
differential diagnosis.
I: Infection that is advanced or severe based on
clinical assessment and supporting laboratory
values. Severe infection beyond the scope of an-
tibiotic therapy alone is an indication for surgery.
T: Temperature $37.8°C (100°F). The degree of
febrile response can correlate with the severity of
infection and risk of sepsis. Although the exact
threshold for discrimination between the groups re-
mains undefined, we selected $37.8°C (100°F) as
an operational value.
I: Informed consent for initial trial of antibiotic
therapy is not granted by patient. The decision for
treatment requires detailed informed consent by
the patient, including review of the various options
and the potential risks and benefits.
FIG. 1. The “APPENDICITIS” scoring system for recommending possible nonoperative management is summarized. All of our
patients who were successfully managed nonoperatively with antibiotics had a total score of 0 or 1. (Every “Yes” 4 1, every “No” 4 0.)
February 2018 Vol. 84
S: Surgery deemed preferable option, either by the
surgery team or by the patient. Many factors in-
fluence the decision making process, and it should
be emphasized that this APPENDICITIS scoring
system is only presented as a suggested guide in
managing patients with mild appendicitis (Fig. 1).
When all of the aforementioned criteria were absent or
negative in patients with mild appendicitis, a trial of
nonoperative therapy was offered as an alternative to
traditional appendectomy. This scoring system was
developed to guide patient selection and informed
consent, but patients were offered treatment based on
the surgeon’s clinical judgment.26 As the introduction
of nonoperative treatment for appendicitis was a cul-
tural shift at our institution, we chose to initially re-
strict this option to only patients with mild cases of
appendicitis.
Patients managed nonoperatively were treated with
broad-spectrum antibiotics for 7 to 10 days. Standard
treatment in our model was ampicillin/sulbactam, 3.0 g
intravenously every six hours, or a similar broad-
spectrum antibiotic. Antibiotics were started immedi-
ately on diagnosis in ED and then continued throughout
the course of hospitalization until normalization of
leukocytosis and clinical improvement. The course of
antibiotics was then completed orally with amoxicillin/
clavulanic acid, 875 mg every twelve hours, as an
No. 2 EARLY UNCOMPLICATED APPENDICITIS
outpatient. In patients with penicillin allergy, in-
travenous ciprofloxacin and metronidazole were used
instead and the course was completed orally as an
outpatient.
If any patient failed to improve significantly within
24 to 48 hours, surgical intervention would be antici-
pated. Laparoscopic appendectomy was recommended
for any progression of symptoms or failure to respond
to antibiotic therapy.
All patients presenting with appendicitis during
a three-year period to a single surgeon were included
for this review with follow-up data analyzed for evi-
dence of recurrence. Implementation of nonoperative
management within the department over the ensuing
three years was then subsequently reviewed.
Results
A total of 73 patients were treated by a single sur-
geon for appendicitis over the three-year period from
2011 through 2013. Of this group, 37 patients were
classified as having more advanced appendicitis and
were only offered surgery. This advanced appendicitis
group included 29 patients who were noted on CT
evaluation to have appendicoliths and eight patients
who had other relative contraindications to non-
operative management based on criteria outlined in the
proposed APPENDICITIS scoring system (see
Methods). The APPENDICITIS score for the operative
group of patients averaged 2.7 (range 1–4 with n 4 1
for score of 1, n 4 11 for score of 2, n 4 23 for score
of 3, and n 4 2 for score of 4; Fig. 2).
Of the 36 patients with mild appendicitis, 22 were
offered laparoscopic appendectomy instead of antibiotics
FIG. 2. Mean APPENDICITIS score with standard deviation for nonoperative management group (ABX), operative cases due to
scheduling rather than clinical presentation (SCH), operative cases due to clinical presentation (OP), and nonoperative cases following
protocol implementation (IMP).
? Horattas et al. 177
because of scheduling conflicts or matters of timing.
These conflicts or timing matters included variable
operating room availability, on-call cross-coverage
constraints, and unavailability of adequate immediate
nonoperative follow-up in certain instances. The
APPENDICITIS score for this group averaged 0.32
(range 0–1 with n 4 15 for score of 0, and n 4 7 for
score of 1).
Of these remaining 14 patients with mild or early
appendicitis who were offered nonoperative treatment,
all initially opted for a trial of initial nonoperative
therapy. One patient selected nonoperative treatment
and improved; but following further discussions with his
family, he elected after 48 hours to proceed with a con-
ventional laparoscopic appendectomy succeeded by an
uneventful postoperative recovery. Thirteen patients
were treated with an initial one- to two-day course of
inpatient intravenous antibiotic therapy followed by a 7-
to 10-day outpatient course of oral antibiotics. Their
overall APPENDICITIS score averaged 0.15 (range 0–1
with n 4 11 for score of 0 and n 4 2 for score of 1). All
of these patients experienced complete resolution of
their symptoms and resolution of leukocytosis before
discharge. These patients were followed for recurrent
appendicitis with an average three-year follow-up
(range: 2–4 years). One patient later developed re-
current appendicitis within a year and subsequently
underwent uneventful appendectomy.
Demographic data were similar across the 73 pa-
tients with a mean age of 41 (range 17–70) in the
operative group and a mean age of 37 (range 18–52) in
the nonoperative group. The operative treatment group
was 48 per cent male and the nonoperative treatment
group was 54 per cent male.
178 THE AMERICAN SURGEON
During the following three years, from 2014 through
2016, several other surgeons began to consider treating
mild appendicitis nonoperatively. This resulted in an-
other 17 patients with mild appendicitis who were
successfully treated using antibiotics alone. Their
overall average APPENDICITIS score was 0.29 (range
0–1 with n 4 12 for score of 0 and n 4 5 for score of
1). No problems or recurrences were noted in this
group with follow-up ranging 1–2 years. In 2017, these
APPENDICITIS guidelines were made available
hospital-wide under oversight of our Department of
Surgery with ongoing monitoring of results.
Discussion
Appendectomy remains one of the most common
emergency surgical procedures in the United States
today. Although there are several international studies
suggesting that nonoperative therapy may be prefera-
ble, treatment for appendicitis in this country still re-
mains essentially surgical.
Only within the past few decades have physicians
begun to routinely rely on radiographic imaging to
diagnose acute appendicitis. Previously, the diagnosis
was primarily determined by patient history, physical
examination, and laboratory testing rather than con-
firmation by CT imaging.19, 27 The accessibility of CT
scanning for patients in the ED has changed this process,
allowing for earlier and more frequent diagnoses of ap-
pendicitis.28 Although CT scanning is associated with
well-established risks including radiation exposure and
intravenous contrast complications, usage of this imaging
modality in the assessment of abdominal pain may have
introduced yet another drawback: over-treatment.
Increased utilization of CT in the ED for evaluating
patients with abdominal pain has coincided with the in-
creasing rate of diagnosing non-perforated appendicitis.
Concurrently, the threshold for surgical intervention for
these patients may have fallen, presumably because of
more definitive diagnosis earlier in the disease process
and the widespread availability of laparoscopic appen-
dectomy.19 Previously these same patients with ambig-
uous presenting symptoms were more likely to initially
undergo a period of observation, during which many
cases would resolve nonoperatively.
Not uncommonly, patients presenting to the ED with
appendicitis in the evening or during the night are al-
ready tentatively scheduled for surgery for the fol-
lowing morning, even before they meet their surgeon.
The patient and family, surgeon, residents, ED staff,
nursing, and all involved with the patient’s care are
comfortable with the practice of proceeding reflexively
to appendectomy as the logical next step once the di-
agnosis has been made. In fact, sometimes the idea of
recommending a nonsurgical option is considered
February 2018 Vol. 84
heretical by any involved, and changing this culture can
be more difficult than just directly proceeding to surgery
as the next step as the path of least resistance. Our AP-
PENDICITIS scoring system is one attempt to more
clearly communicate to everyone involved which patients
may be most appropriate for nonoperative treatment.
An unexpected set of challenges that we encoun-
tered in introducing the idea of nonoperative treatment
was the need to address some of the commonly ac-
cepted notions and preconceptions regarding the
treatment for appendicitis. In our experience, some of
the involved caregivers may share comments with
patients or families regarding their personal biases or
opinions about risks of perforation if appendectomy is
not immediately done, resulting in inherit difficulties
with considering a nonoperative option. Implementa-
tion of the APPENDICITIS scoring system may better
standardize overall communications to the patient. In
this study, one patient changed his mind later and chose
appendectomy primarily due to family discussions and
mixed messaging from caregivers who suggested sur-
gery, despite his initial decision and subsequent clinical
improvement with antibiotic therapy.
Perhaps implementation of nonoperative approaches
to other diseases, such as complicated diverticular
disease, may not have had to overcome such psycho-
logical barriers. For example, even though acute di-
verticulitis historically could be “cured” by urgent
surgery, most cases are now treated primarily with
antibiotic therapy. Similarly, even though all cases of
appendicitis can be cured with appendectomy, it may
be reasonable to consider alternative options, including
the selective use of antibiotic therapy. Not all cases of
appendicitis are identical; perhaps treatment options
should also be individualized. It may be appropriate to
reevaluate the current practice of applying the same
surgical treatment to every patient presenting with
appendicitis.19, 29
Surgeons in the United States have been reluctant to
adopt nonoperative management for appendicitis.
These concerns may relate to safety and effectiveness,
as well as questions to the relative advantages of such
approaches over traditional surgery. However, many
studies indicate that patients with nonperforated ap-
pendicitis might be more effectively treated with an-
tibiotics instead of surgery.4, 6–11, 14, 15 The idea of
appendicitis resolving without the patient undergoing
surgery should not be considered particularly radical.
Antibiotics are the mainstay of therapy for locally
advanced appendicitis associated with an appendiceal
phlegmon, and after resolution, the subsequent need
for elective interval appendectomy is now considered
controversial.30–34
Delay in surgery has been shown to be safe.35 In
addition, there is no evidence of progression toward
No. 2 EARLY UNCOMPLICATED APPENDICITIS
rupture or any difference in overall outcome for those
patients initially assigned to nonoperative management
who then switched to surgical treatment later in
treatment.36, 37 Some disadvantages to a nonoperative
approach remain, including the risk of recurrence. In
the present study, one patient who was treated non-
operatively presented during the follow-up period with
recurrent appendicitis. He underwent an uneventful
appendectomy with full recovery. The recurrence rate
observed in our review was lower than the approxi-
mately 30 per cent reported in some other studies that
did not use selective criteria.10, 36 Although this dis-
crepancy may be a result of the modest sample size, it
may reflect the selective criteria we used in our cohort.
Nonoperative management may have many advan-
tages over traditional appendectomy. These include
earlier return to normal activity as well as reduced
risks of complications and disability that can be as-
sociated with surgery.9, 11, 13, 14 A meta-analysis in-
vestigating the risks and benefits of surgery versus
nonoperative management of appendicitis demon-
strated reduced risks of complications without pro-
longation of hospital stay.15 Additional advantages
over surgical intervention may also include avoiding
risks of anesthesia and prevention of late postsurgical
complications such as adhesions and associated intestinal
obstruction.10 Other factors that are more difficult to fully
quantify include cost effectiveness, patient satisfaction,
and longer term recurrence.24, 26–28 Other limitations of
this study included the limited enrollment of eligible
patients as well as the nature of this report as a retro-
spective review. In addition, follow-up ranged from two
to four years, which may have resulted in a mis-
representation of the long-term rate of recurrent appen-
dicitis. Further investigation is warranted to confirm the
findings presented and to more fully validate the in-
troduction and implementation of this proposed AP-
PENDICITIS scoring system. Many of the individual
criteria used in our APPENDICITIS scoring system were
validated in a similar work published by Salminen et al.25
Changing the traditional surgical approach for even
mild cases of appendicitis can challenge conventional
surgical dogma and clinical practice. The proposed
APPENDICITIS scoring system was a useful tool for
communicating between caregivers and patients. It is
important to note that this study was not designed to
prospectively compare treatment options for all pa-
tients presenting with mild or early appendicitis, but
rather to retrospectively evaluate the characteristics of
patients who were successfully managed nonoperatively.
It is possible that the proposed APPENDICITIS criteria
used for this study were too restrictive and that they may
require refinement as well as further validation. Intro-
duction of the concept of nonoperative management at
our own institution has increasingly become acceptable
? Horattas et al. 179
as an alternative to surgery with several of our surgeons
and the ED staff.
In the future, we intend to follow this report with
a larger investigation initiating our proposed scoring
system with additional surgeons. We plan to revalidate
our preliminary results after implementing this pro-
posed APPENDICITIS scoring system throughout our
ED and Department of Surgery beginning in 2017.
Conclusions
Nonoperative treatment of mild appendicitis was
successful in almost all patients who pursued this option.
Successful candidates for nonoperative management
were initially chosen based on the absence of appendi-
coliths, CT findings consistent with mild appendicitis,
minimal clinical findings, and an observed clinical re-
sponse to antibiotic therapy (i.e. APPENDICITIS
Score 4 0 or 1). Based on our experience, we believe
that patients with mild appendicitis should also have
the option of considering initial nonoperative therapy
with antibiotics.25 As with any treatment decision,
both operative and nonoperative options carry risks,
benefits, and potential complications. Because appen-
dicitis has a diverse array of presentations and out-
comes, it is reasonable to also selectively consider
alternative treatment options instead of only offering
appendectomy as part of full informed patient consent
for treatment.
The patient selection process used in this study sup-
ports consideration of a newly proposed APPENDICITIS
score that was developed to help all involved care-
givers identify eligible patients for whom nonoperative
management may be preferential. We intend to con-
tinue validating our proposed APPENDICITIS scoring
system moving forward. By further adoption by addi-
tional surgeons and refinement of this scoring system
through further evaluation, we hope to better identify
patients who might be better managed nonoperatively.
The purpose of this report was to illustrate how initial
nonoperative management and patient reassessment for
response to antibiotic therapy can be successfully in-
troduced into surgical practice in place of routine rec-
ommendations for appendectomy. Treating early or
mild appendicitis nonoperatively should be considered
when discussing options with these patients based on
our experience as well as the current literature.38 This
proposed algorithm and scoring system have been per-
sonally useful for successfully implementing non-
operative management of appendicitis into a surgical
practice; we believe it will be helpful in selecting other
patients who might truly benefit from this approach.
However, further study is still needed to refine our
proposed algorithm and further determine optimal ap-
proaches for managing appendicitis.
180 THE AMERICAN SURGEON
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