ERcast: Clinical Perspectives Podcast Preview

Subscription Required

Essentials Masterclass: Appendicitis – Do We Need a Surgeon?

Drew Kalnow, DO and Greg Moran, MD

Sign in or Subscribe to listen.
5 starson Spotify
Sign in or Subscribe to view.Sign in or Subscribe to view.

The summary below is from an episode of ERcast: Clinical Perspectives

Acute uncomplicated appendicitis does not always require an appendectomy. In imaging-confirmed adult appendicitis, antibiotics can match 30-day quality-of-life outcomes while getting some patients home from the ED, but appendicolith changes the risk discussion.

Antibiotics for Uncomplicated Appendicitis

  • Changing appendicitis dogma: Appendicitis has an 8% lifetime risk, yet selected adults with acute uncomplicated disease can be managed nonoperatively with antibiotics, analgesia, and close follow-up instead of automatic surgery.
  • CODA trial framing: The CODA trial randomized 1,552 adults with imaging-confirmed appendicitis and found no difference in 30-day quality of life between antibiotics and appendectomy.
  • Outpatient treatment signal: Nearly half of patients assigned to antibiotics went home directly from the ED, showing that nonoperative care can be practical outside the hospital in carefully chosen cases.
  • Appendicolith risk marker: An appendicolith was the clearest warning sign for early crossover to surgery, with higher appendectomy rates at 48 hours, 30 days, and 90 days. We get into how that changes the bedside conversation in the episode.
  • Shared decision pivot: For adults without abscess, free air, diffuse peritonitis, or septic shock, the key move is shared decision-making rather than reflexive consultation for the OR.
  • Work recovery advantage: Patients treated with antibiotics returned to work about 3.5 days sooner, a practical outcome that matters when discussing tradeoffs with patients and families.

Subscribe to ERcast: Clinical Perspectives to listen to the episode.

References:

  1. CODA Collaborative, Flum DR, Davidson GH, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020;383(20):1907-1919. doi:10.1056/NEJMoa2014320 PMID: 33017106
  2. Talan DA, Di Saverio S. Treatment of Acute Uncomplicated Appendicitis. N Engl J Med. 2021 Sep 16;385(12):1116-1123. PMID: 34525287
  3. Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg. 1995;82(2):166-169. PMID: 7749676
  4. Styrud J, Eriksson S, Nilsson I, et al. Appendectomy versus antibiotic treatment in acute appendicitis: a prospective multicenter randomized controlled trial. World J Surg 2006;30:1033-1037. PMID: 16736333
  5. Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 2009;96:473-481.  PMID: 19358184
  6. Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011;377:1573-1579. PMID: 21550483
  7. Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA 2015;313:2340-2348 PMID: 26080338 

Faculty