Acute Appendicitis Medical Slides

Present the CODA trial (2020, NEJM): 1552 adults randomized to antibiotics (10-day course) vs appendectomy for appendicitis. Antibiotic group: 70% avoided surgery by 90 days, no increase in complications, but 29% underwent appendectomy within 90 days (mostly for recurrence or appendicolith). Key finding: among those WITHOUT appendicolith, only 25% crossed to surgery. Patients WITH appendicolith had 41% surgery rate and higher complication rate with antibiotics. Teaching message: antibiotics are a reasonable alternative for uncomplicated appendicitis without appendicolith, enabling shared decision-making particularly when surgical risk is elevated.

Present the risk-stratified approach: High clinical probability (Alvarado ≥9) — may proceed directly to surgery without imaging. Intermediate probability (Alvarado 5-8) — CT abdomen/pelvis with IV contrast (sensitivity 98.5%, specificity 98%) is gold standard. Low probability (Alvarado <5) — observation with serial exams, consider alternative diagnoses. Special populations: children/young women — ultrasound first (avoid radiation), MRI if US equivocal; pregnant women — MRI without gadolinium is preferred over CT. CT findings: appendiceal diameter >6 mm, wall thickening, periappendiceal fat stranding, appendicolith.

Present the classification and management: Gangrenous/perforated without abscess — emergent laparoscopic appendectomy (safe and preferred per AAST guidelines). Perforated with abscess (phlegmon >4 cm) — two management strategies: (1) Percutaneous drainage + antibiotics followed by interval appendectomy at 6-8 weeks (traditional approach), or (2) Early laparoscopic appendectomy (DIAMOND trial showed this is safe with similar outcomes). Important: always perform colonoscopy 6-8 weeks after abscess drainage in patients >40 to rule out underlying cecal malignancy (present in 5-10% of phlegmon cases).