Research Paper Effectiveness of conservative management of uncomplicated acute 

appendicitis: A single hospital based prospective study 

Mumtaz KH. Alnaser a, Qays A. Hassan b, *, Laith N. Hindosh a 
a 
Department of Surgery, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq b Section of Radiology, 
Department of Surgery, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq 
a r t i c l e i n f o 
Article history: Received 8 November 2017 Received in revised form 19 November 2017 Accepted 19 November 2017 Available 
online 6 December 2017 
Keywords: Acute appendicitis Conservative treatment Surgery Antibiotics 
a b s t r a c t 
Background: Acute appendicitis is one of the commonest causes of acute abdomen. There is a wide discussion and controversy 
on the surgical and nonsurgical treatment of acute uncomplicated appen- dicitis. The aim of this study was to evaluate the 
efficacy and outcomes of the conservative management of selected cases of acute appendicitis with an antibiotic first plan. 
Patients and methods: This was a single hospital-based prospective study with a duration of 25 months. Patients with clinical and 
radiological features of acute appendicitis presenting within 72 h of the beginning of abdominal pain with Alvarado score 5 were 
included. The patients received a therapeutic dose of broad-spectrum antibiotics and symptomatic treatment. The follow-up 
period was 6 months. Results: 90 patients were evaluated, 54 (60%) patients were female and 36 (40%) patients were male with 
mean age 34.4 years. Conservative treatment was successful in 68 (75.6%) patients and failed in 22 (24.4%) patients. No 
mortality recorded in this study. The main complications which occurred in those patients who failed to respond to conservative 
treatment were perforated appendicitis (3 patients), appendicular abscess (3 patients) and appendicular mass (4 patients). 
Conclusion: Majority of cases of the first attack of uncomplicated acute appendicitis can be treated successfully by conservative 
treatment. However, conservative treatment demands precise communi- cation, close monitoring and follow-up to recognize 
failure which needs to be treated immediately by surgery. © 2017 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. 
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 
1. Introduction 
Acute  appendicitis  is  one  of  the  most  common  surgical  emer- gencies seen in general surgery practice. Complications can be 
severe  and  include  perforation  and  generalized  peritonitis.  Currently,  ap-  pendectomy  has  been  the  primary  treatment,  even  in 
cases  of  un-  confirmed  diagnosis,  given  the low incidence of major complications. However, in 15e30% of cases the appendix is 
found  to  be  free  of  disease  upon  resection  [1,2].  Appendectomy  can  result  in  many  complications  such  as  surgical  wound 
infection, intestinal obstruc- tion due to adhesions, pneumonia, and tubal infertility in females. 
Non-operative  treatment  of  an  uncomplicated  acute  appendi-  citis has safety implications. But delaying surgery may increase 
the risk of perforated appendicitis, intra-abdominal abscesses, and localized or diffuse peritonitis. 
Surgery  may  be  associated  with  a  longer  hospital  stay  and  higher  costs  compared  with  nonoperative  management  with  an- 
tibiotics,  but  delayed  treatment  and  a  perforated  appendix  may  worsen  morbidity,  duration  of  sick  leave  and  costs.  However, 
nonoperative  management  with  antibiotics  may be a cost-effective alternative to surgery in a large percentage of patients without 
increasing the risk and may reduce hospital stay and costs in both developed and third world countries [3]. 
There  is  considerable  discussion  regarding  the  application  of  conservative  treatment  compared  with  surgical  treatment  in 
selected cases of acute appendicitis, as few studies have addressed this issue to date [4,5]. 
The  idea  of  application  of  conservative  treatment  on  selected  cases  of  acute  appendicitis  is  not  new.  In 1908 Alfred Stengel 
wrote: “Treated in a purely medical or temporary manner, the great ma- jority of patients with appendicitis recovery” [6]. 
Other reports state that immediate appendectomy can be 
* Corresponding author. Baghdad University, Al-Kindy College of Medicine, Al-Nahdha Square, 10071, Baghdad, Iraq. 
avoided for at least 24 h without increasing morbidity if antibiotics are administered [7,8]. Other authors suggest that 
appendectomy 
E-mail address: [email protected] (Q.A. Hassan). 
may not be necessary for the majority of patients with acute 
International Journal of Surgery Open 10 (2018) 1e4 
Contents lists available at ScienceDirect 

International Journal of Surgery Open 

journal homepage: www.elsevier.com/locate/ijso 
https://doi.org/10.1016/j.ijso.2017.11.007 2405-8572/© 2017 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. 
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). 
 
without uncomplicated appendicitis, as the condition resolves spontane- 
the need for surgical intervention and no 
appendicitis ously without the need for a surgical procedure in many patients 
during a follow-up of 6 months. and in others may be 
treatable with antibiotics alone [9]. This 
Failure of conservative treatment was divided into 
two sections. approach has many advantages, including high success and low 
First, treatment failure which indicates a lack of 
clinical improve- recurrence rates, reduced morbidity and mortality, less pain, 
ment, necessitating appendectomy while attempting 
conservative shorter hospitalization and sick leave, and reduced costs [10]. 
treatment in the admitted patient. Second, recurrence 
which in- The aim of this study was to evaluate the effectiveness of con- 
dicates repeated symptoms or disease within the 
follow-up period servative treatment in uncomplicated acute appendicitis using 
of 6 months in an earlier successfully conservatively 
managed antibiotic as a first treatment plan and to assess the treatment 
patient. failure. 
2.1. Statistical analysis 2. Patients and methods 
Statistical package for social science version 20 (SPSS 
20) was This study was carried out in our hospital from January 2015 to 
used for both data entry and data analysis. Discrete 
variable pre- December 2016. A total of 90 patients were enrolled in this study 
sented as number (%). Chi-square test (or fisher exact 
test when based on the inclusion and exclusion criteria. Informed consent for 
appropriate) used to test the significance of association 
for the all patients, as well as ethical approval for the study from the 
discrete variable. p-value of <0.05 were considered 
significant. hospital scientific committee, were obtained. All patients above 16 years of age with a history of pain in right iliac 
fossa for less than 
3. Results 72 h and clinically diagnosed as the first 
attack of appendicitis with Alvarado score 5 (Table 1) were included in this study. Ultrasound 
In this study, 90 cases of uncomplicated acute 
appendicitis were of abdomen and pelvis was done for all patients to confirm the 
included and managed conservatively. 54 (60%) 
patients were fe- clinical diagnosis of acute appendicitis and to exclude the possi- 
male and 36 (40%) patients were male. Mean age was 
34.4 year and bilities of other intraabdominal pathologies. The specificity and 
range between 16 and 60 years. Table 2 show the age 
distribution of sensitivity of ultrasound in our institution to diagnose acute 
the study. The maximum number of patients (40%) 
belonged to age appendicitis was 86.6% and 86.5% according to recent study done by 
 group 20e29 years. Al-Marzooq et al. [11]. 
Sixty (66.7%) patients presented with signs and 
symptoms of Exclusion criteria included recurrent appendicitis, patients 
acute appendicitis to the hospital with time interval 24 
h, 18 (20%) presented with complicated appendicitis such as perforation, ab- 
patients presented with time interval 24e48 h and 18 
(20%) pa- scess, mass on clinical examination or radiological reports, those 
tients presented with time interval 48e72 h as shown in 
Table 3. who are lost during follow-up and patients unwilling for conser- 
In the 90 patients who were managed 
conservatively for un- vative management, patients with a medical disease such as dia- 
complicated acute appendicitis, conservative treatment 
was suc- betes mellitus and hypertension, immunocompromised patients, 
cessful in 68 (75.6%) patients with no treatment failure 
or recurrence pregnancy and allergy to antibiotics. 
in the follow-up period of 6 months. However, in the 
remaining 22 All patients meeting the inclusion criteria then admitted to the 
(24.4%) patients, conservative treatment was failed. 
Treatment fail- hospital and received intravenous antibiotics (cefotaxime 1 g twice 
ure during initial admission was seen in 10 patients 
(11.1%) whereas daily and metronidazole infusion 500 mg/100 ml 3 times per day) 
recurrence was seen in 12 patients (13.3%) cases who 
were suc- for at least 24 h. During this time patients received intravenous 
cessfully managed during primary admission (Table 
4). fluids, no oral intake with 6 hourly charts for (temperature, blood pressure, pulse rate, respiratory rate and local abdominal 
sign). Patients whose signs and symptoms had improved discharged home at the next morning and informed to continue with oral 
antibiotics (ciprofloxacin 500 mg twice a day and metronidazole 500 mg three times a day) for a total of 10 days. In patients 
whose clinical condition had not improved and did not respond to con- servative treatment or worsened were operated by 
appendectomy. Patients were told to contact immediately if pain recurs, vomiting and fever had occurred. Follow-up at the end of 
treatment for six months was done. Patients were told to inform us if they under- went an operation in somewhere else. 
Successful conservative treatment was defined as being dis- charged from the hospital following the resolution of symptoms 
Table 1 Alvarado score. 
Score 
Symptoms Migratory RIF pain 1 Anorexia 1 Nausea and vomiting 1 Signs Tenderness (RIF) 2 Rebound tenderness 1 Elevated 
temperature 1 Laboratory Leukocytosis 2 Shift to left 1 Total 10 
Table 2 Age distribution of the study. 
Age (years) No. of patients (%) Mean age 
19 6 (6.6) 17 20e29 36 (40) 26 30e39 24 (27) 34 40e49 18 (20) 42 50e60 6 (6.6) 53 Total 90 (100) 34.4 
Table 3 Number of the patients according to the duration of presenting symptoms. 
Hours of attack of appendicitis No. of the patients (%) 
24 h 60 (66.7) 24e48 h 18 (20) 48e72 h 12 (13.3) Total 90 (100) 
Table 4 Outcomes of conservative treatment. 
Outcome No. of the patients (%) 
Successful 68 (75.6) Treatment failure 10 (11.1) Recurrence 12 (13.3) 
M.KH. Alnaser et al. / International Journal of Surgery Open 10 (2018) 1e4 2 
 
Out  of  22  patients  who  failed  to  respond  to  conservative  treat-  ment,  10  patients  were  operated  after  2  days  of treatment, 5 pa- 
tients  were  operated  after  completion  of  treatment  course  after 10 days and 7 patients were operated during the follow-up period 
of 6 months as shown in Table 5. 
In  the  operated  patients,  12  patients  had  acute  suppurative  appendicitis, 3 patients had perforated appendix, 3 patients had an 
appendicular abscess and 4 patients had an appendicular mass. 
Our  results  showed  that  the  gender,  the  age  and  the  duration  of  attacks  of  appendicitis  had  no significant association effects 
with the outcomes of the conservative treatment as illustrated in Table 6. 
4. Discussion 
Acute  appendicitis  is one of the commonest causes of acute abdomen. Although appendectomy has been regarded as the gold- 
standard,  conservative  management  with  antibiotics  is  gaining  more  and  more  acceptance.  There  are  many  advantages  of  con- 
servative  treatment  (i.e.  antibiotic  treatment)  over  surgical  treat-  ment.  Antibiotics  give  the  chance  to  treat  acute  appendicitis 
when  surgical  means  are  not  readily  accessible  particularly  in developing countries and isolated areas. Conservative treatment is 
associated  with  less  cost  effect  balanced  to  surgery  [12].  Antibiotic  treatment  can  reduce  the  mortality  and  morbidity  risk 
associated with surgery. 
In  the  present study, 68 patients (75.6%) out of 90 patients were treated with the conservative method and 10 patients (11.1%) 
failed  to  respond  to  conservative  treatment  and  had  been  operated  and  further  12  patients  (13.3%)  show  recurrence  of 
appendicitis  during  the  follow-up  period.  So  a  total  of  22  patients  were  failed  to  respond  and  the  failure  rate  was  24.4%.  In  a 
similar  study  done  in  Sahlgrenska  University  Hospital  (between May 2009 and February 2010) involving 442 patients show that 
342  patients  (77.4%)  treated  conservatively  successfully  and  100  patients  (22.6%)  failed  to  respond  to  conservative  treatment 
[13],  which  nearly  resemble  our  study  results.  Another  study  which  was  done  in  the  surgical  department  of  GMERS  Medical 
College,  Gandhinagar  between  years  2011e2013,  that  involve  a  sample  of  30  patients  undergoing  con-  servative  management 
show  that  21 patients (70%) treated conservatively successfully and 9 patients (30%) failed to respond conservatively [14]. These 
results nearly resemble our results. Our 
M.KH. Alnaser et al. / International Journal of Surgery Open 10 (2018) 1e4 3 
study  results  also  agree  with  a  recent  study  done  in  India  in  2016  by  Gedam PS. Et al which involved 71 patients and showed a 
suc- cessful rate 74.65%, treatment failure rate 14.08% and recurrence rate 13.11 [15]. 
We  used  third generation cephalosporin and metronidazole in all our patients treated conservatively. This was same as used in 
most  randomized  control  trials.  Similar  results  were  found  by  Vons  C  et  al.  using  amoxicillin  plus  clavulanic  acid  [16]  and 
Turhan et al. using ampicillin plus gentamycin [17]. 
Our  results  show  that  the  gender  distribution,  the  difference  in  the age groups and the difference in time of presenting illness 
had no significant effect on the outcomes of conservative treatment of acute appendicitis. 
5. Conclusions 
This  study  evaluated conservative treatment in uncomplicated acute appendicitis and was conducted in a single-based hospital 
for  a  period  of  2  years.  Conservative  treatment  can  be applied safely in the majority of cases of the first attack of uncomplicated 
acute  appendicitis,  therefore,  avoiding  appendectomy  and  its  associated  morbidity  and  mortality.  However,  conservative 
treatment  requires  close  monitoring  and  repeated  re-evaluation  of  the  clinical  condi- tion of the patients to recognize a failure in 
improvement  of  clinical status, which needs to be treated immediately by surgery. Treat- ment failure on initial admission as well 
as the short-term recur- rence after conservative treatment is low and acceptable. 
Ethical approval 
The  ethical  approval  for  the  study  from  the  hospital  scientific  committee  was  obtained.  The  relevant  Judgement’s  reference 
number is 111/2015 (Alkindy Teaching Hospital). 
Funding 
None. 
Author contribution 
 Mumtaz  KH  and  Qays  A.  contributed  towards  conceptualization  of  study  design.  Mumtaz  KH  &  Laith  N.  were  involved in 
data  abstraction  and  analysis.  Qays  A.  &  Laith N. involved in preparation of the manuscript. Mumtaz KH and Qays A. reviewed 
and  edited  subsequent  drafts  and  provided  valuable  feedback.  All  authors  approved  the  final  version  of  the  manuscript  for 
submission. 
Conflicts of interest statement 
The authors declare that they have no conflict of interest. 
Guarantor 
Qays A. Hassan. 
Research registration number 
Research registry 3244. 
Appendix A. Supplementary data 
Supplementary data related to this article can be found at https://doi.org/10.1016/j.ijso.2017.11.007. 
Table 5 Appendectomies after trial of conservative treatment. 
Time of interval appendectomy No. of the patients (n 1⁄4 22) 
Surgery after 48 h of treatment 10 Appendectomy after 10 days of treatment 5 Appendectomy within 6 months 7 
Table 6 Outcomes of conservative treatment according to the gender and age distribution and duration of attacks of appendicitis. 
Variables Outcomes of conservative treatment p-value 
Success Failure 
Gender Male 26 (72.2%) 10 (27.8%) 0.72 
Female 42 (77.8%) 12 (22.2%) Age group 20 4 (66.7%) 2 (33.3%) 0.84 
21e30 33 (91.7%) 3 (8.3%) 31e40 18 (75%) 6 (25%) 41e50 10 (55.5%) 8 (44.5%) 51e60 3 (50%) 3 (50%) Hours of attack 
of appendicitis 
24 h 52 (86.7%) 8 (13.3%) 0.085 24e48 h 11 (61.1%) 7 (38.9%) 48e72 h 4 (33.3%) 8 (66.7%) 
 
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