A recent study in JAMA Surgery has recommended evaluation for appendicoliths in patients with acute appendicitis being managed with antibiotics to assess the need for appendicectomy at a later date.

Researchers examined data from 776 patients treated with antibiotics in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for this multicenter study conducted at 25 medical centers in the US enrolled between May 2016 and February 2020. The primary outcome examined the risk factors associated with the need for an appendicectomy within 30 days of starting antibiotic treatment. The study group included 286 women and 490 men. Data analysis was done between September 2020 and July 2021.

The 30-day data was available for 735 patients; 154 (21%) of these underwent appendectomy within 30 days. Factors found to increase the chances of surgery at 30 days were female sex (odds ratio 1.53), wider appendiceal diameter on imaging (OR per 1-mm increase 1.09) and the presence of appendicolith (OR 1.99). Overall, 212 (27%) patients were found to have an appendicolith on imaging. Sixty-five patients (42%) who underwent surgery at 30 days had an appendicolith, whereas among patients who did not have an appendicectomy, 138 (24%) had an appendicolith.

However, no significant association was observed for factors like older age, presence of comorbid disease that are commonly considered as risk factors for complications or severity of appendicitis as depicted clinically by presence of fever (OR 1.28) and white blood cell count (OR 1.03 per 1,000 cells/μL increase).

In this secondary analysis of data from the CODA trial, the presence of appendicolith nearly doubled the risk of appendicectomy within 30 days. In comparison, severity of appendicitis, which has been traditionally used as a guide to take a decision about surgery, did not show such association. Studies have shown that acute appendicitis can be managed conservatively with antibiotics. However, recognizing patient factors, as illustrated in this study, may help in individualized decision-making regarding approach to treatment.

Reference

1. Writing Group for the CODA Collaborative, Monsell SE, et al. Patient factors associated with appendectomy within 30 days of initiating antibiotic treatment for appendicitis. JAMA Surg. 2022 Jan 12:e216900. doi: 10.1001/jamasurg.2021.6900