Acute appendicitis–advances and controversies

Abstract

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.

Keywords: Appendicitis; Diagnosis; Management; COVID-19; Controversy; Advances

Core Tip: Many controversies exist for the management of acute appendicitis (AA). Imaging modalities complement the clinical examination in AA diagnosis. Various imaging features of different imaging modalities should be considered to reduce diagnostic inaccuracies. Various diagnostic scoring systems augment clinical judgment, but uncertainty exists about the best score. Non-operative management of both uncomplicated and complicated AA is possible and reasonable, especially during the coronavirus disease 2019 pandemic. Intra-operative techniques of securing the base of the appendix stump via suture, clips, or stapling devices are all debated for superiority. Adjuncts and novel treatment ideas using endoscopic retrograde appendicitis therapy are emerging.