Ruptured Appendix

Specialties Emergency

Published

How often has anyone had their ER patient have a ruptured appy and NOT go to the OR? I had a patient with a ruptured appy who was very upset, as was the whole family and was not going to the OR.

The rationale, I'm told, is a "wait and see" approach where they're given antibiotics and are monitored for about a week. I understand that since it has ruptured, the contents (in theory) should reabsorb and perhaps wall off, but the reoccurrence of appendicitis is there in the future. People die of a ruptured appendix, I'm not understanding the simple answer here. How in this day and age, when surgery residents are gung ho to go in and operate, why they would want to NOT go in on this? The chance of overwhelming infection with a perf'd appendix seems worth the risk to me.

I wondered if there was some new literature out there that I might not know about, and as per my usual, I offered the family to ask those questions they have (even after the surgery team spent a great deal of time with them). I'm sure the trauma/surgery chief and attending will see them, as the residents spent so much time and the patient and family were so unhappy about this conservative approach.

I've been doing this a fair amount of time, and not that I know everything or anywhere near everything, but a ruptured appy has always been taken to the OR in my experience until this point. There must be more to the story with this patient. It's fascinating, but my instinct and knowing the risks of Peritonitis and further complications (fecal ball also in there with this patient), how can a "conservative" approach be safer for this patient than the OR?

She had no medical problems, no meds, no allergies. VS had been stable, but she started to look TERRIBLE in the 3 or 4 hours we were with her....

Would love to hear what you all have to write.

Interesting. Can you ask one of your docs what that's all about?

I have seen this several times here recently in my ER. The current practice is, according to our surgeons, in uncomplicated cases of appendicitis or ruptures, they treat with abx, let things cool off then evaluate removal at a different time. We have had several ruptured appys that they opted to do transcutaneous drainage of abscesses, treat with abx and evaluate weeks later. I actually saw a patient return 3 weeks after initial admission who still had not had his appendix removed. I'm not sure on the research or literature, but this is what I have seen.

Complicated cases I've seen have been involving peritonitis or evidence of sepsis.

Specializes in ER.
Interesting. Can you ask one of your docs what that's all about?

I read the operative report. That's pretty much all I need to know. There are some on the fence who will operate, others will not. I guess it's a matter of risk vs. benefit.

That's nice that you can do that. At my facility, nurses aren't allowed to look up a patient once they've left the ED, so we have to ask the doctor if we want to know anything about a patient once they're out of the department. It's a big HIPAA thing, and people have been dinged for it.

Specializes in EMERG.

I have only been an emerg nurse for a few years but my previous back ground is Gen Surg. And I have seen the wait and see approach to a ruptured appy many times. There is obviously certain criteria that go allong with it (IE: No trauma to the cecum from the rupture). The logic was explained as they are going to get the antibiotic treatment with surgical intervention or without surgery. And research has shown that the body will take care of the infection and laceration to the appy on its own almost like it would with an intra abdominal abscess, and take care of rupture same as it does with the spleen (Low grade spleen lacs/ruptures are not sent to the OR).

So we would watch appy's and give IV antibiotics. If there were any signs of infection not resolving, fever being uncontrolled, sepsis, or bleeding, then they would without question go to the OR!

This non invasive approach to appendicitis is mind boggling to alot of laymans, and medical staff alike, but I have only seen a handful of "wait and see's" go to the OR!

I can give you some first hand experience. My 19 year old son went in probably four or five days after a perf/rupture due to a high pain tolerance. They put him on IV for 4 days. He seemed to be getting some fevers at that time and more pain ) so after doing some Ultra sounds that showed massive inflammation they had to do a CT scan. After that they were able to find a route to do laparascopic surgery. With ultra sound they could not find a way to drain the abcess. Did not want to disturb the mass much All they did was put a drain in, remove some pus and did some minor irrigation. The drain filled up pretty regularly for a few days and I think they pulled it four or five days after it dried up. His WBC was over 20 when he arrived. He was negative for peritonitis or septis because his body fat, tissues and gut walled it off perfectly...as perfect as something like this can be. He was switched off IV after 5 days (drain was done on day six) and put on oral antibiotics fifth day in or so for 3 weeks after that. His WBC was about 13 on day 10 that he had been in ther...they were going to discharge him day 10, but WBC count spiked to 17 likely due lab error, so left in few more days and returned to 13 and he was discharged. After one week at home I took him back to just have WBC count checked ..it was 7. That was a request I made.

So basically 3 weeks later (2 after admission and 1 wk of being home) he was feeling much better. Just had another follow up. His laparscopic drain was basically a month ago and it has been five weeks or so since he was first admitted. He is totally back to normal now. If not for a little weight loss you would not even know he was in. He has been eating heavily for weeks. Scars from surgery completely healed, no tenderness or mass on examination. His appendix was obliterated. We are not going back for an Interval appendectomy due to doc recommendation and everything I read online. No point in doing it. So he is done. Sure there is a risk something can happen later, but that exists whether or not we do IA. But since his appendix blew up no point in going in there to poke around and likely remove debris that will be absorbed by his body anyway. Since his body was able to deal with the inital trauma quite well it can certainly handle this. He was lucky. I commend the approach taken. Maybe not all patients could handle it like he did and make no miskate he quite ill, the first six or seven days, but the conservative approach is much less riskier. You will know if it works within 3 weeks, and with how my son is now it worked very well.

Specializes in ED.

Never heard of a ruptured appy not going to surgery. Recently, the docs have been treating early appendicitis with IV abx regimen and close monitoring for about 4-5 days. Recently had my charge nurse admitted for 4 days for appendicitis, she got IV abx and morphine and DC'd home. Research shows NOT rushing to surgery with appendicitis is the best course of tx.

Specializes in Med/Surg, ICU, ER, Peds ER-CPEN.

In peds the rational we're being given is they want the infection cleared up then wait a few weeks and then take out the offending organ, heals faster, with all the infection running around it makes it harder to stitch things together and heal and has a faster recovery time.

I'm a nursing student and found this thread searching for study materials. My Med surg book says "if the appendix has ruptured and there is evidence of peritonitis or an abscess, conservative treatment consisting of antibiotic therapy and parenteral fluids is given for 6 to 8 hours before the appendectomy to prevent sepsis and dehydration. (Lewis,1021 ELSEVIER 8th edition).

Interesting to find out that there are even more conservative non surgical ways of handling it.

Thanks so much for posting! I'm sure to remember more about ruptured appendices now and it seems a lot more interesting.

When A Burst Appendix Doesn’t Kill You | CommonHealth

saw this and thought of this thread. interesting!

Specializes in ER.

great article, thanks!! Even though I understand the rationale for holding off surgery, and the infection to wall off, still that's EIGHT weeks before having it out! I think of the hassle with work, getting time off, etc.

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