Ruptured Appendix

[MassED, BSN, RN]

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.

[VICEDRN, BSN, RN]

I have never heard of a ruptured appy not going to or. I have heard and experienced a discharge of early appendicitis because there is evidence that appendicitis can resolve itself.

[Altra, BSN, RN]

While I work in a Level I trauma center with "gung ho" surgery residents, no one is ever gung ho to open up an abdomen.

I have never had a patient with this exact scenario, but I can see a non-surgical, aggressive antibiotics approach being considered.

[Anna Flaxis, BSN, RN]

How long had she been ruptured? My understanding is that if the person has been ruptured for some time (days to weeks), they might want to treat with abx and take care of infection before going in, and that it's possible that they might not need to go in if the infection resolves, hence the "wait and see".

[MassED, BSN, RN]

While I work in a Level I trauma center with "gung ho" surgery residents, no one is ever gung ho to open up an abdomen.

I have never had a patient with this exact scenario, but I can see a non-surgical, aggressive antibiotics approach being considered.

I, too, work in a level 1 and haven't dealt with this type of scenario before. Not so sure that just antibiotics is considered the aggressive non-surgical approach, but will find out soon enough and will repost back with any update.

[MassED, BSN, RN]

How long had she been ruptured? My understanding is that if the person has been ruptured for some time (days to weeks), they might want to treat with abx and take care of infection before going in, and that it's possible that they might not need to go in if the infection resolves, hence the "wait and see".

not sure how long she had been ruptured, but she had been in pain for less than a day when she came in. I can see about waiting to see if abx improves her s/s. I will check the status shortly and post back.

[srobb11]

Here's my personal experience...my appendix ruptured about 4 years ago and I wasn't taken to the OR initially. I spent 7 days in the hospital with intense antibiotic treatment, a drain was inserted into my abdomen 3 days into my hospital stay to drain the contents, was sent home on antibiotics, then approx 4 weeks after I was discharged I went back and the surgeon went in laparoscopic and took out what was left of the appendix. I was shocked as well when the surgeon laid out his plan. I called my primary doc, she checked with other surgeons and come to find out this wasn't unusual. It is apparently less of a risk to treat the infection and later go in than to go "gung ho" and open an infected abdomen.

We had a patient in the ER not too long ago with a rupture, but the surgeon on call refused to touch him and instead transferred him to a larger hospital...still scratching my head on that one.

[bjaeram]

We just had this last night and the surgeon did the same thing. Antibiotics, watch and surgery in a week or so when it isn't so risky. Your surgeon is not crazy!

[nursegirl75]

Same thing happened at the hospital I worked at. THe OR doctor refused to do surgery because the appendix had ruptured about 4 days ago. Instead we treated the patient with aggressive antibiotics. Although the family members were upset and demanded the pt be taken to surgery, the OR doctor refused.

[sharkdiver]

Did a little research.

A recently released study in the UK concluded that antibiotics are a safe and effective initial therapy for patients with uncomplicated acute appendicitis, which statistically is about 80% of cases. Further, they found that antibiotics alone were an effective treatment for 63% of those cases, eliminating the need for follow-up surgery.

Their key findings:

- antibiotics had a 63% success rate at one year

- compared to surgery, antibiotic treatment had a 39% reduced risk of complications

- 20% of those treated with antibiotics had return symptoms and returned to the hospital, of which 19% had complicated appendicitis

- the length of hospital stay was not different between antibiotic and surgery groups

Sounds promising to me......

[MassED, BSN, RN]

Did a little research.

A recently released study in the UK concluded that antibiotics are a safe and effective initial therapy for patients with uncomplicated acute appendicitis, which statistically is about 80% of cases. Further, they found that antibiotics alone were an effective treatment for 63% of those cases, eliminating the need for follow-up surgery.

Their key findings:

- antibiotics had a 63% success rate at one year

- compared to surgery, antibiotic treatment had a 39% reduced risk of complications

- 20% of those treated with antibiotics had return symptoms and returned to the hospital, of which 19% had complicated appendicitis

- the length of hospital stay was not different between antibiotic and surgery groups

Sounds promising to me......

that would be for uncomplicated appendicitis.

[MassED, BSN, RN]

so an update:

The patient was taken to the OR after a sudden "change in exam." Must have been less than 12 hours after being diagnosed with ruptured appy.

hmmmmm.