Universidad de Guadalajara

Centro Universitario de Ciencias de la Salud

Lic. Médico Cirujano y Partero
Materia: Genética Medica
Profesor: Bobadilla Morales, Lucina
Sección: E07

ARTICULO DOS

Alumno: Ángel Elías Álvarez González

Código: 217782606
Correo: elias.alvarez@alumnos.udg.mx
Apendicitis complicada y consideraciones de apendicectomía de intervalo

La apendicitis aguda ocurre cuando la luz del apéndice vermiforme se inflama, generalmente debido
a una obstrucción causada por fecalitos, hiperplasia linfoide, infección parasitaria o un tumor; estos
tumores pueden ser carcinoide, adenocarcinoma, mucocele o carcinoma metastásico.
La apendicitis se divide en dos formas: complicada y no complicada. La apendicitis aguda no
complicada es la apendicitis aguda sin ningún signo de perforación, absceso o flemón; la apendicitis
complicada es cuando hay ruptura apendicular y genera formación de abscesos o flemones.
Aunque a cualquier edad se puede presentar la apendicitis, existe prevalencia en personas de 10 –
30 años. Aun así, esto varia con más especificidad ya que la apendicitis aguda no complicada es más
común en jóvenes y adultos jóvenes; la apendicitis no complicada es más común en niños porque
que a menudo no pueden comunicar sus síntomas de dolor de está generando complicaciones y
retraso para que se lleve una correcta atención y adultos mayores porque e la demencia, otros
déficits cognitivos o cambios relacionados con la edad en los receptores del
dolor reducen la capacidad de sentir dolor.

La sintomatología de una apendicitis es la presentación de dolor en cuadrante inferior derecho

(RLQ), seguido de pérdida de apetito, náuseas y vómitos. La puntuación de Alvarado es un sistema
de puntuación validado que utiliza una combinación de síntomas del paciente, signos físicos y
valores de laboratorio para ayudar en el diagnóstico de apendicitis.
Puntaje de Alvarado

Una puntuación de 3 o menos de un total posible de 10 significa una baja posibilidad de

apendicitis aguda. Las puntuaciones de 4 a 6 son equivocas y exigen una tomografía
computarizada u otro estudio de imagen para confirmar el diagnostico de apendicitis aguda.
Una puntuación de 7 o más está altamente
correlacionada con la apendicitis aguda y requiere consulta quirúrgica y apendicetomía. La
utilidad del puntaje de Alvarado es limitada en mujeres, niños y adultos mayores.

Valor

Síntomas Migración 1

Anorexia-acetona 1

Náuseas-vómitos 1

Señales Termura en RLQ 2

Dolor de rebote 1

Elevación de la temperatura 1

Resultados de laboratorio Leucocitosis 2

Desplazamiento a la izquierda 1
Laparoscopia, es el método más común y menos invasivo para abordar un caso de apendicitis
(diagnóstico y extracción), este consiste es la realización de tres incisiones pequeñas (5 mm a 10
mm): una justo debajo o arriba del ombligo para los trócares, una en el cuadrante inferior izquierdo
y otra en la línea media inferior o en el cuadrante superior derecho.
 REVIEW ARTICLE

Complicated appendicitis and considerations

for interval appendectomy
Kelly Sue Perez, PA-C; Steven R. Allen, MD, FACS

Source: Siegel, M.S., and Coley, B. (2005). Core Curriculum: Pediatric Imaging.
ABSTRACT
Acute appendicitis is one of the most common surgical
emergencies. Of the 300,000 appendectomies performed
each year, 25% are due to complicated appendicitis. This
article reviews the incidence and pathophysiology of acute

Philadelphia, PA: Wolters Kluwer Health and Pharma.

appendicitis, the nonoperative management of complicated
appendicitis, and the rationales for and against interval
appendectomy.
Keywords: complicated appendicitis, interval appendectomy,
emergency surgery, Alvarado score, phlegmon, colonoscopy

A
ppendicitis is a common cause of abdominal pain
and represents one of the most common surgical
emergencies worldwide (Figure 1).1 Acute appen-
dicitis occurs when the lumen of the vermiform appendix
becomes inflamed, typically due to an obstruction.2 The
obstruction can be caused by a fecalith (“fecal stone” or
mass of feces), lymphoid hyperplasia (most commonly
in the young), a rare parasitic infection, or a tumor.3,4
These tumors can be carcinoid, adenocarcinoma, muco-
cele, or metastatic carcinoma.2
Appendicitis often is separated into uncomplicated or
complicated forms (Table 1). Uncomplicated is acute
appendicitis without any signs of perforation, abscess, or
phlegmon; complicated appendicitis is a result of appen-
diceal rupture with subsequent abscess or phlegmon
formation.
Patients of any age may develop appendicitis but it is
most common in those ages 10 to 30 years.3,5 Uncompli-
cated acute appendicitis is most common in adolescents
and young adults and complicated appendicitis is most
common in the very young and very old. Toddlers and
younger children are often unable to communicate their
symptoms of pain in the same manner as an adolescent or
At the time this article was written, Kelly Sue Perez practiced in the
Division of Trauma, Acute Care, and Critical Care Surgery at Penn
State’s Milton S. Hershey Medical Center in Hershey. Pa. She now
practices at Las Vegas (Nev.) Urology. Steven R. Allen is an associate
professor of surgery at Hershey Medical Center. The authors have
disclosed no potential conflicts of interest, financial or otherwise.
DOI:10.1097/01.JAA.0000544304.30954.40
Copyright © 2018 American Academy of Physician Assistants
FIGURE 1.
Appendicitis with subphrenic abscess (arrows) in a different patient.
adult and therefore there may be a significant delay in
evaluation, diagnosis, and treatment. Similar delays may
occur for older adults because dementia, other cognitive
deficits, or age-related changes in pain receptors reduce
the ability to feel pain (Table 1).
Although acute appendicitis affects males and females
in a nearly equal distribution, complicated appendicitis
may occur slightly more often in males.6 Other demo-
graphic differences between patients with uncomplicated
and complicated appendicitis include mean time with
symptoms (less than 24 hours for uncomplicated appen-
dicitis compared with 48 hours or more for complicated
appendicitis) as well as the distance the patient may live
from the hospital. Studies have demonstrated that patients
who live farther from the treatment facility are more
likely to be diagnosed with complicated appendicitis
(Table 2).6-9
The classic presentation is right lower quadrant (RLQ)
pain, followed by loss of appetite, nausea, and vomiting.
For about 60% of patients, pain typically starts in the
periumbilical region and then localizes in the RLQ.4 The
location of the appendix in the RLQ varies in each patient.
This variable location (for example, retrocecal or pelvic)

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Copyright © 2018 American Academy of Physician Assistants

REVIEW ARTICLE
Key points
Of the 300,000 appendectomies performed each year,
25% are associated with complicated appendicitis.
The decision to operate on a patient with complicated
appendicitis is controversial; however, early operative
intervention can disrupt the inflammation and lead to
complications.
Typically, surgeons treat the patient nonoperatively by
having the abscess drained and administering IV and
oral antibiotics.
Interval appendectomy may be performed 8 to 12 weeks
after successful nonoperative management of a perforated
appendix.
helps to predict location, quality, and severity of pain that
may be considered atypical, mimicking other abdominal
diseases.10 Patients with appendicitis also may have a fever
and an elevated white blood cell (WBC) count. The higher
the WBC count, the greater the risk that the appendix is
gangrenous or perforated (Table 1).3,11
Although not required for diagnosis, imaging modalities
such as CT scans, ultrasound, and MRI may be used to
confirm the diagnosis of appendicitis. CT is the most
common imaging modality used; it can identify inflam-
mation of the appendix, exact location of the appendix,
and help to rule out other possible causes of pain if the
patient presentation is unclear. CT findings that are
indicative of appendicitis include appendiceal diameter
greater than 6 mm and wall thickness greater than 2 mm,
fecalith, and/or periappendiceal inflammation.3,11
Ultrasound or MRI may be used to evaluate for appen-
dicitis, especially in children and in pregnant patients who
should avoid ionizing radiation.3 If the patient has all the
TABLE 1. Characteristics of uncomplicated and complicated acute appendicitis
Uncomplicated
Children and young adults
Equal distribution between men and women
Short symptom duration (24 hours or less)
Elevated WBC count (greater than 10,000 cells/mm3)*
Elevated C-reactive protein (CRP) (greater than 40 mg/L)*
Similar physical signs and symptoms: RLQ pain, nausea and vomiting, diarrhea, anorexia, and fever. Dysuria is more frequent in
patients with complicated appendicitis.
* Elevated WBC count is more predictive of uncomplicated appendicitis compared with mildly elevated CRP; however, significantly elevated CRP is most
predictive of complicated appendicitis compared with variably elevated WBC alone.
36 www.JAAPA.com
Copyright © 2018 American Academy of Physician Assistants
signs and symptoms of appendicitis, a surgeon may choose
to forego the imaging and operate knowing that in 15%
to 30% of these patients, the appendix may be normal and
without inflammation.12
Multiple clinical indicators are used to diagnose acute
appendicitis. The Alvarado score is a validated scoring
system that uses a combination of patient symptoms,
physical signs, and laboratory values to aid in the diagno-
sis of appendicitis (Table 3).13 Although this scoring system
does not offer 100% sensitivity or specificity, higher scores
(7 or greater) were predictive of the need for appendectomy,
especially in males; patients with equivocal scores (4-6)
should be observed closely.13 Use of the Alvarado score in
women is more difficult due to the presence of gynecologic
disorders that may mirror signs and symptoms of appen-
dicitis. In these cases, Alvarado recommended a pelvic
examination to help rule out gynecologic sources.13 Mul-
tiple studies have worked to validate the Alvarado score
in multiple populations.13-15 Ohle and colleagues performed
a systematic review that demonstrated this scoring system
as a useful tool to rule out acute appendicitis in patients
with a score of less than 5.16 The authors also concluded
that the Alvarado score was well suited to make the diag-
nosis of acute appendicitis in men, was inconsistent in
children, and overpredicts appendicitis in women due to
the inclusion of gynecologic factors within the differential
diagnosis across all risk strata.16
A study by McKay and Shepherd found that although
higher scores (greater than 7) were predictive of the
need for surgical intervention, in equivocal Alvarado
scores (4 to 6), adjunctive CT scan is recommended to
confirm the diagnosis.17 The authors also found that
patients with Alvarado scores of 3 or lower did not
warrant a CT scan, as their likelihood of acute appen-
dicitis was sufficiently low.17
Complicated
Children under age 3 years and adults over age 65 years
Slightly increased incidence in men
Longer symptom duration (48 hours or more)
Significantly elevated WBC count (16,000 cells/mm3 or greater)*
Significantly elevated CRP (greater than 140 mg/L)*
Volume 31 • Number 9 • September 2018
 Complicated appendicitis and considerations for interval appendectomy

Before laparoscopy, open appendectomy was the only

TABLE 2. Demographic and clinical differences
surgical option. The surgeon examined the patient for the
in patients with appendicitis
point of maximal tenderness or a palpable mass. Once
this point was detected, the incision was placed at that Factors
Uncomplicated Complicated
specific location; alternately, the incision was placed at appendicitis appendicitis
one-third the distance from the anterior superior iliac Age: mean (range)* 31 years (7-79) 44 years (3-81)
spine to the umbilicus, also known as McBurney point.10
Laparoscopic surgery has been helpful in safely and effec- Equal distribution between More males than
Sex
males and females females
tively diagnosing the disease as well as removing the
Mean miles from
appendix.18 Laparoscopy has become the favored approach hospital*
<20 miles <20 miles
for noncomplicated appendicitis over the past 15 years
Mean time with
(Figure 2).18 symptoms*
<24 hours >48 hours
Port placement in the laparoscopic approach can vary;
RLQ pain* 49% 59%
the key is to maximize triangulation so that the appen-
dix is easily seen and surgery can be performed safely Nausea/vomiting 68% 69%
and effectively. The laparoscopic approach uses three
Diarrhea 9% 15%
small (5 mm to 10 mm) incisions: one just below or
above the umbilicus for the trocars, one in the left lower Anorexia 63% 63%
quadrant, and one in the lower midline or in the right
upper quadrant.6 Dysuria 3% 7%
Complicated appendicitis About 300,000 appendecto- Mean temperature 98.8° F 99.2° F
mies are performed each year; complicated appendicitis
accounts for nearly 25% of these cases.4,19,20 Complicated Mean WBC count* 13,400 cells/mm3 16,000 cells/mm3
appendicitis is defined as a perforation of the appendix Mean CRP (mg/L)* 38 (15-77) 124 (71-187)
that develops into a phlegmon (an ill-defined mass of
inflammatory tissue) or abscess if contained.19 A phlegmon
may mature into a well-delineated, walled-off fluid col- * demonstrates significant differences between uncomplicated and
lection, or abscess, that can be visualized on CT or complicated appendicitis.6-9

ultrasound.2,21 About 20% of patients who present with

a perforation will develop an abscess.20 TABLE 3. Alvarado score (MANTRELS mnemonic)13
The decision to operate on a patient with complicated
appendicitis is controversial. The surgeon must decide which A score of 3 or lower out of the possible total of 10 means a
low probability of acute appendicitis. Scores of 4 to 6 are
approach to take depending on the patient and the surgeon’s equivocal and call for a CT scan or other imaging study to
comfort level. Typically, surgeons treat the patient nonop- confirm a diagnosis of acute appendicitis. A score of 7 or
eratively by having the abscess drained by interventional greater is highly correlated with acute apendicitis and calls for
radiology and administering IV and oral antibiotics.22 Con- surgical consultation and appendectomy. The Alvarado score’s
sideration for an interval appendectomy (done after the patient usefulness is limited in women, children, and older adults.
has waited a period of time) follows the successful nonop- Value
erative management of the perforated appendix. Interval
appendectomy usually is performed 8 to 12 weeks after Migration 1
symptom resolution.23 The rationale for the delay is to let the Symptoms Anorexia-acetone 1
inflammation subside, making the procedure less difficult.24
For the nonoperative pathway, surgeons recommend that Nausea-vomiting 1
patients undergo a screening colonoscopy or barium enema Tenderness in RLQ 2
as part of their preoperative workup to evaluate for other
possible causes that mimic complicated appendicitis, such Signs Rebound pain 1
as inflammatory bowel disease (IBD) or colorectal cancer.25 Elevation of temperature 1
A repeat CT scan is indicated for patients who have con-
tinued pain and/or other symptoms suggesting the appen- Leukocytosis 2
Laboratory results
dicitis is still active. Shift to the left 1

TREATMENT DILEMMAS
Appendectomy at initial hospitalization Patients who pres- laparoscopic approach may be appropriate, surgeons also
ent with complicated appendicitis and generalized perito- must consider an open appendectomy or even an explor-
nitis require emergency surgical intervention. Although a atory laparotomy to ensure adequate visualization of the

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Copyright © 2018 American Academy of Physician Assistants

REVIEW ARTICLE

cecum and appendix and adequate irrigation if the perito- ics and drainage of the periappendiceal abscess, leads to
neal cavity has significant purulent or fecal soiling. symptom resolution in about 90% of patients.27 Studies
Patients who present with localized abdominal pain and have demonstrated a 5% to 15% recurrence rate.19,20,25,26
evidence of a contained perforation of the appendix also A meta-analysis by Simillis and colleagues supported non-
may be considered for an acute appendectomy (laparoscopic operative treatment in patients with complicated appendi-
or open). However, early operative intervention can disrupt citis.28 This treatment was shown to result in fewer overall
the inflammation and lead to complications. For example, complications (odds ratio [OR] 0.24; 95% confidence
a contained perforation may become a free perforation that interval [CI] 0.13-0.44), wound infections (OR 0.28; 95%
requires significant irrigation and washout to minimize CI 0.13-0.60), abdominal/pelvic abscess (OR 0.19; 95%
abscess formation.26 Additionally, significant inflammation CI 0.07-0.58), ileus/bowel obstruction (OR 0.35; 95% CI
in the area of the cecum may make closure of the appendi- 0.17-0.71), and reoperation (OR 0.17; 95% CI 0.04-0.75).
ceal stump difficult and a larger operation such as ileocecec- About 14% of patients have recurrent appendicitis after
tomy may need to be performed. initial nonoperative treatment.26 In many patients, appen-
IV antibiotics and abscess drainage Initial nonoperative dicitis recurs within 12 weeks and responds to further
treatment for complicated appendicitis, including antibiot- nonoperative treatment, although about 50% of patients
require percutaneous drainage
of the collections (Figure 3).26
FIGURE 2.
Interval appendectomy: Both
General algorithm describing care pathway for appendicitis31 sides of the coin Subsequent
treatment for patients who ini-
tially undergo nonoperative
Patient arrives to ED with abdominal pain RLQ pain, nausea/vomiting, diarrhea, fever management remains contro-
versial. Patients may or may
not undergo an interval appen-
dectomy (Figure 3).
Although surgery carries
Female Male risks, it also may uncover an
additional diagnosis. Lugo and
colleagues found that a subset
Alvarado score Alvarado score of patients benefited from inter-
val appendectomy because it
also revealed other conditions
that required treatment.29 In the
Moderate Moderate study of 46 patients (mean age,
Low (<3) High (>7) High (>7) Low (<3) 43 years), 16% of patients had
(4 to 6) (4 to 6)
a normal or obliterated appen-
dix; however, 84% of patients
had significant pathology results
Adjunctive Adjunctive including acute inflammation
Gynecologic
Appendicitis studies studies Close Appendicitis
cause (44%), mucinous cystadenoma
unlikely CT, MRI, or CT, MRI or observation unlikely
ruled out
ultrasound ultrasound (4%), or IBD (4%). 29 The
authors reported one postop-
erative wound infection and
only two of the 46 patients
Condition Confirms Close Confirms Condition Condition
improves appendicitis observation appendicitis worsens improves required conversion to an open
appendectomy.29
A retrospective review by
Rosen and colleagues supports
Condition
Surgical consultation the research done by Lugo and
worsens colleagues.30 On review, only
three of the 34 patients had a
pathologically normal appendix
Surgical consultation Appendectomy and two had obliteration. The
authors demonstrated a statis-
tically significant difference in

38 www.JAAPA.com Volume 31 • Number 9 • September 2018

Copyright © 2018 American Academy of Physician Assistants

 Complicated appendicitis and considerations for interval appendectomy

the age of those having immediate appendectomy and FIGURE 3.

interval appendectomy; 40 years and 48 years, respectively Algorithm describing care pathways for uncomplicated and
(P = .0046). Although Rosen and colleagues demonstrated complicated appendicitis33
a significant difference in age between patients who under-
went immediate and interval appendectomy, their main Patient arrives to ED with abdominal pain
conclusion was that interval appendectomy may be indi-
cated, especially in patients with chronic or recurrent
abdominal pain, due to the extremely high percentage
High Alvarado score
(91%) of patients who had a pathologically abnormal
appendix at the time of interval appendectomy.30
Further support for interval appendectomy comes from
Wright and colleagues, whose retrospective review looked WBC: >16,000 cells/mm3 WBC: >10,000 cells/mm3
at 6,038 patients from two large community-based teach- CRP: >140 mg/L and/or CRP: >40 mg/L
ing hospitals.20 Patients in the study were adults (age 18
years and older) diagnosed with acute appendicitis who
underwent interval appendectomy between January 2002
and December 2013. Immediate appendectomy was per- CT scan, MRI, or ultrasound CT scan, MRI, or ultrasound
formed on 5,850 patients; the remaining 188 patients were
considered complicated and were treated nonoperatively.
Most of those with complicated appendicitis presented
Drainable
with perforation and two-thirds were treated with percu- Phlegmon Generalized Laparoscopic
abcess
without peritonitis on appendectomy
taneous drainage before undergoing interval appendectomy. without
peritonitis examination
peritonitis
Of those treated nonoperatively, 89 patients had an inter-
val appendectomy.
The primary outcome measure was the rate of appen-
• Antibiotics • Difficult
diceal neoplasm in patients who underwent interval • Antibiotics
and per- Open anatomy
and no
appendectomy. Of the patients who had an appendectomy procedural cutaneous appendectomy • Evidence of
drainage of via McBurney free perforation
immediately upon diagnosis (acute but not complicated intervention
abscess point laparotomy • Unsafe to
• Monitor
appendicitis) the rate of neoplasm was 0.5% compared closely • Monitor incision proceed
closely laparoscopically
with 12% in those who underwent interval appendec-
tomy.20 Wright and colleagues also found that 55% of
patients diagnosed with a neoplasm who underwent
interval appendectomy had a mucinous neoplasm. Sixteen Repeat CT Over age 40 Screening Consider
percent of patients over age 40 years who underwent an scan in 6-8 years? colonoscopy interval
weeks appendectomy
interval appendectomy were found to have a neoplasm.20
Due to an increased risk of neoplasm, colonoscopy is
suggested for patients after complicated appendicitis,
especially patients over age 40 years.27,31 Colonoscopy overall (between the acute and interval appendectomy
can detect abnormalities in the colon and is the gold groups) was 49 years (P = .36). The neoplasms in the
standard for diagnosing colon and rectal cancer and IBD acute appendectomy group were not associated with
but cannot detect neoplasms in the lumen of the appendix. perforation or abscess. The five neoplasms that were
Mucin can be detected if it is spilling out from the appen- removed in the interval appendectomy groups were
diceal orifice but colonoscopy cannot evaluate the tip of mucinous adenocarcinomas or cystadenomas. The authors
the appendix. Additional support for the concept of disclosed that during the study period, two patients who
interval appendectomy, especially in patients over age 40 did not undergo interval appendectomies after presenting
years, comes from Furman and colleagues, who performed with complicated appendicitis later returned to the hos-
a retrospective study of patients over age 18 years who pital with stage IV appendiceal cancer.
underwent appendectomy for appendicitis.24 The 376 Although evidence supports interval appendectomy, the
patients had a mean age of 41 years. Seventeen patients concept remains controversial, as evidenced by work by
had interval appendectomies. The only complication Tekin and colleagues, who did not feel that interval appen-
noted in this group was intra-abdominal abscess after dectomy was necessary.26 Tekin’s group performed a pro-
appendectomy. Fourteen neoplasms were found in the spective review of 94 patients after nonoperative
376 patients. Of the 17 patients who received an interval management of an appendiceal inflammatory mass and
appendectomy, neoplasms were found in five (29.4%). reported a recurrence rate of 14.6% with 53% of recur-
The mean age of the patients with appendiceal neoplasms rences occurring before 3 months. The authors argued that

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Copyright © 2018 American Academy of Physician Assistants

REVIEW ARTICLE
this makes it reasonable to hold on interval appendectomy
and treat the recurrences. Although these authors do not
report any cases of malignancies identified on interval
appendectomy, one must approach these results with cau-
tion, as they do not address patients who did not undergo
interval appendectomy and had a subsequent diagnosis of
cecal cancer. Although these authors do not advocate for
interval appendectomy, they do acknowledge that there is
no consensus on the management of periappendiceal inflam-
matory masses. They also advocate for further investigation
with colonoscopy to rule out a cecal neoplasm in patients
over age 40 years and state that further investigation and
development of management guidelines are necessary.
A recent study by Senekjian and colleagues adds to the
controversy about interval appendectomy.32 The authors
determined cost-effectiveness of interval appendectomy in
patients across base case scenarios at ages 18, 35, and 50
years. In this study, likelihood of recurrence, presence of
malignancy or IBD disease, or any complications associated
with appendectomy stratified by age were all taken into
consideration to develop their model. Senekjian and col-
leagues found that patients age 34 years and older without
atypical symptoms or a family history of cancer should
not undergo interval appendectomy from a cost-benefit
perspective. Despite these findings, the authors caution
clinicians to avoid making a clinical decision against per-
forming an interval appendectomy based on patient age
alone, as they state that baseline health between two patients
of the same age may vary considerably. Patients with a
family history of cancer or symptoms concerning for IBD
should be considered for more aggressive management.32
Reviewing the literature indicates a need for more studies
focused on complicated appendicitis in patients over age 40
years. The younger patients in Wright’s study had a much
lower incidence of neoplasms and complications.20 The
number of cases of acute appendicitis is highest in adolescents
and young adults and declines steadily with age.5 However,
perforation and neoplasm increase with age.20 Keeping both
of these facts in mind, surgeons must realize the risk of
malignancy in older adults with acute appendicitis.
CONCLUSION
Complicated appendicitis and the need for interval appen-
dectomy remain controversial. Data both support and
refute the need for interval appendectomy. Although
laparoscopic appendectomy is widely performed and
considered safe, all surgeries carry the risk of complica-
tions. Clinicians must consider the rate of recurrence and
possible underlying malignancy as well as the patient’s
own perioperative risk to determine whether an interval
appendectomy is in the patient’s best interest. Patients
with complicated appendicitis whose symptoms persist
or those with a fecalith on CT scan may be at higher risk
for complications and failing nonoperative treatment and
should strongly be considered for interval appendectomy.
40 www.JAAPA.com
Copyright © 2018 American Academy of Physician Assistants
Although an algorithm of nonoperative treatment for
complicated appendicitis, with or without interval appen-
dectomy, may be supported by the literature, the decision
to pursue interval appendectomy must be based on the
patient, including his or her risk factors for recurrence
and current state of health. JAAPA
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