Page 131 - Journal of Special Operations Medicine - Spring 2015

other laboratory testing is used to exclude or reduce the The antibiotic regimen used for the treatment of ap­
likelihood of other illness, such as urinary tract infec­ pendicitis is quite varied and dependent on medication
tion, ectopic pregnancy, or pelvic inflammatory disease. available and patient tolerance. If forced to use an an­
tibiotic as a first approach to appendicitis, the clinician
In developed countries, a computed tomography (CT) could try one of the following regimens:
scan has become the mainstay of diagnosis of appendi­
citis. However, for the operational clinician, CT imag­ • Amoxicillin with clavulanic acid 1,000mg by mouth
ing frequently may not be available. Ultrasound can be every 8 hours for 8–15 days
useful in the hands of an experienced technician; how­ • Cefotaxime 1g intravenously (IV) every 8 hours with
ever, it is only valuable if the appendix can be clearly metronidazole 500mg IV every 8 hours for 10–14
distinguished. A healthy appendix usually cannot be days
viewed with ultrasonography. If the appendix can be lo­ • Ciprofloxacin 400mg IV every 12 hours with metro­
cated with ultrasound, appendicitis typically is shown nidazole 500mg IV every 8 hours
as a noncompressible, blind­ended, tube­like structure • Moxifloxacin 400mg IV or by mouth once daily
of 7–9mm diameter that may contain central locula­
tions. One study of 573 patients found ultrasound to Case Resolution
have a sensitivity and specificity of 51.8% and 81.4%,
respectively. These figures allow for a likely confirma­ You reexamine your patient 8 hours after his initial pre­
10
tion of appendicitis but do not allow for the diagnosis to sentation. His pain is now localizing to the right lower
be ruled out. It is generally considered that plain radio­ quadrant. He has a temperature of 38.5°C. He has point
graphs are not helpful in making the diagnosis. tenderness over McBurney’s point. You review the di­
agnosis with your patient and contact medical support
Treatment back home. After discussion with a surgeon, you decide
The classic management of acute appendicitis is prompt to initiate antibiotics and start the evacuation process.
surgical removal of the appendix. Recently, some clini­ You start cefotaxime 1g and metronidazole 500mg IV
cians have advocated for antibiotic therapy as an alter­ every 8 hours. The evacuation takes approximately 32
native strategy. However, significant controversy exists hours. When the patient arrives, his pain and symptoms
regarding this issue; many experienced clinicians have have significantly improved. The surgeon elects to ob­
taken strong stances on either side of the argument. It is serve his patient, and his symptoms resolve within 72
a worthy topic to review here, as there could be many hours. However, the patient has a recurrent episode of
operational situations in which surgery may not be pain 3 months later and undergoes an uncomplicated
readily or safely available. Another scenario involves a appendectomy.
clinician treating the local population where evacuation
is not possible. It is essential, therefore, that the special Disclaimers
operations clinician has an understanding of this issue.
The views and medical opinion herein represent those of
Multiple systematic reviews have been published explor­ the authors. They do not reflect the operation practice
ing antibiotic therapy versus surgical therapy for ap­ or views of the Canadian Forces or other organizations.
pendicitis. 11–13 It appears that antibiotic therapy can be The cases are provided to be educational and thought
successful for the initial treatment of acute appendicitis. provoking; at no time do the authors suggest that the
The actual number is debated, but in one major review, tactical clinicians exceed the scope of their practice or
approximately 63% of patients treated with antibiotics act against the direction of their medical protocols or
did not require surgery for at least 1 year after presenta­ recommendations of their medical leadership.
tion. On the other hand, some patients developed peri­
14
tonitis and required surgery either within the first few Disclosures
days, or required surgery between 1 month and 1 year
of the initial presentation. In this study, no difference The authors have nothing to disclose.
was seen for treatment efficacy, length of stay, or risk of
developing complicated appendicitis. It is unclear which
patients will fail antibiotic therapy, although some spe­ References
cific findings, like fecaliths, on a CT scan may suggest 1. Meltzer A, Baumann BM, Chen EH, et al. Poor sensitivity of a
a higher risk. While an interesting point, it is not really modified Alvarado score in adults with suspected appendicitis.
applicable to the decision­making process of the tactical Ann Emerg Med. 2013;37: 995–1000.
clinician. Either way, even if only effective for a period 2. Martin RF. Acute appendicitis in adults: clinical manifestation and
differential diagnosis. October 2014. http://www.uptodate.com/
of 24–48 hours, antibiotic therapy may provide a win­ contents/acute­appendicitis­in­adults­clinical­manifestations
dow of opportunity for evacuation assets to arrive. ­and­differential­diagnosis.

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