Dr. Elyse Watkins, DHSc, PA-C, DFAAPA, NCMP
Providers working in austere practices such as the military, rural clinics, disaster sites, and wilderness settings often see non-specific abdominal pain that can develop into a surgical abdomen. Appendicitis is a common cause of abdominal surgery globally. Primary diagnosis of appendicitis relies on a mix of physical exam, laboratory findings, and imaging. Many of these tools are unavailable in the austere clinical setting. While some diagnostic tools, such as ultrasound, are available in the resource-confined environment, diagnosis of appendicitis largely relies on clinical suspicion and patient presentation. Conventional treatment consists of laparoscopic appendectomy within 24 hours and perioperative antibiotics; however, appendicitis can resolve with antibiotic therapy alone. In certain circumstances, providers cannot evacuate patients for surgical treatment. Evacuation to surgical care can be costly and potentially undermine missions, expeditions, or recovery operations. Some locations might not even have the capability for evacuation to surgical care. A non-surgical option allows austere practitioners to conservatively treat suspected appendicitis despite a non-definitive diagnosis, limited supplies, and the absence of surgical care. A patient in an austere clinic can receive non-surgical antibiotic therapy as a first-line treatment. Diagnosing complicated versus uncomplicated appendicitis, resources available, and evacuation assets ultimately drive this decision. Overall, appendectomy continuously emerges as the superior treatment for appendicitis, and antibiotic treatment can result in higher morbidity and mortality. However, the recurrence of appendicitis requiring appendectomy is often the worst complication. This can be an acceptable risk given the right clinical scenario.
Serenko G. Antibiotic Treatment of Appendicitis: A Non-surgical Option for Austere Environments. Lynchburg Journal of Medical Science. 2023; 5(1).
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