For more than a century, appendicitis has been treated as a surgical emergency. But groundbreaking research led by David Talan, MD, a UCLA Health emergency medicine/infectious disease specialist, is reshaping that long-held belief. In many cases, particularly when the appendix has not ruptured, appendicitis can be treated safely with antibiotics alone, giving patients an alternative to surgery.
This shift is changing how doctors and patients think about appendicitis, opening the door to more personalized appendicitis treatment decisions while still emphasizing the importance of early diagnosis.
“If appendicitis is uncomplicated, meaning it is localized to the appendix and has not ruptured, which is the case in about 85% of patients, it is not necessarily a surgical emergency and can be treated very safely with antibiotics alone,” Dr. Talan says.
What Is Appendicitis?
Appendicitis is inflammation of the appendix, a small pouch attached to the large intestine in the lower right abdomen. Appendicitis causes include hardened stool, swollen lymph tissue, or tumors that cause a blockage in the lining of the appendix, leading to infection, swelling, and inflammation.
While most cases are localized, called uncomplicated appendicitis, rarely the appendix can rupture, which can be life-threatening, so it is important to be quickly evaluated for severe abdominal pain to determine if appendicitis or another cause is responsible.
Who Is at Risk?
Appendicitis most commonly affects people between the ages of 10 and 30, but it can occur at any age.
“Appendicitis is not as common in the elderly, but when it does occur, it is often associated with more complications,” says Dr. Talan.
Older adults often have additional health conditions that can make both diagnosis and treatment more complex. These factors are especially important when considering whether appendicitis surgery or antibiotics may be the better option.
“Any type of general surgery is more complex in older adults, particularly because of chronic conditions like diabetes, heart disease, lung disease, or cancer. As people get older, they may not be as healthy overall, which can increase the risks when appendicitis occurs,” says Dr. Talan.
Symptoms: How to Recognize Appendicitis
The hallmark symptom of appendicitis is abdominal pain that typically starts near the belly button and shifts to the lower right side. The pain usually worsens over time.
Other symptoms may include:
- Nausea and vomiting
- Loss of appetite
- Fever
- Abdominal swelling
- Constipation or diarrhea
Symptoms can vary, especially in older adults, who may experience less typical presentations. Because of this variability, any persistent or worsening abdominal pain should be evaluated by a health-care provider.
When to Seek Medical Help
Appendicitis requires prompt medical attention. Seek care immediately if you experience:
- Persistent or worsening abdominal pain
- Pain that intensifies with movement or pressure
- Fever with abdominal symptoms
- Ongoing nausea or vomiting
While antibiotics may be an option in some cases, early evaluation is critical to determine if there is a ruptured appendix or if complications are developing.
How Is Appendicitis Diagnosed
Doctors diagnose appendicitis using a combination of physical examination, laboratory tests, and imaging.
A physical exam typically focuses on tenderness in the lower right abdomen. Blood tests may show signs of infection, while imaging—such as ultrasound or computed tomography (CT) scans—helps confirm the diagnosis and determine whether the appendicitis is uncomplicated or complicated. This distinction helps guide treatment decisions.
Treatment Options for Appendicitis
Appendicitis surgery, known as an appendectomy, has long been the standard treatment for appendicitis. It is necessary in cases in which the appendix has ruptured or when complications are present. But it’s no longer the only option.
“Our group conducted the CODA [Comparison of Outcomes of antibiotic Drugs and Appendectomy] trial, the largest study ever done on this, which included adults over 18, with about 15% of participants over age 65. We showed that treating appendicitis with antibiotics was safe and not associated with more serious adverse events or deaths,” Dr. Talan says.
This approach is particularly valuable for older patients who may face higher surgical risks. “Antibiotics can be an option for all patients, particularly for those over 65 or with more advanced health conditions, where the risks of general anesthesia and abdominal surgery are greater,” he explains.
Another important benefit is the potential to avoid hospitalization. “One of the most important findings is that many patients can be treated and sent home from the emergency department, rather than being admitted for surgery,” Dr. Talan says.
Still, there are trade-offs to consider.
“There is a risk of recurrence, and that’s something patients need to weigh. When looking at all trials, recurrence occurs in 20% to 25%, almost all cases within the first year,” he notes. “However, if appendicitis recurs, it is no more difficult to treat or riskier than when it occurred initially.”
Follow-up analyses from the CODA Collaborative, centered at the University of Washington, have helped doctors better understand which patients are most likely to succeed with antibiotics alone and which may be better served by surgery. In a study published in JAMA Surgery, CODA investigators found that patients with an appendicolith, a small, hardened deposit of stool or mineral material that can block the appendix, were nearly twice as likely to require an appendectomy after initially being treated with antibiotics.
In addition, there is a small risk of missing an underlying condition. “In rare cases, appendiceal cancer can mimic appendicitis. If treated only with antibiotics, there is a small chance that cancer could be missed, although studies suggest this is extremely uncommon,” Dr. Talan says.
Despite strong evidence, widespread adoption of antibiotic-first treatment has been gradual.
“For over 100 years, appendicitis has been considered a surgical emergency. The idea that if you don’t operate, it will rupture and be life-threatening has been deeply ingrained,” says Dr. Talan.
“There is a lot of inertia. surgeons are trained to treat it surgically, and that’s what they are used to. But this approach is now increasingly being discussed with patients,” he adds.
What Happens If Appendicitis Isn’t Treated?
If left undiagnosed and untreated, appendicitis can result in peritonitis, abscess formation, and even sepsis.
These complications can be life-threatening and require emergency care, which is why appendicitis should never be ignored, even with newer, less invasive treatment options available.
Recovery and Outlook
Recovery depends on the chosen treatment approach. Patients who undergo surgery typically recover within a few weeks, although recovery may take longer in older adults or those with underlying health conditions.
Patients treated with antibiotics alone may experience a faster initial recovery and avoid the risks associated with surgery. However, they should be aware of the possibility of recurrence and stay engaged in follow-up care.
“I think this will increasingly become an option that patients choose,” Dr. Talan says. “Most people want to avoid surgery if they can.”
