Date: June 12, 2026

Guest Skeptic: Mr. Ross Fisher. Ross is a paediatric surgeon, presentation guru (P-Cubed), and long-time friend of the SGEM. 

Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026

Case: A 29-year-old healthy man presents to the emergency department (ED) with 18 hours of abdominal pain that began around the umbilicus and migrated to the right lower quadrant. He has anorexia, nausea, a temperature of 38.1°C, and focal right lower quadrant (RLQ) tenderness without diffuse peritonitis. The white blood cell (WBC) count is 13,500/µL. CT abdomen/pelvis shows an 8-mm inflamed appendix with periappendiceal fat stranding but no abscess, phlegmon, perforation, mass, or appendicolith. He is hemodynamically stable, not immunocompromised, has no history of inflammatory bowel disease (IBD), can return to the ED if worse, and asks whether he really needs surgery tonight.

Background: Appendicitis is one of those diagnoses we don’t want to miss. It’s common, it can be sneaky, and the classic textbook presentation only shows up around half the time. That means labs and scores can help, but they often can’t rule out appendicitis. In 2026, imaging (especially CT scans) is still doing much of the heavy lifting.

For more than a century, appendicitis was taught as a surgical emergency: diagnose it, call surgery, and remove the appendix before it ruptures. This new narrative review challenges that mental model. It argues that modern imaging can identify uncomplicated appendicitis, that perforated and nonperforated appendicitis may be biologically different entities, and that short delays to surgery in uncomplicated disease do not appear to increase perforation risk. This new narrative review notes that the American College of Surgeons (ACS) has endorsed antibiotics as a safe alternative for selected patients while continuing to endorse appendectomy.

The SGEM has followed this topic for years, and our interpretation of the literature has evolved as the evidence has changed (see list of other SGEM episodes at the end of this blog post). In 2015, the SGEM emphasized diagnostic uncertainty and concern that failed antibiotics could increase morbidity; in 2017, the pediatric conclusion was that NOTA was “not ready for prime time.” By 2019, we were more open to antibiotics in selected patients, using shared decision-making and acknowledging that nonoperative care may be better than we thought, though it may (or may not) come with a small absolute increase in complications.

So, the question is no longer whether to cut or not to cut. The ED question is: who is safe for an antibiotic-first pathway, who needs the surgeon now, and who can reliably come back if things go sideways? This is a classic preference-sensitive decision: surgery is highly definitive, while antibiotics may reduce pain, disability, and time away from school or work, but with a meaningful recurrence/appendectomy risk. This review by Talan et al explicitly places emergency physicians in the shared decision-making role for selected uncomplicated appendicitis patients.

Clinical Question: In ED patients with imaging-confirmed acute uncomplicated appendicitis, can initial nonoperative management with antibiotics and observation, with appendectomy reserved for worsening, nonresponse, or recurrence, be considered a safe and effective alternative to urgent appendectomy?

This matters because appendicitis sits right at the intersection of emergency medicine, surgery, radiology, antibiotics, patient values, and system capacity. Some patients want the most definitive treatment. Others want to avoid surgery if it’s safe to do so. Our job is not to sell one option. Our job in the emergency department is to explain the trade-offs.

Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026

  • Population: Adults and children with clinically suspected, localized, imaging-confirmed acute, uncomplicated appendicitis. The included trials enrolled children as young as 5 years and adults older than 80 years.
    • Exclusions: The major exclusions were diffuse peritonitis, severe systemic illness/sepsis, pregnancy, immunocompromise, renal failure, inflammatory bowel disease (IBD), prior antibiotic-treated appendicitis, and imaging evidence of major abscess, phlegmon, perforation, mass, or tumour. Some trials also excluded appendicolith, abnormal WBC thresholds, prolonged pain duration, or older age.
      Intervention: Nonoperative treatment: initial antibiotics plus observation, with appendectomy if the patient worsened, failed to improve, or later recurred. Antibiotic regimens varied but generally used parenteral antibiotics followed by oral antibiotics to complete a total therapy of 7–10 days.
  • Comparison: Urgent appendectomy with perioperative antibiotics, usually laparoscopic in the more recent trials.
  • Outcome
    • Primary Outcome: There was no single primary outcome in the review. Across the major trials, the most important outcomes were 1-year appendectomy/treatment failure rates for antibiotic-first care, and in CODA, 30-day EQ-5D health-status noninferiority.
    • Secondary Outcomes: Complications/serious adverse events, pain resolution or pain medication use, disability days, recurrence, ED return visits, feasibility of ED discharge/outpatient treatment, cancer detection, cost-effectiveness, and appendicolith subgroup outcomes
  • Type of Study: Narrative review of the major comparative trials, not a true systematic review or meta-analysis.

Authors’ Conclusions: “Nonoperative treatment of uncomplicated appendicitis will be increasingly considered as experience and confidence grows among physicians and as awareness grows among patients in this new treatment option. Emergency physicians are being asked about nonoperative treatment of uncomplicated appendicitis and have an important role now to inform patients of their treatment options and expected associated outcomes, and an emerging role in expanding access to safe and cost-effective care for patients with appendicitis, including those who can be managed by nonoperative treatment of uncomplicated appendicitis as outpatients.”

Quality Checklist for Systematic Reviews: (Yes/No/Unsure)

  1. Was the clinical question sensible and answerable? Yes
  2. Was the search for studies detailed and exhaustive? No
  3. Were the primary studies of high methodological quality? Unsure
  4. Were the assessments of studies reproducible? No
  5. Were the outcomes clinically relevant? Yes
  6. Was there low statistical heterogeneity for the primary outcomes? N/A
  7. Was the treatment effect large enough and precise enough to be clinically significant? Unsure
  8. Who funded the review? The authors stated that no funding was received for this work.
  9. Did the authors declare any conflicts of interest? The authors reported no conflicts of interest.

Results: The review focused on four major comparative trials: APPAC, CODA, MPSC, and APPY. Together, they included more than 2,000 adults and more than 2,000 children. The review did not provide a pooled table of sex, race, baseline pain duration, comorbidities, or socioeconomic demographics.

Key Result: In selected patients with uncomplicated appendicitis, antibiotics initially worked in about 90% and reduced pain/disability, but roughly one-third underwent appendectomy within 1 year, with higher appendectomy rates among patients with appendicolith.

  • Primary Outcome:
    • APPAC reported a 1-year appendectomy rate of about 27% in adults treated with antibiotics.
    • CODA found antibiotics noninferior to appendectomy for 30-day EQ-5D health status, but the 1-year appendectomy rate was 36% without appendicolith and 52% with appendicolith.
    • MPSC reported a 1-year appendectomy rate of about 33% in children
    • APPY reported about 34% treatment failure/appendectomy in the antibiotic group. The table on page 3 of the review summarizes these trial-specific results.
  • Secondary Outcomes: These generally favoured antibiotics for short-term recovery, but not always for adverse events.
    • APPAC reported fewer 1-year complications with antibiotics than surgery, 2.8% vs 20.5%, with faster pain resolution and fewer disability days.
    • CODA reported similar serious adverse event rates, 3% vs 3%, and fewer disability days with antibiotics.
    • MPSC reported similar complicated appendicitis rates, 3.6% vs 3.3%, and fewer disability days with antibiotics.
    • APPY reported no serious adverse events in either group, but more mild-to-moderate adverse events with antibiotics, largely GI distress; antibiotics reduced post-discharge pain medication use and disability days.

The ED discharge data came mainly from CODA. In a CODA sub-analysis, 335 of 726 antibiotic-treated adults, 46%, were discharged from the ED after longer-acting parenteral antibiotics, observation, oral tolerance, stable status, and pain control. Serious adverse events over 7 days were uncommon: 0.9 per 100 outpatients vs 1.3 per 100 inpatients. ED discharge was associated with fewer appendectomies and about one day less disability, without a significant increase in first-week ED return visits.

Summary of the Four RCTs:

1. Narrative Review: This was not a systematic review, and that matters. No PRISMA diagram, no duplicate screening, no formal risk-of-bias assessment, and no pooled estimate. That does not make it useless, and we should not judge it against a formal SRMA. It just means we should treat it for what it is, an expert narrative synthesis, not the final word.

Open Label

2. Open-Label: The included RCTs were not masked and vulnerable to performance, detection, and preference bias. You really can’t blind antibiotics vs surgery. But when outcomes include pain, disability, and the decision to operate, lack of blinding can push things around. Some failures may have been true clinical deterioration. Others may have been surgeon, patient, or system discomfort with waiting.

3. Uncomplicated Appendicitis: ED clinicians must exclude abscess, phlegmon, perforation, tumour, diffuse peritonitis, pregnancy, immunocompromise, and other higher-risk conditions. Yet appendicitis diagnosis itself is imperfect: classic symptoms occur in only about half of patients, labs and clinical prediction rules are insufficient to rule in or rule out disease, ultrasound is operator-dependent, and CT can still produce false positives and negative appendectomies. This means the evidence applies best to carefully selected, stable, imaging-confirmed uncomplicated cases, not to all RLQ pain or all appendicitis.

Heterogeneity

4. Heterogeneity: The RCTs differed by age group, randomization method, inclusion of appendicolith, antibiotic regimen, inpatient versus outpatient management, thresholds for surgery, primary outcome definitions, and noninferiority margins. A one-year appendectomy rate is not the same as patient-important success if a patient’s goal is avoiding an operation today, reducing pain, minimizing time off work, or avoiding recurrence of anxiety. Without a formal meta-analysis, there is no pooled I², no forest plot, and no systematic exploration of heterogeneity.

5. Rare & Long-Term Outcomes: These outcomes remain uncertain. Missed appendiceal cancer is uncommon, but the review reports cancer in 5 of 1,033 CODA-qualifying antibiotic-treated adults at 2 years, with a median diagnosis at 3 months and all stage 1. That is reassuring but not definitive for older adults or those with atypical imaging. Pediatric outpatient data remain sparse, and cost-effectiveness depends heavily on the health system, discharge model, return visits, recurrent symptoms, and whether recurrences are treated with antibiotics or surgery. The review is promising for ED pathways, but the evidence is not equally mature for children, patients with appendicolith, older adults, rural sites without surgical backup, or patients with unreliable follow-up.

Compare the Authors’ Conclusion Compared with the SGEM Conclusion: The authors seem more optimistic about an expanded ED role. They argue that nonoperative treatment is a safe alternative for selected uncomplicated appendicitis patients, that ED discharge/outpatient care is feasible in many adults, and that emergency physicians should be prepared to initiate shared decision-making and outpatient pathways.

We are more cautious due to the strength of the evidence, diagnostic uncertainty, patient selection, the possibility of increased perforation/complications with failed nonoperative care, and the importance of shared decision-making (SDM).

SGEM Bottom Line: Antibiotics-first is a reasonable option for carefully selected stable patients with CT-confirmed uncomplicated appendicitis. It is not meant for everyone. Appendectomy is still the definitive treatment, and appendicoliths are a big red flag. It should be shared decision-making, not shared wishful thinking.

Case Resolution: The patient’s CT shows uncomplicated appendicitis without appendicolith. Surgery is consulted. After discussing appendectomy versus antibiotics, he says avoiding surgery today is very important because he has no paid sick leave, but he is comfortable returning if getting worse. He receives intravenous (IV) ceftriaxone plus metronidazole, analgesia, and antiemetics. After several hours, he is afebrile, pain is improved, he tolerates oral intake, and he remains hemodynamically stable. He is discharged with oral antibiotics to complete a 7- to 10-day total course, written instructions to return immediately if worse, and follow-up within 24 to 48 hours.

Clinical Application: This review should not make ED clinicians offer antibiotics to every patient with appendicitis. It should prompt EDs to create local pathways with surgery, radiology, pharmacy, and follow-up systems. Candidates should have localized uncomplicated appendicitis, no diffuse peritonitis, no abscess/phlegmon/perforation/tumour, no severe sepsis, no pregnancy, no major immunocompromise, no inflammatory bowel disease, and ideally no appendicolith unless the higher failure risk is explicitly discussed. Outpatient management should be reserved for patients who improve, tolerate oral intake, have controlled pain, can access antibiotics, and can reliably return.

What Do I Tell the Patient? You have appendicitis, but the CT scan suggests it is the uncomplicated kind. There are two reasonable options. Surgery is the most definitive option. It removes the appendix, so this problem is very unlikely to come back, but it means an operation, anesthesia, incisions, and recovery time. Antibiotics may let you avoid surgery today. In the large studies, most people improved at first, and about 2 out of 3 avoided surgery for at least a year. The trade-off is that about one out of three still needs surgery within a year, and the risk is higher if there is a stone in the appendix. There is not one right answer for everyone. Let’s talk about what matters most to you, and you can decide with the surgery team.

Keener Kontest: Last week’s winner was our friend, Dr. Steven Stelts from New Zealand. He knew the 2024 international consensus report defines diabetic ketoacidosis (DKA) by the presence of all three of these features:

  • Diabetes or Hyperglycaemia – Blood glucose ≥200 mg/dL (11.1 mmol/L) or a prior history of diabetes
  • Ketosis – Beta-hydroxybutyrate ≥3.0 mmol/L or urine ketones ≥2+
  • Metabolic Acidosis – Venous/arterial pH <7.3 and/or bicarbonate <18 mmol/L

Listen to the SGEM podcast for this week’s question. If you know the answer, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shout-out.

Other SGEM Episodes:

  • SGEM #115: Complicated-Non-operative Treatment of Appendicitis (NOTA)
  • SGEM #180: The First Cut is the Deepest- N.O.T. for Paediatric Appendicitis
  • SGEM #256: Doctor Doctor Give Me the News, I Gotta Bad Case of RLQ Pain- Should I have an Appendectomy?
  • SGEM #345: Checking In, Checking Out for Non-Operative Treatment of Appendicitis (APPAC II RCT)
  • SGEM #384: Take Me Out Tonight, I Don’t Want to Perforate My Appendix Alright
  • SGEM#476: Cuts like a Knife or Antibiotics for Pediatric Appendicitis

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.