How should I approach the management of a patient with suspected appendicitis who is on anticoagulant therapy?

Management of a patient with suspected appendicitis who is receiving anticoagulant therapy requires urgent specialist assessment and hospital admission. This is because appendicitis can rapidly progress to complications such as perforation, which increases morbidity and mortality, and anticoagulation may increase bleeding risk during surgical intervention.

Approach:

• Arrange emergency hospital admission for specialist assessment and management without delay, especially given the increased risk of complications in anticoagulated patients.
• Inform the admitting team about the patient's anticoagulant therapy to allow appropriate perioperative planning, including potential reversal or adjustment of anticoagulation.
• Imaging (ultrasound, CT, or MRI) may be used to confirm diagnosis and reduce negative appendectomy rates; ultrasound is preferred in children and pregnant women, but CT is commonly used in adults.
• Specialist teams will balance the risks of surgery versus non-operative management; however, appendicectomy remains the gold standard treatment for uncomplicated appendicitis.
• In patients on anticoagulants, perioperative management may include temporary cessation or bridging therapy as guided by haematology or surgical teams to minimise bleeding risk while preventing thromboembolism.
• Safety-netting advice should be given if immediate admission is not warranted, but in anticoagulated patients with suspected appendicitis, a low threshold for admission is advised.

Overall, the key is prompt hospital admission for specialist evaluation with clear communication about anticoagulation status to optimise timing and safety of surgical or non-surgical management.

References: NICE CKS