Appendicitis - ClinicalKey

13/11/23, 16:42 Appendicitis - ClinicalKey
CLINICAL OVERVIEW
Appendicitis
Elsevier Point of Care (see details)
Updated September 25, 2023. Copyright Elsevier BV. All rights reserved.
Synopsis
Urgent Action
All patients with strongly suspected or confirmed appendicitis require prompt antibiotic therapy
For uncomplicated appendicitis, common agents are cefoxitin, cefotetan, or cefazolin plus metronidazole 8 9
For complicated appendicitis, common regimen is ceftriaxone plus metronidazole
Emergent appendectomy (surgery within several hours of admission) is rarely indicated, unless patient is unstable or
very ill-appearing with generalized peritonitis 4
Early appendectomy (surgery within about 24 hours of admission) is procedure of choice for stable patients with
acute appendicitis; risk of perforation does not increase unless significant delay in definitive care occurs
Emergent operative intervention (appendectomy and peritoneal irrigation within several hours) is necessary for ill-
appearing or unstable patients and patients with generalized peritonitis 2
Key Points
Appendicitis, or acute inflammation of the vermiform appendix, is the most common abdominal surgical emergency; lifetime
risk approaches about 8% 1 2
Often presents with periumbilical abdominal pain that localizes to the right lower quadrant; pain is constant and worse with
movement. Vomiting and low-grade fever develop after onset of abdominal pain, and tenderness develops in the right lower
quadrant
Establishing diagnosis can be challenging and may be aided by biochemical testing, clinical prediction scoring, serial clinical
examinations, imaging, and expert consultation. Definitive confirmation of diagnosis is based on tissue histopathology 3
Standard laboratory testing includes CBC, urinalysis, C-reactive protein, and urine β-hCG in females of childbearing age;
mild leukocytosis is nonspecific but common in patients with appendicitis 4
Use local or regional algorithms to assist in risk stratification to guide best diagnostic and imaging approach
Low-risk patients can often be discharged with scheduled follow-up
Intermediate-risk patients usually require observation with serial clinical examinations and imaging studies; CT is
preferred in nonpregnant adults, and ultrasonography is preferred in children and pregnant patients 5
High-risk patients require immediate surgical consultation for appendectomy without further workup
Start antibiotics promptly at the time of confirmed or highly suspected acute appendicitis 3 6
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Standard treatment of both uncomplicated (simple, nonperforated) and most complicated (perforated) acute appendicitis is
prompt laparoscopic appendectomy 6
Optimal management strategy for patients with phlegmon and walled-off abscess is not standardized
Initial strategy usually involves antibiotics, supportive care, bowel rest, and percutaneous drainage of significant fluid
collections 3 4 7
Prognosis for most otherwise healthy patients with uncomplicated appendicitis is good. Patients with perforation are at much
higher risk for postoperative complications (20%-30%) 6
Pitfalls
Maintain a high index of suspicion for appendicitis in patients presenting with abdominal pain
Significant delays in diagnosis can lead to increased morbidity secondary to increased risk for complications (eg,
perforation, abscess, peritonitis)
Diagnosis may be challenging given variability in presentation; manifestations may vary according to anatomic position of
inflamed appendiceal tip 10
Occasionally, pain from appendicitis may be difficult to localize or it may localize to atypical positions (eg, right upper
quadrant, suprapubic, flank)
Urinary symptoms or diarrhea may predominate if appendix is located in pelvic position 11
Atypical presentations may occur in very young children, pregnant patients, and older-aged and immunocompromised
people
Very young children usually present with perforated appendicitis

Pregnant patients may present with variations in reported location of pain. Symptoms of early appendicitis overlap with
clinical manifestations of normal pregnancy (eg, vomiting, physiologic leukocytosis). Febrile response may be blunted
Older-aged and immunocompromised people may present with muted symptoms and are at high risk for perforation at
presentation
Consider alternate diagnosis in females of childbearing age because several gynecologic processes mimic acute appendicitis 5
Significant practice variation exists in preferred diagnostic, evaluation, and treatment methods of suspected and confirmed
appendicitis; refer to regional and institutional protocols for guidance
Pretreatment with antibiotics may alter clinical findings in patients with evolving appendicitis 12
Maintain low threshold for specialist consultation; consider advanced imaging in patients presenting with right lower
quadrant pain and tenderness who are receiving antibiotics
In children, avoid CT imaging owing to excessive exposure to radiation; first line imaging for children is ultrasonography to
assess for signs of appendicitis
Consider consultation and transfer to facility with pediatric capabilities (eg, pediatric imaging protocols, pediatric
radiologists, pediatric surgeons) if ultrasonography to assess for appendicitis is not available
Terminology
Clinical Clarification
Appendicitis is acute inflammation of the vermiform appendix, the wormlike diverticulum originating at the base of the
cecum 1
Most common abdominal surgical emergency; lifetime risk approaches 8% 2
13/11/23, 16:42 Appendicitis - ClinicalKey CO/CA 0-12 E,H,CV
SU/FLE 12-24 MCVAS, EFP,PB
GA/NE 24-36 CAVL, A,NP
Classification PER >36 PP, LMPF
Uncomplicated appendicitis (simple or nonperforated appendicitis)
Inflamed appendix without signs of gangrene, perforation, intra-abdominal abscess, contained phlegmon, or intra-
abdominal purulent fluid 3
Complicated appendicitis (includes perforated appendicitis)
Gangrenous inflamed appendix with or without perforation, intra-abdominal abscess, contained phlegmon, or purulent
intra-abdominal fluid 3
Perforation is defined as a hole in the appendix or fecalith in the abdomen 2
Diagnosis
Clinical Presentation
History
Abdominal pain
Typically the earliest symptom and present in most patients
Classic description of pain

McBurney point. - Surface anatomy
Gradual onset of dull periumbilical pain that migrates to right lower quadrant within representing the base of the
12 to 48 hours 13 appendix.
Migration of pain is a strong predictor of appendicitis in both children (positive

likelihood ratio, 1.9-3.1) and adults (positive likelihood ratio, 3.2) 14 15
Presence of right lower quadrant pain is a stronger predictor of appendicitis in

adults (positive likelihood ratio, 7.3-8.5) than in children (likelihood ratio, 1.2-3.1) 2
14 15
Pain is commonly exacerbated by movement (eg, bumping during car ride, walking,
coughing)
Appendix positions and
Pain usually is constant and progressive rather than intermittent corresponding symptoms. - Anterior
located appendix floats in an
6 7 anterior position in an arc from a
Classic presentation is noted in only about half of patients with appendicitis
common base. When inflamed,
appendix tip may affix to
Eventual localization of pain depends on anatomic position of inflamed appendiceal tip surrounding structures in a
(noninflamed appendix usually floats from a fixed base in an arc through various anterior subcecal, pelvic, or ileal position.
positions; inflamed appendiceal tip may become adherent to surrounding structures in a Anterior positioning includes
relatively fixed position) positions to the right of the
diagonal line (positions other than
retrocecal/retrocolic).
Pain at McBurney point (one-third way from right anterior superior iliac spine to
umbilicus): indicative of anterior location of tip of appendix 7
Pain below McBurney point (low pelvic pain) or suprapubic pain: indicative of tip of appendix located in pelvis 16
Back pain, flank pain, or ill-defined pain: indicative of tip of appendix located in retrocecal position 16
Periumbilical pain (may persist and increase in intensity rather than migrate to another position): indicative of tip of
appendix located adjacent to terminal ileum (post- or preileal)
Right upper quadrant pain: may occur in patients with conditions associated with altered anatomy (eg, malrotation,
third trimester of pregnancy) 5
Other variable symptoms
Nausea and vomiting
Occurs in more than half of patients; presence of vomiting may increase likelihood of appendicitis by at least 2-fold, and
absence diminishes likelihood by about half 6 14
Typically develops after onset of pain
May become bilious with persistent emesis
Fever
Usually low grade (lower than 38 °C in adults) unless perforation has occurred 13
Presence of fever increases likelihood of appendicitis at least 3-fold 2 14
Absence of fever does not exclude appendicitis; however, it lowers likelihood of appendicitis by at least two-thirds 2 14
16
Anorexia is common
Diarrhea
Most often noted in patients with appendix located in pelvic position
Urinary symptoms (eg, frequency, urgency)
Most often noted in patients with appendix located in pelvic position
Tenesmus and constipation may develop
Symptoms suggestive of perforation
Localized right lower quadrant pain that suddenly improves then gradually worsens, becoming generalized and diffuse
Associated symptoms may include abdominal bloating, firmness, and high fever (above 38 °C 17 ) with chills
Longer duration of pain (more than 48 hours from onset) 6 is typical in patients presenting with perforated compared with
nonperforated appendicitis 17
Physical examination
General appearance
Gait is often guarded, hunched, and associated with a slight limp favoring right side
Patients move tentatively and prefer to remain still
Patients are more comfortable lying in the right lateral recumbent position
Right leg may be flexed at hip to decrease peritoneal stretch
Fever (higher than 37.3 °C) 18 13 may be present
Overall, one-half of patients with appendicitis have fever; 13 lack of fever diminishes likelihood of appendicitis by about
two-thirds 2
Fever above 38 °C is more common in patients with appendiceal perforation 17
Abdominal examination may show signs of ileus, location of inflamed appendix, or peritonitis
Abdominal distention suggests perforation, ileus, or bowel obstruction
Bowel sounds may be hyperactive or normal early in illness and become hypoactive as disease progresses
Absent or decreased bowel sounds is associated with appendicitis in children (positive likelihood ratio, 3.1) 15
Localized (focal) abdominal tenderness is the most reliable overall finding 6
Voluntary guarding may occur near area of maximal tenderness
May reflect anatomic position of appendix
Periumbilical tenderness may indicate tip of appendix adjacent to terminal ileum (post- or preileal appendix)
Right lower quadrant tenderness at McBurney point is consistent with anterior position of appendix
Minimal tenderness may indicate tip of appendix positioned in pelvis (pelvic appendix)
Delayed, inconsistent, or absent tenderness may occur when tip of appendix is behind cecum (retrocecal appendix)
Pregnant patients may present with variable tenderness due to displacement of appendix by gravid uterus
Mass in right lower quadrant suggests phlegmon or localized abscess
Psoas or obturator sign also may indicate anatomic location of appendix
Neither sign is associated with severity of disease or perforation
Psoas sign—elicitation of pain with passive right hip extension or active right thigh flexion—is consistent with appendix
in retrocecal location
Obturator sign—elicitation of pain with internal rotation of right hip—is consistent with appendix in pelvic location
Positive psoas (positive likelihood ratio: 2 [in adults] or 3.2 [in children]) and obturator (positive likelihood ratio, 3.5 in
children) signs appear to be strong predictors of appendicitis, when present 14 15
Peritoneal signs
Rovsing sign (right lower quadrant pain elicited with palpation of left lower quadrant) suggests peritoneal irritation
Positive likelihood ratio of 3.5 for appendicitis in children 15
Rebound tenderness (elicited by gentle tapping on abdomen or rapid release of pressure from abdomen) suggests
peritoneal irritation
Abdominal rigidity (positive likelihood ratio, 3.8 in adults) 15
Involuntary guarding and abdominal wall rigidity
Pelvic examination, when indicated (particularly females of childbearing age)

Cervical motion tenderness with absence of purulent cervical discharge may be noted, particularly in patients with pelvic
location of appendiceal tip
Right adnexal tenderness may be appreciable
Right adnexal mass may be noted in patients with inflammatory mass (eg, abscess, phlegmon)
Causes and Risk Factors
Causes
Appendicitis is caused by obstruction of appendiceal lumen, resulting in distention and venous congestion. Intraluminal
bacterial overgrowth and subsequent bacterial invasion of the appendix wall occur; appendiceal ischemia and necrosis may
ensue
Obstruction
Localized lymphoid hyperplasia obstruction is the most common cause of appendicitis in children and accounts for
one-half of occurrences overall
Fecalith obstruction is the most common cause of appendicitis in adults and accounts for one-third of occurrences
overall
Foreign body (eg, intestinal worms, food seeds, intestinal calculi, inspissated barium) causes obstruction in less than 5%
of cases 19
Obstructive neoplasms (eg, carcinoid tumor, metastatic spread to appendix, primary appendiceal carcinoma) account for
less than 1% of acute appendicitis cases 20
Incidence of appendicular neoplasms is higher with complicated appendicitis (3%-17%) in adults older than 40 years
4
Bacteria
Most common bacteria include typical fecal flora (eg, Escherichia coli, Bacteroides fragilis, Pseudomonas)
Bacterial invasion and ensuing inflammation can eventually result in perforation with contamination of peritoneal
cavity
Risk factors and/or associations
Age
Peak occurrence is in patients aged 15 to 25 years 5
Incidence steadily increases in children with advancing age
Extremely rare in children younger than 3 years (less than 1% of cases) 6
Rare in children younger than 5 years (less than 5% of cases) 6
Most common in children aged 10 years or older 6
Less than 25% of cases occur in patients older than 45 years 5
Sex
Male to female ratio is 1.4 to 1 until age 30 years; in patients older than 30 years, the prevalence is equal in both sexes 21
Genetics
Positive family history imparts a nearly 3-fold increased risk for developing appendicitis 6
Other risk factors/associations

Appendicitis overall is most common in summer months 22
Perforated appendicitis
Occurs more frequently in fall and winter 2
More common in younger children (90% in children younger than 3-4 years) 6 than older children (20% in children aged
10-17 years) 2 14
More common in older patients (40%-70%) 16 and immunocompromised patients
More common in males than females
Diagnostic Procedures
Primary diagnostic tools

Suspect diagnosis based on history and physical examination
Consider diagnosis in all patients who have abdominal pain and tenderness on
examination; a significant percentage of appendicitis cases are initially missed on
presentation (up to 20% of all cases) 5 Imaging in appendicitis. - A,
Ultrasonogram showing a thickened
Note that prior treatment with antibiotics may alter clinical findings and decrease appendix wall (arrow), with an
confidence in examination findings; lower threshold for imaging and surgical appendicolith at its tip. B, CT
consultation may be warranted in patients pretreated with antibiotics 12 showing an appendix mass (arrow).
C, CT showing an inflamed
appendix, with a tiny appendicolith
Laboratory testing as its cause (arrow).
Order standard tests including CBC, urinalysis, and C-reactive protein 4
Interpret laboratory studies with caution in patients with suspected appendicitis. Use
these studies to support increased or decreased likelihood of appendicitis rather than
definitively prove or exclude diagnosis 4
Combined test performance of WBC count more than 10,000/mm³ and C-reactive
protein more than 8 mg/L is associated with positive likelihood ratio of 23 and
negative likelihood ratio of 0.03 for diagnosis of acute appendicitis Ultrasonogram of dilated appendix
(thick arrow pointing to wall of
appendix) with appendicolith (thin
Among pediatric patients, C-reactive protein more than 10 mg/L and leukocytosis arrow) measuring 2.7 cm in
(greater than 16,000 cells/mL) are strong predictors of acute appendicitis 4 diameter.
Establishing diagnosis can be challenging and may be aided by laboratory testing,

clinical prediction scoring, serial clinical examinations, imaging, and expert
consultation; definitive confirmation of diagnosis is based on histopathologic changes 3
Use local or regional algorithms to assist in risk stratification to guide best diagnostic
and imaging approach
Most algorithms are based on baseline probability of appendicitis as determined by

clinical presentation, laboratory findings, and clinical prediction scoring tools
Transverse section of appendix. -
Clinical prediction rules (Alvarado score, Pediatric Appendicitis Score, Pediatric Appendicitis in ultrasonogram is
Appendicitis Risk Calculator) can aid in identifying pediatric patients at low risk of identified as a well-circumscribed
echogenic round structure
appendicitis but should not be the sole criteria used to exclude need for advanced surrounded by hypoechoic soft
imaging for diagnosis of appendicitis 23 tissue collection.
Clinical prediction rules should not be used as basis to withhold advanced

imaging in adult patients
Patients are stratified into low-, intermediate-, and high-risk groups 6
Low risk: further evaluation includes:
Assess and treat alternate causes of abdominal pain
Early appendicitis is possible; provide clear instructions to return for further Longitudinal section of appendix (A)
evaluation if pain persists or worsens to assess for evolving appendicitis which appears to be a blind-ended
loop attached to the cecal pole lying
Discharge with close follow-up without specific imaging studies to further on psoas major muscle (M). - Point
evaluate for appendicitis. If patient has right lower quadrant pain or of care ultrasonography showed a
well-circumscribed swollen
tenderness, follow-up for repeated abdominal examination in 12 to 24 hours echogenic appendix lying on the
psoas major muscle lateral to the
Intermediate risk: patients often require imaging studies, observation with serial common iliac vessels and it was not
clinical assessments, and possibly surgical consultation 5 compressible.
High risk: patients often move straight to surgery consultation for possible
surgical intervention without imaging 24
Significant regional and institutional practice variation exists in preferred

diagnostic and evaluation measures 2 6 Transvers and longitudinal color
Doppler ultrasonagrams of
inflamed appendix. - A, Transverse
Consider early consultation with an appropriate specialist (eg, general surgeon for ultrasonogram shows inflamed
adults, pediatric surgeon for children) to aid in diagnostic evaluation appendix with enlarged diameter
and wall thickening and
Consider early transfer to care facility that has experts available for special hyperechogenicity of
populations (eg, pediatric radiologists, pediatric surgeons, high-risk obstetricians) periappendiceal fat. B, Longitudinal
color Doppler ultrasonogram shows
before imaging when appropriate specialty resources are lacking 2 inflamed appendix with hyperemic
wall.
Imaging
Preferred imaging for acute appendicitis
Nonpregnant adults
CT scan with IV contrast of abdomen and pelvis is preferred imaging modality

to diagnose appendicitis and exclude alternative diagnoses 25 26
Based on a 2019 Cochrane review, sensitivity is 95% (95% confidence interval, Contrast-enhanced axial CT image
0.93-0.96) and specificity is 94% (95% confidence interval, 0.92-0.95); positive shows an abnormal appendix
predictive value is 92% (95% confidence interval, 0.90-0.94) 25 (arrows) with mild luminal
distention and abnormal mural
Sensitivity and specificity of low-dose CT are comparable to standard-dose CT enhancement and thickening. - No
significant periappendiceal
inflammatory stranding is present.
MRI is a highly accurate radiation-free modality that may be used to diagnose
appendicitis in all age groups 27
May be used to clarify equivocal findings in other studies (eg, CT or

ultrasonography)
May be used when other studies are not available or contraindications exist
Children
Unenhanced sagittal multiplanar
Abdominal ultrasonography is recommended first line imaging modality to reconstruction CT image shows a
evaluate for appendicitis in children 4 15 23 28 fluid-filled dilated appendix (arrow)
with multiple appendicoliths
If ultrasonography is inconclusive or appendix is not visualized, next options (arrowheads) and periappendiceal
include secondary imaging strategies (repeat ultrasonography/MRI with inflammatory changes.
contrast/CT), admission for a period of observation with serial clinical
examinations, or diagnostic laparoscopy 4 6
Some data suggest that the diagnostic accuracy of ultrasonography approaches

that of CT and MRI in children; however, acute appendicitis cannot be
reliably excluded unless a normal appendix is visualized 29
A meta-analysis of accuracy of imaging studies in pediatric patients showed

area under receiver operating characteristic curve data: MRI (0.995),
ultrasonography (0.987), CT (0.982) 29 Unenhanced coronal multiplanar
reconstruction CT image shows a
Pregnant patients fluid-filled dilated appendix (circled)
with periappendiceal inflammatory
Graded compression transabdominal ultrasonography is first line imaging changes.
modality 4
Ultrasonographic evaluation in pregnancy has been shown to have low

sensitivity (77.6%) and specificity (75.3%); therefore, consideration for follow-
up imaging in a different modality should be considered in a patient with
negative or uncertain ultrasonogram findings 30 A 23-year-old man with acute
appendicitis. - Axial (A) and coronal
contrast-enhanced abdominopelvic
MRI without contrast enhancement is preferred second line option 16 27 31 CT (B) show enlarged appendix with
a diameter of 10 mm medial to iliac
American College of Obstetricians and Gynecologists recommends avoiding vessels (white arrows) and fat
stranding around the dilated
exposure to gadolinium in pregnant patients 32 appendix (arrow head). Appendix
also shows wall enhancement. C,
Abdominal radiograph cecum.
Often ordered during evaluation for appendicitis; however, study usually does not
aid in diagnosis 6
Most helpful to assess for complications such as small bowel obstruction or free air These 3 CT scans show differing
and for alternate causes of abdominal pain (eg, lower lobe pneumonia, presentations for appendicitis. - A,
The appendix (arrow) is enlarged
constipation) and has a thickened wall. There are
no inflammatory changes such as
Laboratory periappendiceal fat stranding seen
on this study. B, The appendix
(arrow) is enlarged, and there is free
fluid and inflammatory changes
Imaging medially indicating likely
perforation. C, The patient
presented with a 1-week history of
Other diagnostic tools pain and the appendix has
perforated with the development of
2 abscesses (asterisks). In addition, a
fecalith is seen medially (dotted
arrow). This patient was initially
managed nonoperatively with
drainage of the abscesses and
Appendicitis risk stratification and initial management strategy. intravenous antibiotics. She
underwent laparoscopic interval
Supplemental Risk for appendectomy 10 weeks after the
Typical clinical manifestations Typical initial management strategy
evaluation appendicitis initial admission.
Low likelihood of appendicitis

Appendicitis
Inflammatory
Response: 0 to 4
Adult Appendicitis
Score: 0 to 10
Assess for and treat alternate causes of
abdominal pain. Provide clear
Presence of few signs and
instructions for return for continued This sagittal CT image depicts 3
symptoms with lack of right Alvarado score: 3 or Roughly 5%
evaluation if symptoms worsen. appendicoliths (arrow) and an
lower quadrant tenderness, less to 6%
Discharge with close follow-up enlarged appendix.
no fever, and soft abdomen
(establish physician follow-up in 12-24
hours)
Pediatric Appendicitis
Score: 3 or less
WBC count, absolute
neutrophil count, and
C-reactive protein (if
obtained): within
reference range
Moderate likelihood of appendicitis
Appendicitis
Inflammatory
Response: 5 to 8
Adult Appendicitis
Score: 11 to 15
Presence of some signs and Further evaluation includes
symptoms of appendicitis (eg, observation with serial abdominal
mild right lower quadrant examinations, imaging to assess for
Roughly
tenderness or right lower Alvarado score: 4 to 6 appendicitis (ultrasonography in
26% to 66%
quadrant pain with children and pregnant patients, CT in
movement, vomiting, low nonpregnant adults), and possibly
grade fever) surgical consultation
Supplemental Risk for

Typical clinical manifestations Typical initial management strategy
evaluation appendicitis
Pediatric Appendicitis Score: 4
to 7
WBC count, absolute

neutrophil count, and C-
reactive protein: may be
within reference range or
elevated
High likelihood of appendicitis
Appendicitis Inflammatory
Response: 9 to 12
Adult Appendicitis Score: 16

or higher
Presence of classic
manifestations of appendicitis (1- to 2-day Immediate surgical consultation for further diagnostic
history of progressively and treatment recommendations; patients may not Roughly
Alvarado score: 7 or more
worsening abdominal pain with migration require further imaging if taken directly to operating 80% to 93%
to right lower quadrant, pain worse with room
movement, fever, vomiting, anorexia)
Pediatric Appendicitis Score: 8

or more
WBC count, absolute

neutrophil count, and/or C-
reactive protein: typically
elevated
Caption: Prior treatment with antibiotics may alter presentation pattern. Maintain a lower threshold for surgical consultation and/or imaging in patients with prior treatment
with antibiotics.
Differential Diagnosis
Most common
Mesenteric adenitis
Inflammation of lymph nodes in the intestinal mesentery; may be primary without associated acute inflammatory process
or secondary to another underlying condition (eg, Crohn, infectious colitis, ascending diverticulitis, lymphoma) 61
Most common alternative diagnosis in children. Typically presents after a viral upper respiratory tract infection 62
Difficult to differentiate on clinical grounds alone; may be associated with longer duration of symptoms, higher fever, and
absence of rebound tenderness or percussion tenderness on examination
Usually diagnosed by radiographic (eg, abdominal CT or ultrasonography) findings or at the time of operative exploration
Gastroenteritis d1 (Related: Gastroenteritis in Children)
Presents similarly with abdominal pain, vomiting, and fever
Diarrhea is usually a prominent feature in patients with gastroenteritis. Diarrhea may be present in patients with
appendicitis but is often less prominent than in those with gastroenteritis
Abdominal pain is characteristically more diffuse and intermittent (crampy) in patients with gastroenteritis rather than
constant and progressive as in patients with appendicitis
Patients with gastroenteritis usually lack focal tenderness, guarding, or rebound on examination. Children with
gastroenteritis do not resist movement, whereas in those with appendicitis, movement exacerbates pain
A notable exception is gastroenteritis caused by Yersinia enterocolitica, which sometimes causes focal abdominal pain
and tenderness virtually indistinguishable from appendicitis
Differentiation is usually based on clinical presentation. Diagnosis of gastroenteritis is clinical and its cause is determined
by stool testing (eg, bacterial culture), when indicated
Intussusception
Presents similarly with abdominal pain and vomiting; commonly affects infants and young children 63
Pain is often more colicky than the constant and progressive pain typically associated with appendicitis; fever is much less
common in patients with intussusception than in those with appendicitis
Differentiating features include sausage-shaped right upper quadrant mass, blood in stool, and propensity for mental
status depression in children presenting with intussusception
Differentiate based on clinical presentation and radiographic findings; ultrasonography is about 90% sensitive and specific
for diagnosis of intussusception 63
Air contrast enema is gold standard for confirming diagnosis and is preferred initial treatment option in stable patients
without signs of perforation 63
Urinary tract infection (Related: Urinary Tract Infection in Children)
Presents similarly with abdominal pain, vomiting, and fever
Abdominal pain and tenderness is often suprapubic and/or flank in patients with urinary tract infection as opposed to
periumbilical migrating to right lower quadrant
Sterile pyuria may occur with appendiceal inflammation; however, bacteriuria is not expected in patients with appendicitis
64
Differentiate based on presenting features and urinalysis (showing nitrate positivity with dipstick testing and/or bacteria
with microscopy)
Diagnosis is based on signs of inflammation in urine (eg, pyuria) and culture positive for a uropathogen
Functional constipation 65
Presents similarly with abdominal pain and sometimes vomiting; pain is often colicky
Manifestations are often more insidious and chronic in patients with constipation; history of fecal soiling, large volume
hard stools, and withholding behaviors may be elicited
Rectal examination is usually notable for substantial stool burden, and abdominal examination may show palpable, mobile
masses of stool and lack of focal right lower quadrant tenderness
Differentiate by clinical presentation; large stool burden on abdominal radiograph suggests constipation
Constipation is usually a clinical diagnosis
Pneumonia (Related: Community-Acquired Pneumonia in Children (Older Than 3 Months))
May present similarly with abdominal pain, fever, and vomiting, particularly in children with pneumonia involving right
lower lobe
Cough and difficulty breathing are usually presenting features in children with pneumonia, but occasionally these
manifestations are subtle or lacking
Tachypnea, focal diminished breath sounds, and lower than normal oxygen saturation values are often clues to presence of
pneumonia
Abdominal tenderness is either mild and diffuse or lacking in children with pneumonia
Diagnose pneumonia by clinical presentation (cough, tachypnea) and confirm with supportive chest radiography findings
when indicated (eg, admission requirement, suspicion of complications) 66
Testicular torsion (Related: Testicular Torsion)
May present similarly with abdominal pain and often vomiting; most common in first year of life and around puberty 67
Pain is usually acute at onset. Examination is significant for scrotal swelling, abnormal horizontal testicular lie, high
position of testicle in scrotum, and lack of cremasteric reflex
Differentiate by clinical presentation and abnormal findings on genital examination
Diagnose testicular torsion with ultrasonography and confirm at time of surgical exploration 67
Renal colic (Related: Nephrolithiasis)
Right-sided ureteral or renal calculus may present similarly with abdominal pain and vomiting
Quality and progression of pain are somewhat different than with appendicitis. Patients often describe pain beginning in
flank then radiating down to right lower quadrant, and pain is intermittent and colicky rather than constant and
progressive
Urolithiasis is frequently associated with hematuria, either gross hematuria or microscopic hematuria; focal right lower
quadrant tenderness is not a typical finding in patients with urolithiasis
Differentiate based on clinical presentation, urinalysis, and CT or ultrasonography (eg, normal appendix and visualization
of calculus and/or dilated ureter or renal collecting system) 68
Ovarian cysts
Most commonly occur in postmenarchal adolescents. Hemorrhage or rupture of ovarian cyst causes severe pain
Presentation may be clinically indistinguishable from appendicitis when right sided with abdominopelvic pain and
sometimes vomiting; guarding and rebound tenderness may be evident on examination
In contrast to patients with acute appendicitis, fever is uncommon
Imaging is often required to differentiate. Ultrasonography is the imaging modality of choice, but ovarian cyst may be
diagnosed using CT
Ruptured hemorrhagic cyst may mimic appendicitis on imaging with fat stranding and free fluid in pelvis. Absence of free
air noted in some patients with ruptured appendicitis may help to differentiate conditions 68
Crohn disease (Related: Crohn Disease)
Terminal ileitis associated with Crohn disease can present with right lower quadrant pain and signs suggestive of systemic
inflammation (eg, fever, increased C-reactive protein level, leukocytosis)
Historic manifestations suggestive of Crohn disease include weight loss, chronic diarrhea with blood and/or mucus,
unexplained fever, perianal disease, and extraintestinal symptoms (eg, rashes, arthritis)
CT findings consistent with Crohn disease include mucosal hyperenhancement and bowel wall thickening in discrete
lesions (skip lesions) throughout the gastrointestinal tract. Complications (eg, abscesses, strictures, fistula) may be
identified 61
Differentiate based on clinical presentation and radiographic findings consistent with Crohn disease; histopathology may
be required to definitively exclude Crohn disease from acute appendicitis in some patients
Diagnosis of Crohn disease is based on a combination of clinical, endoscopic, radiologic, histologic, and pathologic
findings showing some degree of focal, asymmetrical, and transmural granulomatous inflammation of the luminal
gastrointestinal tract 69
Meckel diverticulitis (Related: Diverticulitis)
Congenitally derived ileal diverticulum that, when inflamed, can produce symptoms and a clinical picture
indistinguishable from acute appendicitis 70
Patients may have a history of painless gastrointestinal bleeding
Occasionally differentiated based on radiologic findings; however, appearance can bear striking resemblance to
appendicitis on imaging (enlarged tubular mass surrounded by inflammatory changes) 68
Diagnosis usually confirmed at time of operative procedure
Ovarian torsion
Symptoms may closely mimic appendicitis and include nausea and right lower quadrant pain (with right ovarian
involvement)
Onset and severity of pain is acute and severe compared with progressive nature of pain in patients with appendicitis.
Adnexal mass may be found on examination
Fever is unusual unless associated with significant ovarian necrosis
Differentiate by clinical presentations and ultrasonography findings (no Doppler flow to ovary) 68
Ectopic pregnancy d9 (Related: Ectopic Pregnancy) 71
Presents similarly with abdominal pain and vomiting
Fetus implanting in right side of pelvis causes right-sided abdominal pain and tenderness developing over hours or
days; β-hCG test result is positive
As opposed to appendicitis, ectopic pregnancy is frequently associated with vaginal bleeding
Differentiate based on clinical presentation and positive β-hCG test result. Confirm diagnosis by using transvaginal
ultrasonography to show absence of intrauterine pregnancy. Also may be detected by MRI and CT 68
Pelvic inflammatory disease and/or tubo-ovarian abscess (Related: Pelvic Inflammatory Disease)
Presents similarly with progressive abdominal pain, nausea, vomiting, and fever
Pain is usually more suprapubic, bilateral, and longer lasting than in appendicitis; development of tubo-ovarian abscess
leads to lateralization of pain
History of unprotected sexual activity may be elicited and patient may report vaginal discharge and possibly urinary
symptoms (eg, dysuria); characteristic onset of pain is during or shortly after menses
Differentiate by clinical presentation and pelvic examination findings consistent with pelvic inflammatory disease (eg,
purulent cervical discharge, cervical motion tenderness, adnexal tenderness) with or without abscess
Pelvic inflammatory disease is a clinical diagnosis; cause is determined by culture or polymerase chain reaction
confirmation of chlamydia or gonorrhea in genital tract
Tubo-ovarian abscess diagnosis usually is confirmed with transvaginal ultrasonography 68
Spontaneous bacterial peritonitis (Related: Spontaneous Bacterial Peritonitis)
Presents similar to perforated appendicitis with abdominal pain, fever, and abdominal tenderness
Classically occurs in preadolescent girls or patients with nephrotic syndrome or cirrhosis 6
Differentiate by clinical presentation and imaging; ultrasonography with diffuse ascites, coupled with visualization of
normal appendix, suggests diagnosis
Diagnosis is based on analysis of ascitic fluid; cause is confirmed by microbiologic culture 72
Epiploic appendagitis
Benign and self-limiting condition. Develops secondary to torsion, ischemia, or infarction of lobulated, fat-filled omental
appendages on the antimesenteric surface of the colon; inflammation then results 6
Presents similarly when process involves right lower quadrant with acute and subacute, localized, right lower quadrant
pain; right lower quadrant tenderness may be present but fever is usually lacking
Differentiate based on clinical presentation and findings on imaging (eg, ultrasonography, CT); definitive diagnosis is
usually based on imaging 61 68
Treatment
Goals
Treat and contain infection and inflammation with antibiotics and prompt appendectomy
(standard treatment of acute appendicitis) 6
Provide fluid resuscitation and supportive care with IV fluids; prepare for potential surgery
by establishing NPO status
Prevent infectious complications and sepsis 6

Algorithm shows suggested clinical
Provide symptomatic care with pain relief, fever control, and treatment of nausea and management pathway for
vomiting emergency department patients
with possible appendicitis.
Disposition
Admission criteria
Most patients with appendicitis require admission for treatment; however, some patients with uncomplicated appendicitis may
be taken directly to surgery and then discharged home without an inpatient stay
Criteria for ICU admission

Sepsis with hemodynamic compromise (eg, in cases of suppurative appendicitis with perforation and peritoneal
contamination)
Recommendations for specialist referral

Consult a general surgeon for further diagnostic and management considerations when there is a moderate or strong clinical
suspicion of appendicitis in adults
Consult early with an obstetrician for diagnosis and management considerations when the patient is pregnant and there is
suspicion of appendicitis. The general surgeon manages surgical issues and performs appendectomy 7
Crucial to consult with a pediatric surgeon for diagnosis and management of young children given high rate of complicated
appendicitis in very young age groups 7
Treatment Options
Initial resuscitation, stabilization, and supportive care 73
Fluids, electrolytes, and nutrition
Place patient on NPO status
Replace fluid deficits with normal saline or Ringer lactate solution as indicated; continue maintenance IV fluids while
patient on NPO status
Correct any electrolyte abnormalities before surgery
Antiemetics
Use antiemetics when indicated. Ondansetron is preferred when contraindications are lacking; promethazine is an option
for adults
Nasogastric tube decompression is only necessary for patients with bowel obstruction or persistent emesis
Analgesia
Manage pain with parenteral opioid analgesics as needed

Opioid analgesia does not adversely affect diagnostic accuracy or interfere with surgical decision making in patients with
an abdominal condition that may require surgery; may be used unless otherwise contraindicated 6 73
Antibiotic therapy
Promptly begin IV antibiotic therapy (broad spectrum with activity against aerobic gram-negative and anaerobic bacteria)
when diagnosis of appendicitis has been reasonably established or is highly suspected regardless of whether operative or
nonoperative treatment is anticipated 74
Refer to community-acquired intra-abdominal infection guidelines for detailed guidance 75
Antibiotic prophylaxis is required for patients who are scheduled for appendectomy or for those in whom delayed surgical
management is anticipated 3 6 76
Antibiotics reduce rates of postoperative wound infections and intra-abdominal abscesses
Follow institutional clinical practice pathway for preferred antibiotic prophylaxis, when available 5
Uncomplicated appendicitis: routine perioperative antibiotic prophylaxis for gastrointestinal surgery is appropriate 5
Common antibiotic choices include single dose of cefoxitin, cefotetan, and cefazolin or ceftriaxone plus
metronidazole 4 8 9
Clindamycin plus gentamicin or metronidazole plus gentamicin are options for patients with β-lactam allergy 9
77
Give single dose IV 30 to 60 minutes before incision 4 78 79
Consider redosing intraoperatively if the procedure exceeds 2 half-lives of the antibiotic or excessive blood loss
occurs 9
Single-dose prophylaxis is usually sufficient and postoperative antibiotics are unnecessary 9
Complicated appendicitis: broad coverage for facultative and anaerobic colonic flora 5 80
Common antibiotic choices include ertapenem, imipenem-cilastatin, moxifloxacin, or piperacillin-tazobactam

monotherapy or combined therapy (eg, ceftriaxone plus metronidazole, cefotaxime plus metronidazole) 2 76 81
Perforated appendicitis requires ongoing antibiotic therapy after appendectomy; total duration is usually about 3 to
7 days; however 2 days may be sufficient 82 4 80
Once source control is achieved, outcomes after 3 to 5 days are similar to those with prolonged course of
antibiotics
Patient may transition to oral antibiotics to complete the course 6 78
If planning to manage nonoperatively, initially administer a long-acting parenteral antibiotic, such as ertapenem or
ceftriaxone, plus high-dose, once-daily metronidazole 74
Can be followed by oral regimens, such as metronidazole plus advanced-generation cephalosporin or fluoroquinolone
Use ciprofloxacin plus metronidazole or moxifloxacin monotherapy for patients with serious β-lactam allergy 75
Antipyretics
Administer antipyretics for fever 6
Most experts recommend avoiding preoperative NSAIDs (postoperative NSAIDs are appropriate)
Management of uncomplicated appendicitis (simple or nonperforated appendicitis)
Either operative or nonoperative management can be considered as first line therapy for selected patients 4 76 83 84
Patients who are fit for surgery and have no high-risk CT findings (appendicolith, presence of a mass, dilated appendix) are
candidates for either appendectomy or antibiotics alone
Appendectomy is recommended for patients who are fit for surgery and have high-risk findings on CT
Antibiotics-first approach is recommended for patients who are not fit for surgery and have no high-risk CT findings
Benefits and risks of alternative treatment options should be discussed with patient and approach should be individualized
based on clinical and radiographic findings and patient preferences
Operative management (appendectomy)
Standard of care and definitive treatment for most patients
Overwhelming majority of patients undergo appendectomy when there are no contraindications 62
Early appendectomy (surgery within 24 hours of admission) is recommended for acute appendicitis, including pediatric
cases 2 4
Emergent appendectomy (surgery within several hours of admission) is not necessary for stable patients with acute
appendicitis 4
No differences are noted among patients treated with early appendectomy versus emergent appendectomy in rates of
gangrenous or perforated appendixes, operative length, readmission, postoperative complications, or hospital stay 85
Avoid delaying operative intervention for more than 24 hours. A delay of up to 24 hours does not appear to
significantly increase odds of complicated appendicitis with appropriate and timely antibiotic administration 4 86 87
Operative delay beyond 48 hours is associated with increased risk for surgical site infection and postoperative
complications 86
Removal of normal-appearing appendix is recommended by the 2020 World Society of Emergency Surgery guideline due
to variability in accuracy of visual assessment by surgeons, although it is a weak recommendation based on low-quality
evidence
Nonoperative management
Entails treatment with antibiotics and initial observation without appendectomy; appendectomy is reserved for refractory
or recurrent cases
Appropriate alternative to appendectomy in patients with uncomplicated appendicitis with no signs of diffuse peritonitis
or high-risk CT findings 74
Feasible and safe approach; however, risk of recurrence is higher than operative treatment and patients should discuss
risks/benefits in detail with surgical team 4
Systematic reviews and meta-analyses, as well as publication of long-term outcomes of randomized controlled trials,
determined that antibiotic-first approach can be used safely for nonpregnant adults and children with uncomplicated acute
appendicitis
Not recommended for pregnant patients 88
American College of Surgeons 2020 guidelines for managing patients presenting with surgical emergencies in the early
part of the COVID-19 pandemic states that antibiotics are an acceptable first line treatment for uncomplicated acute
appendicitis, with appendectomy offered for those with worsening or recurrent symptoms 84
Patients must be carefully selected to meet the following conditions:
Clinical diagnosis of localized appendicitis without signs of diffuse peritonitis on examination 74
Hemodynamically stable without severe sepsis or septic shock 74
On imaging the appendix is fully visualized and intact with none of the following: 6 89
Suppuration (ie, abscess or phlegmon)
Findings suggestive of perforation (significant limitation of ultrasonography and CT is lack of high sensitivity for
detection of perforation 28 )
Presence of an appendicolith
Not pregnant or immunocompromised 74
No history of inflammatory bowel disease
For adult patients, the following criteria are associated with 89% chance of recovery with nonoperative management: 90
C-reactive protein less than 60 mg/L
WBC count less than 12 × 10⁹/L
Age younger than 60 years
For pediatric patients:
Patient must be old enough to reliably describe symptoms (age older than 7 years) 89
Appendiceal diameter smaller than 1.1 cm 89
WBC count higher than 5 × 10⁹/L and less than 18 × 10⁹/L 6 89
Antibiotic therapy
First line antibiotic regimens include metronidazole plus either ceftriaxone or cefotaxime, or ertapenem 75
For those with β-lactam allergy, guidelines recommend ciprofloxacin plus metronidazole or moxifloxacin
monotherapy 75
IV antibiotics are recommended for 48 hours followed by outpatient oral antibiotics for total antibiotic duration of 5 to
10 days 2 6 49 74 75
Optimal duration of admission and parenteral therapy is not definitively known
Adult patients discharged on oral antibiotics within 24 hours of diagnosis and first administration of IV antibiotics
had no greater risk of complications or appendectomy than those who remained in hospital for more than 24 hours
before discharge on oral antibiotics 91
Outcomes
1-year treatment failure rate is approximately 27.4% to 40% with antibiotic-first approach, with an increased
complication rate compared to surgical approach 92 93 94 95
Antibiotic-first treatment group has a 5-year treatment failure rate of 39% and reduced overall complication rate and
health care costs 96
The following factors are associated with increased risk of antibiotic treatment failure within 30 days: 97
Female sex (odds ratio 1.53; 95% confidence interval, 1.01-2.31)
Radiographic finding of wider appendiceal diameter (odds ratio per 1-mm increase, 1.09; 95% confidence interval,
1.00-1.18)
Presence of appendicolith (odds ratio, 1.99; 95% confidence interval, 1.28-3.10)
Among pediatric patients specifically, failure rate is 14% 98
Higher level of reported pain at presentation was associated with an increased risk of in-hospital treatment failure
(relative risk, 2.1 [95% confidence interval, 1.0-4.4]) 99
Data regarding complication rates are mixed. Data from a high-quality meta-analysis 93 show increased complication
rate after antibiotic-first approach, while results from the APPAC (Appendicitis Acuta) randomized controlled trial did
not show increased rates of intra-abdominal abscess or other major complications with this strategy 94
Among adults and children, nonoperative approach was associated with reduced overall complication rate and health
care costs 96 98
The necessity of antibiotics in management of uncomplicated appendicitis has not been definitively established
APPAC III clinical trial found no statistical superiority in patient outcomes with antibiotic-first versus no-antibiotic
strategy for patients with uncomplicated appendicitis 100 101
Further study is warranted to further determine whether antibiotics are necessary for nonoperative management
Management of complicated appendicitis (includes perforated appendicitis)
All patients should receive prompt surgical evaluation. The 2020 World Society of Emergency Surgery guideline 4 provides
recommended operative strategies
Management depends on patient status (stable or unstable), type of perforation (contained or free) if any, and whether an
abscess or phlegmon has formed
Patients who are septic or unstable and those with a free perforation or generalized peritonitis (noncontained, free-floating,
purulent fluid in peritoneal cavity) require emergency appendectomy with drainage and irrigation of peritoneal cavity 4 7
Immediate appendectomy in patients with a phlegmon or abscess often requires extensive dissection and may lead to
injury of adjacent organs and complications such as a postoperative abscess or enterocutaneous fistula 102
Initial nonoperative management to allow local inflammation to subside and interval (delayed) appendectomy carries
lower risk of complications
Specific clinical scenarios
Stable patients with acute appendicitis with perforation
Some controversy exists regarding optimal initial management strategy 2
Appendectomy at time of presentation (early or up-front appendectomy) is usual treatment for patients with perforated
appendicitis without known significant abscess or phlegmon in preoperative period 2
Antibiotics, with or without interval appendectomy (6-8 weeks after acute inflammatory process has subsided), are an
alternative 2 6
Stable patients with periappendiceal, walled-off (contained), well-defined abscess or phlegmon (inflammatory mass) 3 7
Some controversy exists regarding optimal management strategy 2
Standard initial management includes antibiotics, supportive care, bowel rest, and percutaneous drainage of significant
fluid collections when accessible 3 4 7
Failure to improve clinically with nonoperative management indicates need for prompt appendectomy 6
Early primary appendectomy, along with antibiotics and percutaneous drainage, is an alternative 2
Operative approach and considerations
Laparoscopic surgical appendectomy
Gold standard; preferred over open laparotomy for both acute 103 simple and perforated appendicitis 6 4 7 16 103 104
Associated with faster recovery, diminished risk for wound infection, decreased pain, and improved cosmesis compared
with open appendectomy 73
Associated with reduced pain, decreased incidence of wound infections, shorter length of stay (1 day), and shorter recovery
time in adults; however, also associated with 65% higher rate of intra-abdominal abscess formation compared to open
procedure (odds ratio, 1.65; 95% confidence interval, 1.12-2.43) based on a 2018 Cochrane review 103
Among children, laparoscopic approach has shown lower rates of complications including lower rate of postoperative
wound infections and reduced length of stay (0.8 days), as compared with the open approach 103 105
Open surgical appendectomy
Conversion to open approach may be required in some patients. Most common reasons include technical difficulties
during laparoscopic approach secondary to presence of adhesions or complications of perforation 73
Interval appendectomy 7
Performed 4 to 8 weeks after initial medical management, after nonoperative management for perforated appendicitis or
phlegmon 4
Rate of recurrence ranges from 12% to 24%; however, nonoperative treatment with recurrence of appendiceal phlegmon
has similar mortality to appendectomy
Current guidelines recommend against routine interval appendectomy for adults younger than 40 years and children with
complicated appendicitis
Guidelines recommend consideration of interval appendectomy for recurrent symptoms after nonoperative management
of acute appendicitis
Proponents cite procedure eliminates risk of recurrence and excludes underlying medical conditions (eg, malignancy,
carcinoid) 3 7
Opponents 3 caution that most patients will not develop recurrence after perforation owing to belief that most appendiceal
lumens become obliterated after perforation process 7
Postoperative care
Follow institutional protocol for postoperative care 2
Postoperative antibiotics
No postoperative antibiotics are required after appendectomy for nonperforated acute appendicitis 73
Postoperative IV antibiotics are indicated for patients with perforated appendicitis in consultation with a surgeon; current
recommendations include a short course (3-7 days), starting with IV and transitioning to oral as tolerated 4 75 78 80 82
Diet
Advance diet as soon as clinically feasible in postoperative period 7
Pain management
Optimal management and standardized approach are lacking
Treatment often consists of multimodal approach with short-duration IV opiate in combination with NSAID and
acetaminophen as tolerated
Monitor for complications
Obtain imaging to assess for intra-abdominal abscess in patients not improving on anticipated clinical trajectory (eg,
prolonged fever, ileus, inability to tolerate oral intake, persistent pain)
If patient requires more than 6 days of inpatient care after perforated appendicitis, evaluate for intra-abdominal abscess 2
Discharge
General discharge criteria include:
Ability to tolerate diet and oral medications
Lack of fever
Ability to ambulate
Pain under control with oral pain medications

Patients are usually discharged within 24 hours after laparoscopic appendectomy for uncomplicated acute appendicitis 73
Continue antibiotics for patients with perforated appendicitis until fevers subside and patients can tolerate diet 2
Drug therapy
Antibiotics for surgical prophylaxis 9
Cephalosporins
Cefotetan
Cefotetan Disodium Solution for injection; Infants†, Children†, and Adolescents†: 40 mg/kg/dose (Max: 2 g/dose) IV
as a single dose within 30 to 60 minutes prior to the surgical incision; consider intraoperative redosing 6 hours from
the first preoperative dose. May continue 40 mg/kg/dose (Max: 2 g/dose) IV every 12 hours for no more than 24 hours
post-operatively if necessary.
Cefotetan Disodium Solution for injection; Adults: 1 to 2 g IV as a single dose within 30 to 60 minutes prior to the
surgical incision; consider intraoperative redosing 6 hours from the first preoperative dose. May continue 1 to 2 g IV
every 12 hours for no more than 24 hours post-operatively if necessary.
Cefoxitin
Cefoxitin Sodium Solution for injection; Infants 1 to 2 months†: 40 mg/kg/dose IV as a single dose within 30 to 60
minutes prior to the surgical incision; consider intraoperative redosing 2 hours from the first preoperative dose. May
continue 40 mg/kg/dose IV every 6 hours for no more than 24 hours post-operatively if necessary.
Cefoxitin Sodium Solution for injection; Infants, Children, and Adolescents 3 months to 17 years: 30 to 40 mg/kg/dose
(Max: 2 g/dose) IV as a single dose within 30 to 60 minutes prior to the surgical incision; consider intraoperative
redosing 2 hours from the first preoperative dose. May continue 30 to 40 mg/kg/dose (Max: 2 g/dose) IV every 6 hours
for no more than 24 hours post-operatively if necessary.
Cefoxitin Sodium Solution for injection; Adults: 2 g IV as a single dose within 30 to 60 minutes prior to the surgical
incision; consider intraoperative redosing 2 hours from the first preoperative dose. May continue 2 g IV every 6 hours
for no more than 24 hours post-operatively if necessary.
Cefazolin (in combination with metronidazole)
Cefazolin Sodium Solution for injection; Infants and Children 1 month to 9 years†: 30 mg/kg (Max: 2 g/dose) IV/IM as
a single dose within 60 minutes prior to the surgical incision; consider intraoperative redosing 4 hours from the first
preoperative dose. May continue 30 mg/kg (Max: 2 g/dose) IV/IM every 6 to 8 hours for no more than 24 hours post-
operatively if necessary.
Cefazolin Sodium Solution for injection; Children and Adolescents 10 to 17 years weighing less than 50 kg: 1 g IV/IM
as a single dose within 30 to 60 minutes prior to the surgical incision; consider intraoperative redosing 4 hours from
the first preoperative dose. May continue 500 mg to 1 g IV/IM every 6 to 8 hours for no more than 24 hours post-
Cefazolin Sodium Solution for injection; Children and Adolescents 10 to 17 years weighing 50 kg or more: 2 g IV as a
single dose within 30 to 60 minutes prior to the surgical incision; consider intraoperative redosing 4 hours from the
first preoperative dose. May continue 500 mg to 1 g IV/IM every 6 to 8 hours for no more than 24 hours post-
Cefazolin Sodium Solution for injection; Adults weighing less than 120 kg: 1 g IV/IM or 2 g IV as a single dose within
30 to 60 minutes prior to the surgical incision; consider intraoperative redosing 4 hours from the first preoperative
dose. May continue 500 mg to 1 g IV/IM or 2 g IV every 6 to 8 hours for no more than 24 hours post-operatively if
necessary.
Cefazolin Sodium Solution for injection; Adults weighing 120 kg or more: 3 g IV/IM as a single dose within 30 to 60
minutes prior to the surgical incision; consider intraoperative redosing 4 hours from the first preoperative dose. May
continue 3 g IV/IM every 6 to 8 hours for no more than 24 hours post-operatively if necessary.
Ceftriaxone (in combination with metronidazole)
Ceftriaxone Sodium Solution for injection; Infants†, Children†, and Adolescents†: 50 to 75 mg/kg/dose (Max: 2
g/dose) IV as a single dose within 60 minutes prior to the surgical incision; no intraoperative redosing is necessary.
Ceftriaxone Sodium Solution for injection; Adults: 2 g IV as a single dose within 60 minutes prior to the surgical
incision; no intraoperative redosing is necessary.
Nitroimidazoles
Metronidazole (as part of a combination regimen)
Metronidazole Solution for injection; Infants†, Children†, and Adolescents† weighing less than 80 kg: 30 mg/kg/dose
(Max: 1 g/dose) IV as a single dose within 60 minutes prior to the surgical incision; no intraoperative redosing is
necessary. May continue 15 mg/kg/dose (Max: 500 mg/dose) IV every 8 hours for no more than 24 hours post-
Metronidazole Solution for injection; Children† and Adolescents† weighing 80 kg or more: 30 mg/kg/dose (Max: 1.5
g/dose) IV as a single dose within 60 minutes prior to the surgical incision; no intraoperative redosing is necessary.
May continue 15 mg/kg/dose (Max: 500 mg/dose) IV every 8 hours for no more than 24 hours post-operatively if
necessary.
Metronidazole Solution for injection; Adults: 500 mg to 1.5 g as a single dose within 60 minutes prior to the surgical
incision; no intraoperative redosing is necessary. May continue 500 mg IV every 6 to 12 hours for no more than 24
hours post-operatively if necessary.
For patients with β-lactam allergy
Clindamycin (in combination with gentamicin)
Clindamycin Solution for injection; Infants, Children, and Adolescents: 10 mg/kg (Max: 900 mg/dose) IV as a single
dose within 60 minutes prior to the surgical incision; consider intraoperative redosing 6 hours from the first
preoperative dose. May continue 10 mg/kg (Max: 900 mg/dose) every 8 hours for no more than 24 hours post-
Clindamycin Solution for injection; Adults: 900 mg IV as a single dose within 60 minutes prior to the surgical
incision; consider intraoperative redosing 6 hours from the first preoperative dose. May continue 900 mg IV every 8
hours for no more than 24 hours post-operatively if necessary.
Gentamicin (in combination with clindamycin or metronidazole)
Gentamicin Sulfate Solution for injection; Infants, Children, and Adolescents: 2.5 mg/kg/dose IV as a single dose
within 60 minutes prior to the surgical incision; no intraoperative redosing is necessary.
Gentamicin Sulfate Solution for injection; Adults: 5 mg/kg/dose IV as a single dose within 60 minutes prior to the
surgical incision; no intraoperative redosing is necessary.
Antibiotics for uncomplicated (simple) appendicitis as part of nonoperative management
Combination regimens
Cephalosporins
Ceftriaxone (in combination with metronidazole)
Ceftriaxone Sodium Solution for injection; Infants, Children, and Adolescents: 50 to 75 mg/kg/day (Max: 2 g/day)
IV/IM divided every 12 to 24 hours for at least 48 hours, followed by oral step-down therapy for a total treatment
duration of 5 to 10 days.
Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV/IM every 12 to 24 hours for at least 48 hours, followed
by oral step-down therapy for a total treatment duration of 5 to 10 days.
Cefuroxime (as step-down therapy with metronidazole)
Cefuroxime Axetil Oral suspension; Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (Max: 500 mg/dose) PO
every 12 hours for a total treatment duration of 5 to 10 days as step-down therapy after initial parenteral therapy.
Cefuroxime Axetil Oral tablet; Adults: 250 mg PO every 12 hours for a total treatment duration of 5 to 10 days as
step-down therapy after initial parenteral therapy.
Nitroimidazoles
Metronidazole (as part of combination therapy)
IV dosing
Metronidazole Solution for injection; Infants†, Children†, and Adolescents†: 22.5 to 40 mg/kg/day (Max: 1.5
g/day) IV divided 8 hours every 8 hours for at least 48 hours, followed by oral step-down therapy for a total
treatment duration of 5 to 10 days.
Metronidazole Solution for injection; Adults: 500 mg IV every 6 to 12 hours or 1.5 g IV every 24 hours for at least
48 hours, followed by oral step-down therapy for a total treatment duration of 5 to 10 days.
Oral dosing as step-down therapy
Metronidazole Oral tablet; Infants†, Children†, and Adolescents†: 10 mg/kg/dose (Max: 500 mg/dose) PO every 8
hours for a total treatment duration of 5 to 10 days as step-down therapy after initial parenteral therapy
Metronidazole Oral tablet; Adults: 500 mg PO every 6 hours for a total treatment duration of 5 to 10 days as step-
down therapy after initial parenteral therapy.
Fluoroquinolones (for patients with β-lactam allergy)
Ciprofloxacin (in combination with metronidazole)
IV dosing
Ciprofloxacin Solution for injection; Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (Max: 400 mg/dose)
IV every 12 hours for at least 48 hours, followed by oral step-down therapy for a total treatment duration of 5 to
10 days.
Ciprofloxacin Solution for injection; Adults: 400 mg IV every 12 hours for at least 48 hours, followed by oral step-
down therapy for a total treatment duration of 5 to 10 days as part of combination therapy.
Ciprofloxacin Oral suspension; Infants, Children, and Adolescents: 10 to 20 mg/kg/dose (Max: 500 mg/dose) PO
every 12 hours for a total treatment duration of 5 to 10 days as step-down therapy after initial parenteral therapy.
Ciprofloxacin Hydrochloride Oral tablet; Adults: 500 mg PO every 12 hours for a total treatment duration of 5 to
10 days as step-down therapy after initial parenteral therapy.
Single-agent therapy
Carbapenems
Ertapenem
Ertapenem Solution for injection; Infants and Children: 15 mg/kg/dose IV every 12 hours (Max: 1 g/day) for at least
48 hours, followed by oral step-down therapy for a total treatment duration of 5 to 10 days.
Ertapenem Solution for injection; Adolescents: 1 g IV every 24 hours for at least 48 hours, followed by oral step-
down therapy for a total treatment duration of 5 to 10 days.
Ertapenem Solution for injection; Adults: 1 g IV every 24 hours for at least 48 hours, followed by oral step-down
therapy for a total treatment duration of 5 to 10 days.
Fluoroquinolones (for patients with β-lactam allergy)
Moxifloxacin
IV dosing
Moxifloxacin Hydrochloride Solution for injection; Adults: 400 mg IV every 24 hours for at least 48 hours,
followed by oral step-down therapy for a total treatment duration of 5 to 10 days.
Moxifloxacin Hydrochloride Oral tablet; Adults: 400 mg PO every 24 hours for a total treatment duration of 5 to
10 days as step-down therapy after initial parenteral therapy.
Antibiotics for complicated appendicitis (suppurative appendicitis with abscess, perforation)
Combination regimens
Cephalosporins
Cefotaxime (in combination with metronidazole) 75
Cefotaxime Sodium Solution for injection; Infants, Children, and Adolescents weighing less than 50 kg: 150 to 200
mg/kg/day IV divided every 6 to 8 hours (Max: 2 g/dose) for 3 to 7 days.
Cefotaxime Sodium Solution for injection; Children and Adolescents weighing 50 kg or more: 1 to 2 g IV every 6 to
8 hours for 3 to 7 days.
Cefotaxime Sodium Solution for injection; Adults: 1 to 2 g IV every 6 to 8 hours for 3 to 7 days.
Ceftriaxone (in combination with metronidazole) 75
Ceftriaxone Sodium Solution for injection; Infants, Children, and Adolescents: 50 to 75 mg/kg/day (Max: 2 g/day)
IV/IM divided every 12 to 24 hours for 3 to 7 days
Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV/IM every 12 to 24 hours for 3 to 7 days.
Nitroimidazoles
Metronidazole (as part of combination therapy) 75
Metronidazole Solution for injection; Infants†, Children†, and Adolescents† weighing less than 80 kg: 30
mg/kg/dose (Max: 1 g/dose) IV every 24 hours for 3 to 7 days.
Metronidazole Solution for injection; Children† and Adolescents† weighing 80 kg or more: 30 mg/kg/dose (Max:
1.5 g/dose) IV every 24 hours for 3 to 7 days.
Metronidazole Solution for injection; Adults: 500 mg IV every 6 to 12 hours or 1.5 g IV every 24 hours for 3 to 7
days.
Fluoroquinolones 75
Increasing resistance to Escherichia coli; check susceptibility
For patients with serious β-lactam allergies
Ciprofloxacin (in combination with metronidazole)
Ciprofloxacin Solution for injection; Infants†, Children†, and Adolescents†: 10 to 15 mg/kg/dose (Max: 400
mg/dose) IV every 12 hours for 3 to 7 days.
Ciprofloxacin Solution for injection; Adults: 400 mg IV every 8 to 12 hours for 3 to 7 days.
Single-agent therapy
β-Lactam plus β-lactam inhibitor
Piperacillin-tazobactam 75
Piperacillin Sodium, Tazobactam Sodium Solution for injection; Infants younger than 2 months†: 200 to 300
mg/kg/day piperacillin component (225 to 337.5 mg/kg/day piperacillin; tazobactam) IV divided every 6 to 8 hours
for 3 to 7 days.
Piperacillin Sodium, Tazobactam Sodium Solution for injection; Infants, Children, and Adolescents 2 months to 17
years: 200 to 300 mg/kg/day piperacillin component (225 to 337.5 mg/kg/day piperacillin; tazobactam) IV divided
every 6 to 8 hours for 3 to 7 days.
Piperacillin Sodium, Tazobactam Sodium Solution for injection; Adults: 3.375 g (3 g piperacillin and 0.375 g
tazobactam) IV every 4 to 6 hours or 4.5 g (4 g piperacillin and 0.5 g tazobactam) IV every 6 hours for 3 to 7 days.
Carbapenems
Ertapenem 75
Ertapenem Solution for injection; Infants 1 to 2 months†: 15 mg/kg/dose IV every 12 hours for 3 to 7 days.
Ertapenem Solution for injection; Infants and Children 3 months to 12 years: 15 mg/kg/dose IV every 12 hours
(Max: 1 g/day) for 3 to 7 days.
Ertapenem Solution for injection; Adolescents: 1 g IV every 24 hours for 3 to 7 days.
Ertapenem Solution for injection; Adults: 1 g IV every 24 hours for 3 to 7 days.
Imipenem-cilastatin
Imipenem, Cilastatin Sodium Solution for injection; Infants 1 to 2 months: 25 mg/kg/dose IV every 6 hours for 3 to
7 days.
Imipenem, Cilastatin Sodium Solution for injection; Infants, Children, and Adolescents 3 months to 17 years: 15 to
25 mg/kg/dose IV every 6 hours (Max: 2 g/day for fully susceptible organisms; 4 g/day for moderately susceptible
organisms). Treat for 3 to 7 days.
Imipenem, Cilastatin Sodium Solution for injection; Adults: 500 mg IV every 6 hours or 1 g IV every 8 hours for
fully susceptible organisms and 1 g IV every 6 hours for organisms with intermediate susceptibility. Treat for 3 to 7
days.
Cephalosporins
Cefoxitin
Cefoxitin Sodium Solution for injection; Infants 1 to 2 months†: 80 to 160 mg/kg/day IV/IM divided every 6 to 8
hours for 3 to 7 days.
Cefoxitin Sodium Solution for injection; Infants, Children, and Adolescents 3 months to 17 years: 80 to 160
mg/kg/day IV/IM divided every 4 to 8 hours (Max: 12 g/day) for 3 to 7 days.
Cefoxitin Sodium Solution for injection; Adults: 1 to 2 g IV every 6 hours for 3 to 7 days.
Fluoroquinolones
Moxifloxacin
Moxifloxacin Hydrochloride Solution for injection; Adults: 400 mg IV every 24 hours for 3 to 7 days.
Comorbidities
Chronic appendicitis
Diagnosis and management of condition is controversial; represents a diagnosis of exclusion
Many exhibit findings of dilated appendix, thickened appendix, or appendicolith without acute periappendiceal
inflammation on imaging 7 16
Appendectomy may relieve symptoms; histopathology may show findings consistent with chronic inflammation in some
patients 16
Elective appendectomy in select patients with concern for chronic appendicitis may be warranted 7
Limited data suggest a subset of patients with chronic, persistent, localized, right lower quadrant pain without systemic
manifestations of inflammation (eg, no fever, normal laboratory findings) may benefit from appendectomy 7
Immunocompromised status 16
Appendicitis often manifests atypically in people who are immunocompromised, given body's inability to mount immune
response (eg, lack of fever, lack of leukocytosis, lack of peritonitis). Imaging may show a blunted level of inflammation
compared with nonimmunosuppressed patients
High index of suspicion, low threshold for imaging, and early aggressive treatment are recommended
Special populations
Pregnant patients
Appendicitis affects 1 in 500 to 2000 pregnancies; 7 highest incidence is in the second and third trimesters 16
Results in preterm labor in at least 4% of patients with uncomplicated appendicitis and 11% of patients with complicated
appendicitis 106
Risk of fetal loss is about 2% in patients without perforation and 6% in patients with complicated appendicitis 106
Delay in diagnosis is not uncommon
Clinical manifestations that occur with normal pregnancy overlap with manifestations of appendicitis (eg, nausea,
vomiting, physiologic leukocytosis, mild elevation in C-reactive protein) and febrile response to illness may be blunted
in pregnancy
Displacement of the appendix by the gravid uterus results in variations in reported location of pain
Imaging 107 108
Ultrasonography is the imaging test of choice, particularly during the first trimester when fetal ionizing radiation
exposure risks from CT imaging are greatest
MRI without gadolinium is next test of choice for patients with inconclusive ultrasonography
CT may be necessary if diagnosis cannot be reliably excluded through clinical evaluation, ultrasonography, or MRI
Consult obstetrician early with concern for appendicitis to aid in diagnosis and management; consult anesthesiologist
soon after diagnosis for aid in surgical matters 7
Operative treatment
Surgical management is usually straightforward in the first trimester of pregnancy but may be challenging due to altered
anatomy in the second and third trimesters 88
Higher risk of perioperative complications in second and third trimesters compared to nonpregnant patients
Laparoscopic appendectomy can be performed in all trimesters; 7 16 conversion to open approach may be required 4
Laparoscopic appendectomy is the standard approach up to 20 weeks of gestation or while the uterine fundus is below
the level of the umbilicus 88
Beyond 20 weeks of gestation, or when the uterine fundus is above the level of the umbilicus, laparoscopic or open
appendectomy may be performed depending on preference and expertise of surgeon 88
Nonoperative approach is not recommended for pregnant patients 4
Infants and small children 7
Very young children, infants, and neonates often present with perforation
Early consultation with a pediatric surgeon is important to reduce risk of becoming a complicated appendicitis
Older patients 16
Appendicitis often manifests atypically (eg, muted symptoms), and diagnosis may be challenging in patients with
underlying dementia
Perforation rate at presentation is higher than general population, and presence of various medical problems results in
higher overall morbidity than other age groups
High index of suspicion, low threshold for imaging, and early aggressive treatment are recommended
Laparoscopic appendectomy recommended over open appendectomy 4
Examples of commonly used antibiotics for appendicitis.
Appendicitis type Definition Antibiotics Duration

Inflamed appendix without
Uncomplicated
signs of gangrene, perforation, Cefoxitin, cefotetan, cefazolin
appendicitis (simple, Single dose of preoperative IV antibiotics 30 to 60
intra-abdominal abscess, plus metronidazole, or ceftriaxone
nonperforated): surgical minutes before incision
contained phlegmon, or plus metronidazole
prophylaxis
purulent intra-abdominal fluid
Uncomplicated Inflamed appendix without
appendicitis (simple, signs of gangrene, perforation, Ertapenem, ceftriaxone plus IV antibiotics are recommended for 48 hours
nonperforated): intra-abdominal abscess, metronidazole, cefotaxime plus followed by outpatient oral antibiotics for total
nonoperative contained phlegmon, or metronidazole, or moxifloxacin antibiotic duration of 5 to 10 days
management purulent intra-abdominal fluid
Total duration of IV/PO antibiotic course is usually
Gangrenous inflamed appendix Ceftriaxone plus metronidazole,
about 3 to 7 days and based on clinical response.
with or without perforation, cefotaxime plus metronidazole,
Complicated appendicitis Continue IV antibiotics until patient is afebrile for
intra-abdominal abscess, piperacillin-tazobactam,
(perforated) 24 hours or more, is tolerating diet, has WBC
contained phlegmon, or imipenem-cilastatin,
count within reference range, and is ready for
purulent intra-abdominal fluid moxifloxacin, or ertapenem
discharge
Caption: Follow institutional clinical practice pathway for preferred antibiotic selection. Begin antibiotics in any patient when diagnosis of acute appendicitis is established or
highly suspected.
Standard management for appendicitis.
Type of appendicitis Typical management strategy

Supportive and symptomatic care (NPO, IV resuscitation and maintenance IV fluids,
All patients electrolyte correction [when indicated if abnormality noted], vomiting and fever control,
analgesia, antibiotics)
Uncomplicated appendicitis (simple or nonperforated
Early laparoscopic appendectomy (surgery within about 8 hours of admission)
appendicitis)
Stable patients with acute appendicitis with perforation Early laparoscopic appendectomy (surgery within about 24 hours of admission). Alternate
without obvious abscess or phlegmon noted in options include antibiotics with or without interval appendectomy (4-8 weeks after acute
preoperative assessment inflammatory process is quelled) and antibiotics only
Stable patients with periappendiceal, walled-off Antibiotics, supportive care, bowel rest, and percutaneous drainage of significant fluid
(contained), well-defined abscess or phlegmon collections when accessible with or without interval appendectomy. Alternate option
(inflammatory mass) includes early appendectomy along with antibiotics and percutaneous drainage
Ill-appearing or unstable patients and patients with
Emergent appendectomy (surgery within several hours of admission) with drainage and
generalized peritonitis (noncontained, free-floating,
irrigation of the peritoneal cavity
purulent fluid in peritoneal cavity)
Caption: Nonoperative management (antibiotics, observation, and supportive care only) for early uncomplicated appendicitis may be an option for select patients in
consultation with a surgeon.
Monitoring
Postoperative monitoring
Monitor clinically for postoperative complications (eg, ileus, infection, obstruction)
Monitor clinically for presence of discharge criteria (eg, pain under control, tolerating oral diet and fluids, ability to
ambulate, lack of fever) 7
Obtain imaging to assess for intra-abdominal abscess (ultrasonography and/or CT) by day 5 to 7 if prolonged ileus and
failure to progress on predicted improvement trajectory develops (eg, persistent fever, WBC count higher than 12,000/mm³,
inability to tolerate PO, uncontrolled pain) 2 109
Complications and Prognosis
Complications
Appendiceal perforation
More common when duration of illness extends beyond 48 to 72 hours 6
Time from onset of symptoms may be the most important determinant related to increased risk for perforation 110 111
Rates of perforation at presentation are variably reported
Perforation rates for children younger than 3 years are greater than 85% 7
Perforation rates for children aged 10 to 17 years are less than 20% 62
Perforation rates for adults range from 17% to 32% 15
Highest perforation rates occur in young children, older adults, and patients with 3 or more comorbidities 15
Perforation may be discovered at the time of appendectomy because ability to detect perforation by preoperative imaging
(eg, ultrasonography, CT) is not optimal
May result in development of local complications (eg, appendiceal abscess or phlegmon) or more of a diffuse process (eg,
peritonitis); untreated perforation can lead to sepsis and death
After appendectomy
Postoperative complications may include: 73
Early
Surgical site infection (eg, wound infection, intra-abdominal abscess)
Bleeding
Bowel injury
Prolonged postoperative ileus
Bowel obstruction
Visceral or cutaneous fistula
Wound dehiscence
Late
Stump appendicitis
Infertility (in females)
Small bowel obstruction secondary to intra-abdominal adhesions
Incisional hernia
Risk for postoperative complications is much higher following perforated appendicitis than simple (nonperforated)
appendicitis 73
About 20% of children with perforated appendicitis and 0.8% with nonperforated appendicitis develop postoperative
intra-abdominal abscess 2
Negative appendectomy rate
Negative appendectomy means that a normal appendix is found during surgery
Despite continually improving imaging techniques, negative appendectomy rates may reach up to about 20% in some
institutions, depending on population 5 6
Females of childbearing age, young children, and older people are among the highest groups with negative appendectomy
rates 5
Current guidelines recommend removal of normal-appearing appendix in patients with signs and symptoms of
appendicitis due to variability in ability of surgeons to visually identify appendiceal inflammation 4
Prognosis
Morbidity and mortality largely depend on patient age, existing comorbidity, and appendix status (perforated or
nonperforated)
Mortality
Overall, most pediatric and adult age mortality rates are low (less than 1%) in developed nations; higher with advanced
age and in low- and middle-income countries (1%-4%) 112 6
Estimates are higher overall for patients with perforation (about 1.7%) 1
Morbidity
Previously healthy patients without perforation usually rapidly return to normal activities after appendectomy with
negligible risk of postoperative complications (about 3%) 6
Patients with perforation are at much higher risk for postoperative complications (20%-30%), prolonged hospital stay,
need for prolonged antibiotic therapy, increased postoperative use of CT, and longer time to return to normal activities
6
Course of illness
Spontaneous resolution may occur in a small minority of patients without treatment 11 113
About 40% of children overall present with perforation; about 90% of children younger than 3 years present with
perforation 6
Average postoperative length of stay: 6
For patients with simple appendicitis is about 24 hours
For patients with perforated appendicitis is about 4 to 5 days
Incidental appendicolith
Incidence of incidental appendicolith (calcification in appendiceal lumen without signs of appendicitis) noted on imaging
(abdominal radiograph, CT, ultrasonography) obtained for reasons other than concern for appendicitis may be as high as
10% 6
Patients with and without incidental appendicolith have the same risk for developing appendicitis 6
Clinical follow-up is only measure usually indicated 6
Screening and Prevention
Screening
At-risk populations
Adults 40 years or older with complicated appendicitis have an increased incidence of appendicular neoplasms (3%-17%). For
patients treated nonoperatively, international guidelines recommend screening colonoscopy and full-dose contrast-enhanced
CT after resolution of acute infection 4
Prevention
Incidental appendectomy
Appendectomy performed at time of abdominal surgery for a different indication without evidence of acute appendicitis
114
Although once common practice, this procedure is now controversial 16
May be considered in surgical procedures requiring right lower quadrant incision (eg, Meckel diverticulectomy,
intussusception reduction) 2
Rationale includes eliminating risk for future appendicitis and for complications occurring in the setting of potential
diagnostic uncertainty (eg, Crohn disease) 7
Benefits must be weighed against risks of appendectomy (eg, wound infection, appendiceal stump leakage, adhesions)
and loss of appendix for subsequent gastrointestinal or urogenital reconstructive procedures 7
Therefore, avoid in patients at risk for bowel or bladder incontinence
Indications for incidental appendectomy are individualized to patient and determined by surgeon
Some experts suggest that indications may be best reserved for patients in whom future appendicitis may pose a
diagnostic dilemma or future appendectomy is predicted to be unusually challenging 7
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13/11/23, 16:42 Appendicitis - ClinicalKey

For complicated appendicitis, common regimen is ceftriaxone plus metronidazole

Low-risk patients can often be discharged with scheduled follow-up

Urinary symptoms or diarrhea may predominate if appendix is located in pelvic position 11

Very young children usually present with perforated appendicitis

Most common abdominal surgical emergency; lifetime risk approaches 8% 2

Complicated appendicitis (includes perforated appendicitis)

Perforation is defined as a hole in the appendix or fecalith in the abdomen 2

Typically the earliest symptom and present in most patients

Classic description of pain

Migration of pain is a strong predictor of appendicitis in both children (positive

Presence of right lower quadrant pain is a stronger predictor of appendicitis in

Nausea and vomiting

Typically develops after onset of pain

May become bilious with persistent emesis

Presence of fever increases likelihood of appendicitis at least 3-fold 2 14

Urinary symptoms (eg, frequency, urgency)

Most often noted in patients with appendix located in pelvic position

Tenesmus and constipation may develop

Symptoms suggestive of perforation

Patients move tentatively and prefer to remain still

Right leg may be flexed at hip to decrease peritoneal stretch

Fever (higher than 37.3 °C) 18 13 may be present

Fever above 38 °C is more common in patients with appendiceal perforation 17

Localized (focal) abdominal tenderness is the most reliable overall finding 6

Voluntary guarding may occur near area of maximal tenderness

May reflect anatomic position of appendix

Psoas or obturator sign also may indicate anatomic location of appendix

Neither sign is associated with severity of disease or perforation

Positive likelihood ratio of 3.5 for appendicitis in children 15

Abdominal rigidity (positive likelihood ratio, 3.8 in adults) 15

Involuntary guarding and abdominal wall rigidity

Pelvic examination, when indicated (particularly females of childbearing age)

Right adnexal tenderness may be appreciable

Causes and Risk Factors

Risk factors and/or associations

Incidence steadily increases in children with advancing age

Extremely rare in children younger than 3 years (less than 1% of cases) 6

Rare in children younger than 5 years (less than 5% of cases) 6

Most common in children aged 10 years or older 6

Less than 25% of cases occur in patients older than 45 years 5

Other risk factors/associations

Occurs more frequently in fall and winter 2

More common in older patients (40%-70%) 16 and immunocompromised patients

More common in males than females

Primary diagnostic tools

Order standard tests including CBC, urinalysis, and C-reactive protein 4

Establishing diagnosis can be challenging and may be aided by laboratory testing,

Most algorithms are based on baseline probability of appendicitis as determined by

Clinical prediction rules should not be used as basis to withhold advanced

Patients are stratified into low-, intermediate-, and high-risk groups 6

Low risk: further evaluation includes:

Assess and treat alternate causes of abdominal pain

Significant regional and institutional practice variation exists in preferred

Preferred imaging for acute appendicitis

CT scan with IV contrast of abdomen and pelvis is preferred imaging modality

May be used to clarify equivocal findings in other studies (eg, CT or

Some data suggest that the diagnostic accuracy of ultrasonography approaches

A meta-analysis of accuracy of imaging studies in pediatric patients showed

Ultrasonographic evaluation in pregnancy has been shown to have low

Low likelihood of appendicitis

Supplemental Risk for

WBC count, absolute

High likelihood of appendicitis