Acute appendicitis

Straight to the point of care

Last updated: Dec 19, 2023

 Table of Contents
Overview 3
Summary 3
Definition 3

Theory 4
Epidemiology 4
Risk factors 4
Aetiology 4
Pathophysiology 4
Case history 5

Diagnosis 6
Recommendations 6
History and exam 20
Investigations 28
Differentials 32
Criteria 34

Management 39
Recommendations 39
Treatment algorithm overview 56
Treatment algorithm 58
Patient discussions 75

Follow up 76
Monitoring 76
Complications 77
Prognosis 79

Guidelines 80
Diagnostic guidelines 80
Treatment guidelines 81

Evidence tables 82

References 84

Images 96

Disclaimer 98
Acute appendicitis Overview

Summary
Acute appendicitis typically presents as acute abdominal pain starting in the mid-abdomen and later
localising to the right lower quadrant.

OVERVIEW
Associated with fever, anorexia, nausea, vomiting, and elevation of the neutrophil count.

Diagnosis is usually made clinically. If investigation is required, computed tomographic scan or

ultrasonography may show inflammation or dilatation of the appendix outer diameter to more than 6 mm.

Definitive treatment is surgical appendicectomy.

Definition
Acute appendicitis is an acute inflammation of the vermiform appendix, most likely due to obstruction of the
lumen of the appendix (by faecolith, normal stool, infective agents, or lymphoid hyperplasia).[1] [2]

Acute appendicitis - intraoperative specimen

Nasim Ahmed, MBBS, FACS; used with permission

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 Acute appendicitis Theory

Epidemiology
Acute appendicitis is among the most common causes of lower abdominal pain leading patients to attend
the accident and emergency department and the most common diagnosis made in young patients admitted
THEORY

to the hospital with an acute abdomen.[7] Around 50,000 cases of appendicitis were treated in hospitals
in England in 2020 to 2021.[10] Most cases occurred in the 20 to 59 year age group.[10] A large majority
presented (46,297) as medical emergencies.[10]

One systematic review of population-based studies reported the pooled incidence of appendicitis or
appendectomy in the US in the 21st century to be 100 per 100,000 person-years; the estimated number of
cases in the US in 2015 was 378,614.[11]

In the US, the overall lifetime risk of developing acute appendicitis is 8% for males and 7% for females.[12]
Data suggest a rapid increase in incidence in newly industrialised countries.[11]

Acute appendicitis most commonly occurs between the ages of 10 and 30 years, with the highest incidence
in children and adolescence.[7] [13] There is a slight male to female predominance (1.4:1).[2]

Risk factors
Weak
improved personal hygiene
A balance of gastrointestinal microbial flora is important for prevention of infection, for digestion, and
for providing important nutrients.[20] Frequent use of antibiotics and improved hygienic conditions lead
to decreased exposure and/or imbalance of gastrointestinal microbial flora that may eventually lead to
a modified response to viral infection and thereby trigger appendicitis.[21]

smoking
Children exposed to passive smoking have significantly increased incidence of acute appendicitis.[7]
[22] There is also an increased incidence of acute appendicitis in adult patients who smoke every day
compared with adults who never smoked.[22] [23]

Aetiology
Obstruction of the lumen of the appendix is the main cause of acute appendicitis. Faecolith (a hard mass of
faecal matter), normal stool, or lymphoid hyperplasia are the main causes for obstruction.

Other postulated mechanisms of appendicitis, based on emerging research, include parasitic infection,
schistosomal infection, and neuroimmune aetiology.[14] [15] [16][17] These are ongoing areas of
investigation.

Pathophysiology
The lumen distal to the obstruction starts to fill with mucus and acts as a closed-loop obstruction. This
leads to distension and an increase in intraluminal and intramural pressure. As the condition progresses,
the resident bacteria in the appendix rapidly multiply. The most common bacteria in the appendix are
Bacteroides fragilis and Escherichia coli .[18]

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Acute appendicitis Theory
Distension of the lumen of the appendix causes reflex anorexia, nausea and vomiting, and visceral pain.

As the pressure of the lumen exceeds the venous pressure, the small venules and capillaries become
thrombosed but arterioles remain open, which leads to engorgement and congestion of the appendix. The

THEORY
inflammatory process soon involves the serosa of the appendix, hence the parietal peritoneum in the region,
which causes classic right lower quadrant pain, at McBurney's point.

Once the small arterioles are thrombosed, the anti-mesenteric border becomes ischaemic, and infarction
and perforation ensue. Bacteria leak out through the dying wall and pus forms (suppuration) within and
around the appendix. Perforations are usually seen just beyond the obstruction rather than at the tip of the
appendix.[19]

Case history
Case history #1
A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea,
and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right
lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical
examination reveals a low-grade fever (38°C [100.5°F]), tenderness on palpation at right lower quadrant
9
(McBurney's sign), and leukocytosis (12 x 10 /L or 12,000/microlitre) with 85% neutrophils.

Case history #2
A 12-year-old girl presents with sudden-onset severe generalised abdominal pain associated with nausea,
vomiting, and diarrhoea. On examination she appears unwell and has a temperature of 40°C (104°F).
Her abdomen is tense with generalised tenderness and guarding. No bowel sounds are present.

Other presentations
Atypical appendiceal anatomy, such as a retrocaecal or long appendix, may present with back, hip, or left-
sided abdominal pain that may be confused with other intra-abdominal diagnoses. Older patients with
appendicitis are less likely to have a typical presentation.[3] The delay in presentation or diagnosis in this
group results in increased risk of morbidity and mortality.[3] [4] [5] The diagnosis of acute appendicitis
during pregnancy is often delayed, as the location of the pain is affected by displacement of the appendix
by the uterus, and symptoms such as nausea and vomiting are frequently associated with pregnancy
itself.[6]

Acute appendicitis is the most common surgical emergency in children, but early diagnosis remains
challenging due to atypical clinical features and the difficulty of obtaining a reliable history and physical
examination.[7] Children may present with non-specific abdominal pain, anorexia, and vomiting.[8] The
presence of pain on coughing or hopping can be suggestive of the diagnosis.[9]

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 Acute appendicitis Diagnosis

Recommendations

Urgent
Suspect appendicitis in any patient with:

• Acute severe right iliac fossa pain

• Poorly localised central abdominal pain that becomes localised to the right lower quadrant[24]
• Anorexia, nausea, and vomiting.[12]

Look for signs of a perforated appendix as this is associated with significant morbidity and mortality;
the patient will look unwell and may have signs of shock or sepsis.[2] [25] See Shock , Sepsis in adults ,
and Sepsis in children .

• Examine the abdomen; this may show:

• Localised or generalised peritonitis with guarding[25]

• A palpable mass if a peri-appendiceal abscess is present due to perforation.[7]

• Involve early surgical input because emergency appendicectomy is needed. If there is

evidence of sepsis, consider escalating to critical care. [26]
• Give preoperative resuscitation while waiting for surgery.[27]

Maintain a high level of suspicion of appendicitis in pregnant women because a delay in

diagnosis and treatment may result in perforation, which is associated with significant maternal and fetal
mortality.[28]

• Appendicitis is the most common non-obstetric surgical condition during pregnancy.[28]

• After the first trimester, atypical pain such as right upper quadrant or right flank pain can occur.[29]

Refer all children with suspected appendicitis to the paediatric surgery team on call, if
available. Where no paediatric surgery team is available, joint care should be managed between
paediatrics and surgical teams.
DIAGNOSIS

Key Recommendations
History
While taking a history bear in mind that typical symptoms and signs of appendicitis are present in only
around 50% of cases.[29]

• The most common presenting symptom is poorly localised central abdominal pain that
becomes localised to the right lower quadrant as inflammation progresses.[24]

• Remember that the location of the appendix varies, and consequently so does the location of
the pain.[25]

Examination
Assess for:

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Acute appendicitis Diagnosis
• Right lower quadrant tenderness[24][25] [30]

• However, in pregnant women, atypical pain such as right upper quadrant or right flank pain
may occur in the later stages of pregnancy[29]

• Low-grade pyrexia (>37.8°C [>100.1°F])[2]

• Tachycardia
• Flushed face and fetor oris[29]
• Flexed right hip (psoas sign) in retrocaecal appendicitis.[12]

Risk stratification
In adults, use a scoring system to determine the likelihood or rule out the diagnosis of appendicitis
in order to guide further investigations and management (see Risk stratification in the full
recommendations section, below).[7]

• The most commonly used scoring systems are the Alvarado score, the Appendicitis
Inflammatory Response (AIR) score, and the Adult Appendicitis Score (AAS).[7] The AIR
and AAS scores perform better as predictors of acute appendicitis than the Alvarado score.

• Any one of the three scores can be used to rule out appendicitis in low-risk patients, reducing
the need for imaging and the risk of negative appendicectomy. But do not use the Alvarado
score to positively confirm an appendicitis diagnosis.[7]

In children and elderly patients, do not make the diagnosis of appendicitis based on clinical scores
alone.[4] [7]

Initial investigations
Use the results of initial blood tests, in combination with history and examination, to risk stratify patients
via a scoring system (AIR or AAS is most accurate); this will determine whether imaging is required.[7]
See Risk stratification in the full recommendations section, below.

Consider imaging, along with observation, in intermediate-risk patients. Use either abdominal

DIAGNOSIS
ultrasound or computed tomography; magnetic resonance imaging may be used in pregnant women if
ultrasound is inconclusive.[7] In children, order an ultrasound if an imaging investigation is indicated
based on clinical assessment.[7] [30] A combination of blood tests (raised white cells and C-reactive
protein) and ultrasound is usually enough to confirm the diagnosis. In rare instances of diagnostic doubt in
children with an inconclusive ultrasound, choose computed tomography or magnetic resonance imaging
based on local availability and expertise.[7]

• High-risk patients who are aged <40 years and have strong symptoms and signs of appendicitis
may go straight to surgery without imaging. However, if they are >40 years they should generally
have imaging before surgery.[7] Check your local protocols as this varies in practice.
• Low-risk patients may be safely discharged without diagnostic imaging, as long as they have
appropriate safety-netting.[7]

If imaging is required, seek advice from a radiologist to determine the best imaging modality for
your patient.

Order a pregnancy test in all women of childbearing age.

Use urinalysis to rule out urinary tract infection (UTI).[25]

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 Acute appendicitis Diagnosis
• However, do not make a diagnosis of UTI on urinalysis alone. A history of urinary symptoms and
positive urine microscopy are also required.

Full Recommendations
Diagnostic goals
Have a high level of suspicion of acute appendicitis because this can be challenging to diagnose.[13]

• The clinical presentation can vary from mild non-specific symptoms to a haemodynamically
unstable patient with sepsis or shock.[2]

Diagnose appendicitis based on a combination of history, examination, laboratory findings, and imaging.
The goals are to:[7]

• Ensure diagnoses aren’t missed, particularly in older patients, pregnant women, and children, who
are more likely to have an atypical presentation[7]
• Minimise the rate of negative appendicectomy (removal of a normal appendix), which is reported to
be as high as 15% to 20% and even higher (28%) in young women.[7] [13] [31]
DIAGNOSIS

Acute appendicitis - intraoperative specimen

Nasim Ahmed, MBBS, FACS; used with permission

Clinical presentation

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Acute appendicitis Diagnosis

History
While taking a history bear in mind that typical symptoms and signs of appendicitis are present in only
around 50% of cases. In most patients, symptoms start with anorexia, followed by abdominal pain and
then vomiting.[12] [29]

• Abdominal pain is the main presenting symptom:

• Typically starts as central abdominal pain, and 1 to 12 hours later it moves to the
right lower quadrant as the inflammation progresses[24]
• Usually constant with intermittent cramps[24]
• Often worse on movement and coughing.[9]

• Anorexia is almost always present.[12]

• If the patient is hungry and wants to eat, this is reassuring and makes appendicitis less
likely.[25]

• Nausea and vomiting are present in 75% of patients.[12]

• Either loose stool or constipation can occur.[12] [29]

Always consider intra-abdominal malignancy, particularly in patients aged 50 and over presenting with
abdominal pain, weight loss and change in bowel habit.[32]

Practical tip

Some patients may present with diarrhoea or vomiting. Ensure you take a detailed history of the
nature, volume, and frequency of these symptoms as the underlying appendicitis is easily missed.
• Vomiting may occur in late appendicitis if there is small bowel obstruction due to an appendiceal
abscess.[33]
• The patient may also pass small volumes of mucus from the rectum if there is a pelvic
appendicitis with a collection. The patient may describe this mucus as ‘diarrhoea’ (whereas stool
volume is increased in true diarrhoeal illness).[12]

Don’t make the diagnosis of appendicitis in a pregnant woman based on history and

DIAGNOSIS
examination only; order blood tests including inflammatory markers.[7]

• Appendicitis is the most common non-obstetric surgical condition during pregnancy.[28]

• A delay in diagnosis and treatment may result in perforation, which is associated with significant
maternal and fetal mortality.[28]
• Features that are significantly associated with appendicitis in pregnant patients are:[34]

• Nausea
• Vomiting
• Localised peritonitis.

Take a collateral history if communication is a challenge: for example, when there is a language barrier
or in patients who are very young, have dementia, have a mental health diagnosis, or have a learning
difficulty.[35]

• Suspect appendicitis if there is a history of becoming withdrawn or less active, or having reduced
oral intake.[35]

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 Acute appendicitis Diagnosis
Practical tip

Keep an open mind to other diagnoses when examining the patient.[29]

• It can be difficult to differentiate appendicitis from other causes of abdominal pain, particularly in
older patients, women of childbearing age, and children.[29]
• In most patients, symptoms start with anorexia, followed by abdominal pain and then
vomiting.[12]

Remember that the location of the pain can vary depending on the position of the appendix.[25]
• A retrocaecal appendix can cause flank or back pain.
• A retroileal appendix can cause testicular pain due to irritation of the spermatic artery or ureter.
• A pelvic appendix can cause suprapubic pain.
• A paracolic long appendix with tip inflammation in the right upper quadrant may cause pain in
this region.

Examination
Examine for the following signs of appendicitis:

• Right lower quadrant tenderness[25]

• However, in pregnant women, atypical pain such as right upper quadrant or right flank
pain may occur after the first trimester due to displacement of the appendix by the gravid
uterus[29]

• Low-grade pyrexia (>37.8°C [>100.1°F])[25]

• However, consider other causes if there is a very high fever[2]

• Tachycardia[29]

• May be present but remember that this can also indicate a perforated appendix
DIAGNOSIS

• Flushed face and fetor oris[29]

• Flexed right hip (psoas sign) in retrocaecal appendicitis.[12]

Assess for signs of a perforated appendix. The patient will appear unwell and may have:

• Signs of shock or sepsis.[2] See Shock , Sepsis in adults , and Sepsis in children .
• Localised peritonitis with guarding[25]
• Generalised peritonitis; a tense, distended abdomen with guarding or rigidity and absent bowel
sounds[25]

• This is caused by free perforation in the peritoneal cavity[25]

• A palpable mass

• This is due to a peri-appendiceal abscess caused by a perforation that is contained by the

omentum.[7]

Do not routinely perform a rectal examination; this should be done only if the diagnosis is
unclear.[27] [36]

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Acute appendicitis Diagnosis
Practical tip

Examining children
Consider giving analgesia to children with suspected appendicitis if pain limits the examination.
• Analgesia does not lead to missed diagnoses in children.[37] [38]

Ask children to cough or hop to elicit abdominal pain.[9]

Children may need to be distracted by parents, guardians, or a play specialist in order to obtain an
accurate examination.
See our topic Assessment of abdominal pain in children.

Risk stratification
In adults, use a scoring system to determine the likelihood or rule out the diagnosis of appendicitis in
order to guide further investigations and management.[7]

• Use either the Appendicitis Inflammatory Response (AIR) score or the Adult Appendicitis
Score (AAS) to determine whether your patient is at high, intermediate, or low risk of having
appendicitis.[7]

• High-risk patients who are aged <40 years, and have strong symptoms and signs of
appendicitis, may go straight to surgery without imaging.[7] However, check your local
protocols as this varies in practice.
• Intermediate-risk patients may undergo further imaging and observation.[7]
• Low-risk patients may be safely discharged without diagnostic imaging, as long as they have
appropriate safety-netting.[7]

• The Alvarado score can be used to rule out appendicitis but do not use it to positively confirm a
diagnosis of appendicitis; it is not specific enough for that purpose.[7]
• The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score is an alternative but is less
commonly used. It is not covered in this guidance.[39]
• All the scoring systems involve a combination of history, examination findings, and investigation
results.[7]
• These scoring systems should not be used in place of cross-sectional imaging to make a diagnosis
of appendicitis in elderly patients owing to limited evidence in this patient group.[4] [5]

DIAGNOSIS
In children, do not make the diagnosis of appendicitis based on clinical scores alone.[7]

• Children frequently have atypical clinical features and obtaining a reliable history can be
challenging.
• The diagnosis of acute appendicitis in children should be made on the basis of clinical suspicion,
blood tests, and, if needed, imaging (see the Investigations section).
• Clinical scores are useful tools in excluding acute appendicitis in children.
• Scoring systems used in children include the Alvarado score and the Pediatric Appendicitis Score
(PAS). The PAS includes similar clinical findings to the Alvarado score in addition to a sign more
relevant in children: right lower quadrant pain with coughing, hopping, or percussion.[7]

Use the following table to calculate the score for your patient, depending on which scoring system you are
using:[40] [41]

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 Acute appendicitis Diagnosis
Alvarado*[40]
AIR[40] AAS[41] [42] PAS*[43]

History

Vomiting 1 point N/A 1 point for either 1 point for either

vomiting OR vomiting OR
nausea nausea

Anorexia N/A N/A 1 point 1 point

Pain in right 1 point 2 points 2 points N/A

lower quadrant

Migration of N/A 2 points 1 point 1 point

pain to the right
lower quadrant

Examination

Right lower N/A • Women N/A 2 points for right

quadrant aged lower quadrant
tenderness 16-49: 1 tenderness
point to cough,
• Women percussion, or
aged ≥50 hopping
and men:
3 points

Right iliac fossa N/A N/A N/A 2 points

tenderness
DIAGNOSIS

Rebound 1 point N/A

• Light: 1 • Mild: 2
tenderness or
guarding point points
• Medium: • Moderate
2 points or severe:
• Strong: 3 4 points
points

Fever >38.5#: 1 point N/A >37.3#: 1 point >38.0#: 1 point

Blood test results

Leukocytosis N/A N/A 1 point N/A

shift

Proportion of • <70: 0 • <62: 0 N/A N/A

neutrophils points points

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Acute appendicitis Diagnosis
Alvarado*[40]
AIR[40] AAS[41] [42] PAS*[43]

• 70-84: 1 • ≥62 and

point <75: 2
• ≥85: 2 points
points • ≥75 and
<83: 3
points
• ≥83: 4
points

Absolute N/A N/A N/A >7500: 1 point

neutrophil count

White blood cell • <10.0: 0 • <7.2: 0 • ≤10: 0 • >10: 1

9
count (× 10 /L) points points points point
• 10.0– • ≥7.2 and • >10: 2
14.9: 1 <10.9: 1 points
point point
• ≥15.0: 2 • ≥10.9 and
points <14.0: 2
points
• ≥14.0: 3
points

C-reactive • <10: 0 Symptoms <24 N/A N/A

protein (mg/L) hours
points
• 10–49: 1 • <4: 0
point points

DIAGNOSIS
• ≥50: 2 • ≥4 and
points <11: 2
points
• ≥11 and
<25: 3
points
• ≥25 and
<83: 5
points
• ≥83: 1
point

Symptoms >24
hours

• <12: 0
points

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 Acute appendicitis Diagnosis
Alvarado*[40]
AIR[40] AAS[41] [42] PAS*[43]

• ≥12 and
<152: 2
points
• ≥152: 1
point

Add up the total number of points for your patient to calculate the risk of appendicitis as follows:[40] [41]

High risk

• AIR: 9-12 points

• AAS: ≥16 points
• Alvarado: 9-10 points
• PAS: ≥7 points

Intermediate risk

• AIR: 5-8 points

• AAS: 11-15 points
• Alvarado: 5-8 points
• PAS: 4-6 points

Low risk

• AIR: 0-4 points

• AAS: 0-10 points
• Alvarado: 0-4 points
•
DIAGNOSIS

PAS: <4 points

*In children, do not make the diagnosis of appendicitis based on clinical scores alone.[7] Children
frequently have atypical clinical features and obtaining a reliable history can be challenging. Clinical
scores are useful tools in excluding acute appendicitis in children.[7]

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Acute appendicitis Diagnosis

Evidence: Scoring systems in adults

Scoring systems are useful to identify adults (>16 years) at low or intermediate risk of acute
appendicitis and can reduce the need for imaging.

Guidelines agree that scoring systems are useful to exclude appendicitis and to identify low-risk
patients who do not require imaging, although they differ in which score they recommend and the cut-
off used.

• The World Society of Emergency Surgery (WSES) 2020 guideline concludes that an Alvarado or
Appendicitis Inflammatory Response (AIR) score <5 or an Adult Appendicitis (AAS) score <11
can be used to identify adults (>16 years) with a very low likelihood of having acute appendicitis
and who therefore do not need further investigation.[7]

• However, the WSES states that the Alvarado score cannot be used to diagnose
acute appendicitis due to its low specificity, and it seems unreliable in distinguishing
complicated from uncomplicated appendicitis in people aged over 75 years.[4]
• Therefore the WSES recommends AIR or AAS as the best performing clinical prediction
scores for adults with suspected appendicitis.

• The European Association for Endoscopic Surgery 2015 consensus statement recommends the
use of the Alvarado score to divide patients into:[13]

• A low probability group (<4) who do not need imaging

• Intermediate (4-8) and high (≥9) probability groups for whom ultrasound scanning is
indicated.

A large UK study (n=5345) of adults (16-45 years) also showed that scoring systems may be useful
in identifying low-risk patients who are unlikely to have appendicitis. This may reduce the rate of
admissions, CT scans, and unnecessary surgeries. This is particularly important in the UK as there is
a high rate of normal appendixes removed.[31]

• The study found that low-risk patients who are initially discharged and then re-attend with

DIAGNOSIS
appendicitis had low rates of complications such as perforation.

The study authors proposed a clinical algorithm using an AIR score ≤2 for men and an AAS ≤8 for
women to identify people at low risk.

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 Acute appendicitis Diagnosis

Evidence: Scoring systems in children

Scoring systems are useful to exclude acute appendicitis in children; they should not be used
alone to make a diagnosis.

The World Society of Emergency Surgery (WSES) 2020 guideline recommends the Alvarado score or
the Pediatric Appendicitis Score (PAS) for excluding acute appendicitis in children.[7] This is based
on the following evidence.

• A systematic review (search dates January 1950 to January 2012) found that while these
scores were the best validated in children (each included in five studies), both failed to meet the
performance benchmarks and tended to overdiagnose acute appendicitis.[44]

• PAS sensitivity 0.82 to 1 (median 0.93); negative likelihood ratio (LR-) 0 to 0.27 (median
0.1); predicted appendicitis frequency 0.43 to 0.98 (median 0.52); actual appendicitis
frequency (median) 0.34; average overdiagnosis 35%.
• Alvarado rule sensitivity 0.72 to 0.93 (median 0.88); LR- of 0.09 to 0.34 (median 0.14);
predicted appendicitis frequency 0.34 to 0.64 (median 0.6); actual appendicitis frequency
(median) 0.41; average overdiagnosis 32%.

• These scores are less reliable in preschool-age children due to the presentation often being
atypical, and increased risk of rapid progression and complications in this age group.[45]
• There is some evidence that the Alvarado score may also help predict postoperative
complications in children with acute appendicitis.[46]

Other scores considered in the WSES guideline

A retrospective study of 747 children (mean age of 11 years) with suspected acute appendicitis
showed the Appendicitis Inflammatory Response (AIR) score, which includes C-reactive protein (CRP)
levels, outperformed the Alvarado score and PAS (area under the receiver-operating curve: AIR 0.90;
Alvarado score 0.87; PAS 0.82).[47] Further research is needed validating the AIR score in children.

The Pediatric Appendicitis Laboratory Score (PALabS), which includes CRP and calprotectin levels,
has shown some promise in predicting which children are at low risk of acute appendicitis.[48]
DIAGNOSIS

Key investigations
Use the results of blood tests, in combination with history and examination, to risk stratify patients using
a scoring system (AIR, AAS, or Alvarado); this will determine whether imaging is required.[7] See Risk
stratification above.

Blood tests
Request a full blood count and C-reactive protein (CRP) in all patients.[27]

• 9
Leukocytosis (10-18 x 10 /L) with neutrophilia is present in 80% to 90% of people with
appendicitis.[29]
• C-reactive protein is likely to be elevated.[9]
• 9
In children, elevated CRP level (≥10 mg/L) on admission and leukocytosis (≥16 x 10 /L) are
strong predictive factors for appendicitis.[7]

Consider a ‘group and save’ for patients having surgery.[27]

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Acute appendicitis Diagnosis
Practical tip

The rise in WBC occurs within 5 to 24 hours after symptom onset, whereas the rise in CRP may
only be seen after the patient has had symptoms for >12 hours.[7] [27] [50]

Evidence: Blood tests

Blood tests, in combination with a clinical assessment, are sensitive for diagnosing
appendicitis.

• In patients suspected of having acute appendicitis, the combination of an elevated WBC and
elevated CRP gives a sensitivity of over 95% for supporting the diagnosis.[27]
• A raised CRP is thought to be slightly more specific than a raised WBC.[51]

Imaging
Consider imaging, along with observation, for intermediate-risk patients.[7]

• High-risk patients who are >40 years should also have imaging before going to surgery.[7]

Imaging is not always needed.

• High-risk patients who are <40 years and have strong symptoms and signs of appendicitis may go
straight to surgery without imaging.[7] However, check your local protocols as this varies in practice.
• Low-risk patients may be safely discharged without diagnostic imaging, as long as they have
appropriate safety-netting.[7]

If imaging is required, seek advice from a radiologist to determine the best imaging modality for
your patient.

Ultrasound
Order an ultrasound if radiation risk is a concern; it should be used as first line in pregnant women
and children.[7] [27] [52] [53] It is a rapid test and can be performed at the bedside.[7] Check local
protocols as guidelines differ in their recommendations on use of ultrasound.

DIAGNOSIS
• Acute appendicitis can be ruled out if a normal appendix is visualised in its full length.[7] [30]
• Ultrasound is also useful for detecting alternative causes of abdominal pain (e.g., gynaecological
conditions).[7] [27]

Order magnetic resonance imaging (MRI) in a pregnant woman if ultrasound is inconclusive.[7] [54]
MRI has been proven to be a highly accurate diagnostic test for acute appendicitis, with a sensitivity of
0.96 and specificity of 0.97 in pregnant women.[55] However, a negative or inconclusive MRI does not
exclude appendicitis and surgery should still be considered if clinical suspicion is high.[7] In children, if
there is diagnostic doubt and ultrasound results are inconclusive, choose a second-line imaging technique
(computed tomography or MRI) based on local availability and expertise.[7]

Abdominal computed tomography (CT)

Consider contrast-enhanced CT scan if: [7]

• Ultrasound is inconclusive and there is ongoing clinical suspicion of appendicitis[7]

• Low-dose CT is preferred if negative is ultrasound.[7]

• You suspect malignancy[7]

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 Acute appendicitis Diagnosis
• You suspect an appendicular mass or abscess.[7]

A positive CT scan will show wall thickening, wall enhancement, and inflammatory changes in the
surrounding tissues.[56]

CT abdomen - thickened appendix

Nasim Ahmed, MBBS, FACS; used with permission
DIAGNOSIS

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Acute appendicitis Diagnosis

Evidence: Debate on role of imaging in diagnosis of acute appendicitis

If imaging is required, discuss with a radiologist to determine the best imaging modality for
your patient. [7] Use of imaging differs markedly between countries and institutions.

CT has a greater sensitivity and specificity than ultrasound and may reduce normal appendicectomy
rates.[31] [57] [58] However, its use may depend on local resources and patient choice regarding
exposure to ionising radiation.

• Ultrasound has a sensitivity of 71% to 94% and a specificity of 60% to 98% for acute
appendicitis; if ultrasound is unequivocally positive for appendicitis, ultrasound has comparable
accuracy to a positive CT or MRI for ruling in appendicitis.[13] [59]
• In a study based on a large UK dataset (published 2020) the performance of ultrasound imaging
for diagnosis of appendicitis was poor in both men and women (women: sensitivity 36%, false
negative rate 8·4%; men: sensitivity 38%, false negative rate 18.8%).[31]

• CT showed much better accuracy (women: sensitivity 92%, false negative rate 2.1%;
men: sensitivity 94%, false negative rate 4.5%).

• A Cochrane systematic review (search date June 2017) assessed the diagnostic accuracy of CT
based on 71 separate study populations in 64 studies. The sensitivity was 95% (95% CI 93% to
96%), and specificity 94% (95% CI 92% to 95%).[60]

• The probability of having appendicitis following a positive CT result was 92% (95% CI
90% to 94%), and following a negative CT result was 0.4% (95% CI 0.3% to 0.5%).
• There was little to no difference in sensitivity or specificity for low-dose CT compared with
standard‐dose or unspecified‐dose CT.

• A CT with contrast has 92% sensitivity compared with 95% sensitivity in non-intravenous
contrast-enhanced CT scan (no statistical significance).[61] [62] [63] Therefore, CT without
contrast has equivalent diagnostic utility as a CT with contrast.[64]

Use of imaging differs between Europe and the US.

DIAGNOSIS
• In Europe, the use of ultrasound for the diagnosis of acute appendicitis is becoming more
widespread. However, young men with typical symptoms and signs of appendicitis often
proceed straight to surgery without imaging, which might contribute to the rate of negative
appendicectomies.[7]

• A large UK study (published 2020) found that 73% (2638/3613) of women had
preoperative imaging. The vast majority had ultrasound imaging (2289/3613, 63%) with
CT performed in only 15% (547/3613).[31]
• This compared with only 36% (627/1732) of men who had preoperative imaging
(ultrasound 16% [276/1732]; CT 23% [398/1732]).[31]

• In the US, it is common practice for all non-pregnant adults to have a CT scan to confirm
appendicitis.[7]

Guidelines differ in their recommendations.

• The World Society of Emergency Surgery’s 2020 guideline recommends using a combination of
clinical parameters (initial assessment and clinical scores) and ultrasound imaging to improve
diagnostic sensitivity and specificity and reduce the need for CT scan.[7]

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 Acute appendicitis Diagnosis
• It also makes a weak recommendation that CT scan should not be used for high-risk
patients (Appendicitis Inflammatory Response score 9–12, Alvarado score 9–10, or Adult
Appendicitis score ≥ 16) younger than 40 years prior to laparoscopy.

• The European Association for Endoscopic Surgery 2015 consensus statement recommends
ultrasound for any patient with a high or intermediate Alvarado score (≥4). CT or MRI scanning
is reserved for patients in whom ultrasound is inconclusive.[13]
• In its 2014 commissioning guide, the Association of Surgeons of Great Britain and Ireland
recommends either imaging or laparoscopy for any patient suspected of having appendicitis
who has an elevated white blood cell and C-reactive protein.[27]

Other investigations

Urinalysis
Use urinalysis to help exclude a urinary tract infection (UTI).[25]

• UTI can present with very similar symptoms and signs to appendicitis.
• Do not make a diagnosis of UTI on urinalysis alone. A history of urinary symptoms and urine
microscopy are also required.

Be aware that urinalysis may be abnormal in about 50% of people with acute appendicitis
because of inflammation adjacent to the right-sided urinary tract and bladder.[65]

Pregnancy test
Test all women of childbearing age to exclude pregnancy, including ectopic pregnancy.[66]

Emerging tests
Several novel biomarkers may be of value in the diagnosis and severity assessment of acute appendicitis:
DIAGNOSIS

• Neutrophil-to-lymphocyte ratio. The simple ratio between neutrophils and lymphocytes measured
in peripheral blood has been shown to have moderate predictive power for acute appendicitis and
may be a useful adjunctive tool for diagnosis.[67]
• Hyponatraemia. Several studies have shown a link between hyponatraemia and acute appendicitis,
and as a predictor of complicated appendicitis.[68] [69]
• Pentraxin 3.[70]
• Serum amyloid A. A systematic review and meta-analysis showed that serum amyloid A has a
sensitivity and specificity for acute appendicitis of 0.87 and 0.74 respectively.[71]
• Platelet indices. Studies suggest that low mean platelet volume is a marker of acute
appendicitis.[72] [73]

History and exam

Key diagnostic factors
abdominal pain (common)
Abdominal pain is the main presenting symptom.

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Acute appendicitis Diagnosis
• Typically starts as central abdominal pain, and 1 to 12 hours later it moves to the right lower
quadrant as the inflammation progresses.[24] Remember that the location of the appendix
varies, and consequently so does the location of the pain.[25]
• Usually constant with intermittent cramps.[24]
• Often worse on movement and coughing.[24]

Remember that the location of the pain can vary depending on the position of the appendix:[25]

• A retrocaecal appendix can cause flank or back pain

• A retroileal appendix can cause testicular pain due to irritation of the spermatic artery or ureter
• A pelvic appendix can cause suprapubic pain
• A paracolic long appendix with tip inflammation in the right upper quadrant may cause pain in
this region.

anorexia (common)
Almost always present.[12]

• If the patient is hungry and wants to eat, this is reassuring and makes appendicitis less
likely.[25]

nausea and vomiting (common)

Present in 75% of patients.[12]

• Significantly associated with appendicitis in pregnant patients.[34]

• Vomiting may also occur in late appendicitis if there is small bowel obstruction due to an
appendiceal abscess.[33]

right lower quadrant tenderness (common)

DIAGNOSIS
A common sign of appendicitis.[25]

• However, in pregnant women, atypical pain such as right upper quadrant or right flank pain may
occur after the first trimester due to displacement of the appendix by the gravid uterus.[29]
• Localised peritonitis with guarding may be a sign of a perforated appendix and is also strongly
associated with appendicitis in pregnant patients.[34]

high’ or ‘intermediate’ risk score (common)

Use a scoring system in adults to determine the likelihood or rule out the diagnosis of appendicitis
in order to guide further investigations and management.[7]

• Use either the Appendicitis Inflammatory Response (AIR) or the Adult Appendicitis
Score (AAS) to determine whether your patient is at high, intermediate, or low risk of having
appendicitis.[7]

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 Acute appendicitis Diagnosis
• High-risk patients who are aged <40 years, and have strong symptoms and signs of
appendicitis, may go straight to surgery without imaging.[7] However, check your local
protocols as this varies in practice.
• Intermediate-risk patients may undergo further imaging and observation.[7]
• Low-risk patients may be safely discharged without diagnostic imaging, as long as they
have appropriate safety-netting.[7]

• The Alvarado score can be used to rule out appendicitis but do not use it to positively confirm a
diagnosis of appendicitis; it is not specific enough for that purpose.[7]
• All the scoring systems involve a combination of history, examination findings, and investigation
results.[7]
• Evidence for the use of scoring systems, such as the Alvarado score, in elderly patients is
limited, and they should not be used to replace cross-sectional imaging to make a diagnosis of
appendicitis in this patient group.[4] [5]

In children, do not make the diagnosis of appendicitis based on clinical scores alone.[7]
Children frequently have atypical clinical features and obtaining a reliable history can be challenging.
Clinical scores are useful tools in excluding acute appendicitis in children. The diagnosis of acute
appendicitis in children should be made on the basis of clinical suspicion, blood tests, and, if needed,
imaging (see the Investigations section).

Use the following table to calculate the score for your patient, depending on which scoring system you
are using:[40] [41]
DIAGNOSIS

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Acute appendicitis Diagnosis
Alvarado*[40]
AIR[40] AAS[41] [42] PAS*[43]

History

Vomiting 1 point N/A 1 point 1 point

for either for either
vomiting OR vomiting OR
nausea nausea

Anorexia N/A N/A 1 point 1 point

Pain in 1 point 2 points 2 points N/A

right lower
quadrant

Migration of N/A 2 points 1 point 1 point

pain to the
right lower
quadrant

Examination

Right lower N/A • Women N/A 2 points for

quadrant aged right lower
tenderness 16-49: quadrant
1 tenderness
point to cough,
• Women percussion,
aged or hopping
≥50

DIAGNOSIS
and
men:
3
points

Right iliac N/A N/A N/A 2 points

fossa
tenderness

Rebound 1 point N/A

tenderness • Light: • Mild:
or guarding 1 2
point points
• Medium: • Moderate
2 or
points severe:

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 Acute appendicitis Diagnosis
Alvarado*[40]
AIR[40] AAS[41] [42] PAS*[43]

• Strong: 4
3 points
points

Fever >38.5#: 1 N/A >37.3#: 1 >38.0#: 1

point point point

Blood test results

Leukocytosis N/A N/A 1 point N/A

shift

Proportion • <70: • <62: N/A N/A

of 0 0
neutrophils points points
• 70-84: • ≥62
1 and
point <75:
• ≥85: 2
2 points
points • ≥75
and
<83:
3
points
• ≥83:
4
DIAGNOSIS

points

Absolute N/A N/A N/A >7500: 1

neutrophil point
count

White blood • <10.0: • <7.2: • ≤10: • >10:

cell count (× 0 0 0 1
9
10 /L) points points points point
• 10.0– • ≥7.2 • >10:
14.9: and 2
1 <10.9: points
point 1
• ≥15.0: point
2 • ≥10.9
points and
<14.0:

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Acute appendicitis Diagnosis
Alvarado*[40]
AIR[40] AAS[41] [42] PAS*[43]

2
points
• ≥14.0:
3
points

C-reactive • <10: Symptoms N/A N/A

protein (mg/ 0 <24 hours
L) points
• <4: 0
• 10–
points
49: 1
• ≥4
point
and
• ≥50:
<11:
2
2
points
points
• ≥11
and
<25:
3
points
• ≥25
and
<83:
5
points
• ≥83:

DIAGNOSIS
1
point

Symptoms
>24 hours

• <12:
0
points
• ≥12
and
<152:
2
points
• ≥152:
1
point

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 Acute appendicitis Diagnosis
Add up the total number of points for your patient to calculate the risk of appendicitis as follows:[40]
[41]

High risk

• AIR: 9-12 points

• AAS: ≥16 points
• Alvarado: 9-10 points
• PAS: ≥7 points

Intermediate risk

• AIR: 5-8 points

• AAS: 11-15 points
• Alvarado: 5-8 points
• PAS: 4-6 points

Low risk

• AIR: 0-4 points

• AAS: 0-10 points
• Alvarado: 0-4 points
• PAS: <4 points

*In children, do not make the diagnosis of appendicitis based on clinical scores alone.[7] Children
frequently have atypical clinical features and obtaining a reliable history can be challenging. Clinical
scores are useful tools in excluding acute appendicitis in children.[7]

tense, rigid abdomen (uncommon)

A sign of generalised peritonitis that indicates a perforated appendix.[25]
DIAGNOSIS

hypotension and tachycardia (uncommon)

Signs of shock or sepsis that indicate a perforated appendix.[2]

palpable mass (uncommon)

Due to a peri-appendiceal abscess caused by a perforation that is contained by the omentum.[7]

Other diagnostic factors

age of occurrence (common)
Most commonly occurs between the ages of 10 and 30 years, with the highest incidence in children
and adolescence.[7] [13]

low-grade pyrexia (common)

Temperature >37.8°C (>100.1°F).[2] [25]

• Consider other causes if there is a very high fever.

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Acute appendicitis Diagnosis
flushed face and a fetor (common)
May be present in both complicated and uncomplicated appendicitis.[29]

reduced bowel sounds (common)

A sign of perforated appendicitis.[25]

tachycardia (common)
Tachycardia may be present, particularly in patients with perforation.[29]

loose stool (uncommon)

The patient may pass small volumes of mucus from the rectum if there is a pelvic appendicitis with a
collection. The patient may describe this mucus as ‘diarrhoea’ (whereas stool volume is increased in
true diarrhoeal illness).[12]

constipation (uncommon)
Sometimes present in appendicitis.[29]

flexed right hip (psoas sign) (uncommon)

Present in retrocaecal appendicitis.[12]

DIAGNOSIS

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 Acute appendicitis Diagnosis

Investigations
1st test to order

Test Result
FBC 9
leukocytosis (10-18 x 10 /L
Request an FBC in all patients.[27] or 10,000 to 18,000/microlitre
9

Use the results of initial blood tests, in combination with history in adults; ≥16 x 10 /L or
and examination, to risk stratify patients using a scoring system; 16,000/microlitre in children)
this will determine whether imaging is required.[7] See Risk
stratification in the Diagnosis recommendations section.

• 9
Leukocytosis (10-18 x 10 /L) with neutrophilia is present in
80% to 90% of adults with appendicitis.
• 9
Leukocytosis (≥16 x 10 /L) and elevated CRP level (≥10 mg/
L) on admission are strong predictive factors for appendicitis in
children.[7]

CRP likely to be elevated

Request a CRP in all patients.[27]

• C-reactive protein is likely to be elevated.[9]

• Elevated CRP level (≥10 mg/L) on admission and leukocytosis
9
(≥16 x 10 /L) are strong predictive factors for appendicitis in
children.

In adults, use the results of initial blood tests, in combination with

history and examination, to risk stratify patients using a scoring
system; this will determine whether imaging is required.[7] See Risk
stratification in the Diagnosis recommendationssection.
DIAGNOSIS

abdominal ultrasound aperistaltic or non-

If imaging is required, seek advice from a radiologist to compressible structure with
determine the best imaging modality for your patient. outer diameter >6 mm
Order an ultrasound if radiation risk is a concern; it should
be used as first-line in children and in pregnant women.[7] [27] [52]
[53] It is a rapid test and can be performed at the bedside.[7] Check
local protocols as guidelines differ in their recommendations on use
of ultrasound.

• Acute appendicitis can be ruled out if a normal appendix is

visualised in its full length.[7] [30]
• Ultrasound is also useful for detecting alternative causes of
abdominal pain (e.g., gynaecological conditions).[7] [27]

Order an MRI in a pregnant woman if ultrasound is inconclusive.[7]

[54]
contrast-enhanced abdominal CT abnormal appendix (diameter
If imaging is required, seek advice from a radiologist to >6 mm) identified or calcified
determine the best imaging modality for your patient. appendicolith seen in

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Acute appendicitis Diagnosis

Test Result
Consider contrast-enhanced CT scan if:[7] association with peri-
appendiceal inflammation
• Ultrasound is inconclusive and there is ongoing clinical
suspicion of appendicitis[7]

• In children, order CT or MRI based on local availability

and expertise if there is diagnostic doubt and ultrasound
is inconclusive.[7]
• Low-dose CT is preferred if ultrasound is negative.[7]

• You suspect malignancy[7]

• You suspect an appendicular mass or abscess.[7]

Intravenous contrast-enhanced CT scan with or without oral contrast

has up to 100% sensitivity compared with 92% sensitivity in non-
intravenous, contrast-enhanced CT scan.[61] [63] [74]

CT abdomen - thickened appendix

Nasim Ahmed, MBBS, FACS; used with permission

DIAGNOSIS

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 Acute appendicitis Diagnosis

Other tests to consider

Test Result
urinalysis if positive for red cells, white
Use urinalysis to help exclude a urinary tract infection (UTI).[25] cells, or nitrites, an alternative
diagnosis such as renal colic
• UTI can present with very similar symptoms and signs to
or UTI should be considered
appendicitis.
• Do not make a diagnosis of UTI on urinalysis alone. A history
of urinary symptoms and urine microscopy are also required.

Be aware that urinalysis may be abnormal in about 50% of

people with acute appendicitis because of inflammation adjacent
to the right-sided urinary tract and bladder.[65]
pregnancy test positive in pregnancy
Test all women of childbearing age to exclude pregnancy,
including ectopic pregnancy.[66]
group and save for operating-theatre use
Consider a ‘group and save’ for patients having surgery.[27]
abdominal MRI abnormal appendix (diameter
If imaging is required, seek advice from a radiologist to >6mm) identified and
determine the best imaging modality for your patient. evidence of periappendiceal
Order an MRI in a pregnant woman if ultrasound is inconclusive.[7] inflammatory changes,
appendicolith, fat stranding
In children, order MRI or CT based on local availability and expertise
if there is diagnostic doubt and ultrasound is inconclusive.[7]
DIAGNOSIS

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Acute appendicitis Diagnosis

Emerging tests

Test Result
neutrophil-to-lymphocyte ratio elevated neutrophil-to-
The simple ratio between neutrophils and lymphocytes measured lymphocyte ratio (>4.7)
in peripheral blood has been shown to have moderate predictive
power for acute appendicitis and may be a useful adjunctive tool for
diagnosis.[67] [75]
serum sodium hyponatraemia
Several studies have shown a link between hyponatraemia and acute
appendicitis, and as a predictor of complicated appendicitis.[68] [69]
Pentraxin-3 elevated Pentraxin-3
Pentraxin-3 is an acute phase protein, which may be elevated in
acute appendicitis.[70]
serum amyloid A elevated serum amyloid A
One systematic review and meta-analysis showed that serum amyloid
A has a sensitivity and specificity for acute appendicitis of 0.87 and
0.74 respectively.[71]
platelet indices low mean platelet volume
Studies suggest that low mean platelet volume is a marker of acute
appendicitis.[72] [73]

DIAGNOSIS

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 Acute appendicitis Diagnosis

Differentials

Condition Differentiating signs / Differentiating tests

symptoms
Acute mesenteric adenitis • Usually presents in children • There is no specific test to
with a recent history of upper confirm the diagnosis.
respiratory infection. • Relative lymphocytosis in
• Pain in the abdomen WBC differential counts is
is usually diffuse with suggestive.
tenderness not localised to • Negative ultrasound or CT
the right lower quadrant. findings help exclude other
• Guarding may be present, diagnoses.
but rigidity is usually absent.
• Generalised
lymphadenopathy may be
noted.

Viral gastroenteritis • Common in children; caused • No specific test

by viruses, bacteria, or toxin. unless symptoms of viral
• Characterised by profuse gastroenteritis are atypical
watery diarrhoea, nausea, and you suspect a bacterial
and vomiting. or parasitic aetiology
• Crampy abdominal
pain often precedes the
diarrhoea, and no localising
signs are present.
• If caused by typhoid fever,
intestinal perforation
may cause localised
abdominal pain and/or
generalised and rebound
tenderness. In this scenario,
associated maculopapular
rash, inappropriate
DIAGNOSIS

bradycardia, and leukopenia

will differentiate from
appendicitis.

Meckel's diverticulitis • Usually asymptomatic. • Technetium pertechnetate

• Only 20% of the patients scan may show the
present with diverticulitis, enhancement of diverticulum
and 50% of this group are if gastric mucosa is present.
aged <10 years.[19]
• Clinical presentation of
diverticulitis is similar to
acute appendicitis.

Intussusception • Occurs in young children • Barium enema may

(aged <2 years). demonstrate the
• Sudden onset of colicky intussusception with a coil-
pain; between episodes of spring sign at the point of
pain the child is calm. bowel invagination.
• A sausage-shaped mass
may be palpable in the right
lower quadrant.

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Acute appendicitis Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
Crohn's disease • Young adult with fever, • CT scan may show intra-
nausea, vomiting, diarrhoea, abdominal abscess.
right lower quadrant pain, • Contrast study of the small
and localised tenderness. bowel and colon may show
stricture or a series of ulcers
and fissures (cobblestone
appearance) of mucosa.

Peptic ulcer disease • May or may not have a • Erect CXR and abdominal x-
history of peptic ulcer ray may show free air under
disease. the diaphragm
• Pain is abrupt, severe
in intensity, and may be
localised to right lower
quadrant.

Right-sided ureteric stone • Pain is usually colicky • Urinalysis positive for blood.
in nature and severe in • Leukocytosis usually absent.
intensity. May be referred • Abdominal x-rays or
to the labia, scrotum, or tomogram may show
penis and associated with calcified stone.
haematuria. • Pyelography and CT
• Fever usually absent. scan without oral and
intravenous contrast confirm
the diagnosis.

Cholecystitis • Pain and tenderness are • Abdominal ultrasound

usually in the right upper shows thick wall with peri-
quadrant. In one third of cholecystic collection, and
patients the gallbladder can tenderness is present over
be palpable.[76] gallbladder area (Murphy's
sign).

DIAGNOSIS
Urinary tract infection • Pain and tenderness is • Urine microscopy and culture
usually in suprapubic area confirm presence of bacteria.
associated with burning
micturition.
• Acute right-sided
pyelonephritis may present
with fever, chills, and
tenderness at the right
costovertebral angle.

Primary peritonitis • Most patients present with • CT scan may show fluid in
abrupt abdominal pain, fever, the abdomen.
distension, and rebound • Peritoneal fluid shows
tenderness. >500/microlitre count and
• History of advanced cirrhosis >25% polymorphonuclear
or nephrosis. leukocytosis.

Pelvic inflammatory • Occurs in females usually • Endocervical swab

disease aged between 20 and 40 may confirm the pelvic
years. inflammatory disease due to
• Presents with bilateral lower Chlamydia trachomatis .[77]
quadrant tenderness, usually

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 Acute appendicitis Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
within 5 days of the last
menstrual period.
• Purulent discharge from
cervical os.

Ruptured Graafian follicle • Mid-menstrual cycle, brief • Clinical diagnosis. No

(mit telschmerz) period of lower abdominal investigation indicated.
pain not usually associated
with nausea and vomiting
and fever.
• Tenderness is usually diffuse
rather than localised.

Ectopic pregnancy • Female within childbearing • Human chorionic

age presents with missed gonadotrophin hormone level
menstrual period, right lower is high in serum and in urine.
quadrant pain, or pelvic • Ultrasound reveals presence
pain with some degree of of mass in fallopian tubes.
vaginal bleeding or spotting.
Cervical motion tenderness
may be present on pelvic
examination.

Ovarian torsion • Female with right lower • Ultrasonography shows

quadrant pain. Occasionally ovarian cyst and decreased
presents with mass in the blood flow.
right lower quadrant.

Caecal diverticulitis • Presents with abdominal • CT has a sensitivity and

pain that localises to the specificity of 99% for
right iliac fossa in 93% the diagnosis of acute
of patients.[78] Patients diverticulitis; it may show
may also have nausea and an inflamed diverticulum or
vomiting, gastrointestinal contrast-filled mass surround
DIAGNOSIS

disturbance, and an elevated by colonic wall thickening,

white cell count.[78] inflammation of the pericolic
fat, localised oedema, free
fluid or extraluminal air.[78]

Criteria
Use a scoring system in adults to determine the likelihood or rule out the diagnosis of appendicitis in order
to guide further investigations and management.[7]

• Use either the Appendicitis Inflammatory Response (AIR)or the Adult Appendicitis Score
(AAS) to determine whether your patient is at high, intermediate or low risk of having appendicitis.[7]

• High-risk patients who are aged <40 years, and have strong symptoms and signs of
appendicitis, may go straight to surgery without imaging.[7] However, check your local protocols
as this varies in practice.
• Intermediate-risk patients may undergo further imaging and observation.[7]
• Low-risk patients may be safely discharged without diagnostic imaging, as long as they have
appropriate safety-netting.[7]

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Acute appendicitis Diagnosis
• The Alvarado score can be used to rule out appendicitis but do not use it to positively confirm a
diagnosis of appendicitis; it is not specific enough for that purpose.[7]
• All the scoring systems involve a combination of history, examination findings, and investigation
results.[7]
• These scoring systems should not be used in place of cross-sectional imaging to make a diagnosis of
appendicitis in elderly patients owing to limited evidence in this patient group.[4][5]

In children, do not make the diagnosis of appendicitis based on clinical scores alone.
[7] Children frequently have atypical clinical features and obtaining a reliable history can be challenging.
Clinical scores are useful tools in excluding acute appendicitis in children. The diagnosis of acute
appendicitis in children should be made on the basis of clinical suspicion, blood tests, and, if needed,
imaging (see the Investigations section).

Use the following table to calculate the score for your patient, depending on which scoring system you are
using:[40] [41]

DIAGNOSIS

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 Acute appendicitis Diagnosis
AIR[40] AAS[41] Alvarado*[40] [42] PAS*[43]

History

Vomiting 1 point N/A 1 point for either 1 point for either

vomiting OR vomiting OR
nausea nausea

Anorexia N/A N/A 1 point 1 point

Pain in right lower 1 point 2 points 2 points N/A

quadrant

Migration of pain N/A 2 points 1 point 1 point

to the right lower
quadrant

Examination

Right lower N/A • Women aged N/A 2 points for right

quadrant 16-49: 1 point lower quadrant
tenderness • Women aged tenderness to
≥50 and men: cough, percussion,
3 points or hopping

Right iliac fossa N/A N/A N/A 2 points

tenderness

Rebound 1 point N/A

• Light: 1 point • Mild: 2 points
tenderness or
• Medium: 2 • Moderate
guarding
DIAGNOSIS

points or severe: 4
• Strong: 3 points
points

Fever >38.5#: 1 point N/A >37.3#: 1 point >38.0#: 1 point

Blood test results

Leukocytosis shift N/A N/A 1 point N/A

Proportion of • <70: 0 points • <62: 0 points N/A N/A

neutrophils • 70-84: 1 point • ≥62 and <75:
• ≥85: 2 points 2 points
• ≥75 and <83:
3 points
• ≥83: 4 points

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Acute appendicitis Diagnosis
AIR[40] AAS[41] Alvarado*[40] [42] PAS*[43]

Absolute neutrophil N/A N/A N/A >7500: 1 point

count

White blood cell • <10.0: 0 • <7.2: 0 points • ≤10: 0 points • >10: 1 point
9
count (× 10 /L) points • ≥7.2 and • >10: 2 points
• 10.0–14.9: 1 <10.9: 1 point
point • ≥10.9 and
• ≥15.0: 2 <14.0: 2
points points
• ≥14.0: 3
points

C-reactive protein • <10: 0 points Symptoms <24 N/A N/A

(mg/L) • 10–49: 1 hours

point • <4: 0 points

• ≥50: 2 points • ≥4 and <11: 2
points
• ≥11 and <25:
3 points
• ≥25 and <83:
5 points
• ≥83: 1 point

Symptoms >24
hours

• <12: 0 points
• ≥12 and

DIAGNOSIS
<152: 2
points
• ≥152: 1 point

Add up the total number of points for your patient to calculate the risk of appendicitis as follows:[40] [41]

High risk

• AIR: 9-12 points

• AAS: ≥16 points
• Alvarado: 9-10 points
• PAS: ≥7 points

Intermediate risk

• AIR: 5-8 points

• AAS: 11-15 points
• Alvarado: 5-8 points

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 Acute appendicitis Diagnosis
• PAS: 4-6 points

Low risk

• AIR: 0-4 points

• AAS: 0-10 points
• Alvarado: 0-4 points
• PAS: <4 points

*In children, do not make the diagnosis of appendicitis based on clinical scores alone.[7] Children frequently
have atypical clinical features and obtaining a reliable history can be challenging. Clinical scores are useful
tools in excluding acute appendicitis in children.[7]
DIAGNOSIS

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Acute appendicitis Management

Recommendations

Urgent
Seek immediate surgical input and consider involving critical care for any patient with
suspected appendicitis and signs of shock or sepsis.

If the patient has signs of shock, give a fluid challenge to correct hypotension and/or tachycardia.[79] See
Shock .

• In adults, give 250 to 500 mL of either normal saline (0.9% sodium chloride) or Hartmann’s solution
(also known as Ringer’s lactate solution), intravenously over 15 minutes.[79]
• For fluid resuscitation in children, see Volume depletion in children .
• Refer to local guidelines for the recommended approach at your institution for prompt assessment
and management of patients with suspected sepsis, or those at risk.[26] [80] [81] [82] [83] See
Sepsis in adults and Sepsis in children .

Complicated appendicitis occurs in 4% to 6% of adults and less than 19% of children and is defined
as appendicitis with any one of:[7] [13] [19]

• Gangrenous appendix with or without perforation

• Intra-abdominal abscess
• Peri-appendicular phlegmon
• Purulent-free fluid.

Involve obstetric support for any pregnant woman with appendicitis as management requires a
multidisciplinary approach.[84]

Refer all children with suspected appendicitis to the paediatric surgery team on call, if
available. Where no paediatric surgery team is available, joint care should be managed between
paediatrics and surgical teams.

Keep the patient nil by mouth if surgery is being considered.

Key Recommendations
Uncomplicated appendicitis
Laparoscopic appendicectomy is the first choice for most adults (including pregnant
patients) provided an appropriately skilled surgeon is available.[7] [27]

• Ensure appendicectomy is not delayed unnecessarily. This is to minimise patient discomfort.

Evidence suggests that delaying surgery by up to 24 hours does not increase the risk of
perforation.[85]
MANAGEMENT

• Consider ambulatory management in patients who are systemically well.

• Give a dose of prophylactic antibiotics before surgery [86].

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 Acute appendicitis Management
• Check local protocols and seek advice from microbiology colleagues.

Consider a conservative (non-operative) approach with intravenous antibiotics only for selected adults
who have uncomplicated appendicitis (suspected or confirmed on computed tomographic scan), and
do not wish to have, or are unfit for, surgery; ensure the patient is aware of the risk of recurrence of
appendicitis.[2] [87] [88] [89] [90] [91] [92][93]

• Do not use a conservative approach for pregnant patients.[7]

• Do not use a conservative approach in adults if an appendicolith is present, because non-operative
management carries a significant failure rate.[2] [7] [94]

Seek a decision from a specialist paediatric surgeon regarding whether to proceed with non-
operative management with antibiotics as an alternative to surgery in children. Non-operative
management is only recommended in the absence of an appendicolith.[2] [7]

• Delaying surgery by up to 24 hours does not increase the risks of perforation for children with
uncomplicated acute appendicitis.[7]
• Advise that there is a chance of failure and misdiagnosis of complicated appendicitis with non-
operative management.[7]
• Do not use a conservative approach in children with appendicolith because non-operative
management carries a significant failure rate.[2] [7] [94]

Complicated appendicitis
Request an immediate surgical review for any patient (adults and children) with confirmed or
suspected complicated appendicitis.

• Patients with a perforated appendix will need urgent appendicectomy.

• Laparoscopic appendicectomy is performed in the vast majority of patients in the UK and

should be considered the treatment of choice for most patients.[95] [96]

Give all patients prophylactic antibiotics before surgery and continue these postoperatively if
complicated appendicitis is confirmed during surgery.[86] Check local protocols and seek advice from
microbiology colleagues.

In children, early appendicectomy within 8 hours should be performed for confirmed or suspected
complicated appendicitis.[7]

Full Recommendations
Initial management for all patients
MANAGEMENT

Involve critical care and seek immediate surgical input for any patient with suspected
perforated appendicitis and signs of shock or sepsis.[7] [13]

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Acute appendicitis Management
In adults with signs of shock, give a fluid challenge to correct hypotension and/or tachycardia.[79] See
Shock .

• In adults, give 250 to 500 mL of either normal saline (0.9% sodium chloride) or Hartmann’s solution
(also known as Ringer’s lactate solution), intravenously over 15 minutes.[79]
• Refer to local guidelines for the recommended approach at your institution for prompt assessment
and management of patients with suspected sepsis, or those at risk.[26] [80] [81] [82] [83] See
Sepsis in adults and Sepsis in children .

For fluid resuscitation in children, see Volume depletion in children .

Give all patients prophylactic antibiotics before surgery to reduce the risk of postoperative
complications.[86] Check local protocols and seek advice from microbiology colleagues.

• Patients with complicated appendicitis require a postoperative course of antibiotics in addition to

this, whereas patients with uncomplicated appendicitis undergoing surgery require only a single
preoperative dose.[7] [86]

Evidence: Antibiotics in acute appendicitis

Evidence generally supports giving preoperative antibiotics for appendicitis.

• A Cochrane analysis showed that a single prophylactic dose of antibiotics prior to surgery
reduced the risk of wound infections and abscess.[86]

• Other studies have supported this finding.[98] [99]

• However, one randomised controlled trial showed no difference in the postoperative
complication rate whether or not antibiotics were given preoperatively.[100]

• There is no evidence to support the use of postoperative antibiotics in uncomplicated

appendicitis.[13] [101] [102] [103] [104]

Involve obstetric support for any pregnant woman with appendicitis as management requires a
multidisciplinary approach.[84]

In the community:

• Have a low threshold for urgently admitting:

• Older patients
• Pregnant women
• Patients with signs of complications.
MANAGEMENT

• Arrange for patients with duration of symptoms <24 hours and who are systemically well to be seen
in hospital within 24 hours.[85]

Give adequate analgesia.[27] [37]

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 Acute appendicitis Management
• Paracetamol may be used, or give an opioid (e.g., morphine) if required.

Practical tip

A common error is to avoid giving stronger analgesia as this was previously thought to mask
symptoms. However, current evidence has shown that giving opioids does not increase the risk of
diagnostic error.[27] [37]

Keep the patient nil by mouth if surgery is being considered.

• Run intravenous maintenance fluids for any patient who is being kept nil by mouth.[27]

Uncomplicated appendicitis: adults

Appendicectomy is the standard treatment for uncomplicated appendicitis.[13]

• Appendicectomy can be either open or laparoscopic.[7]

• Laparoscopic appendicectomy is the first choice for most adults (including pregnant patients)
provided an appropriately skilled surgeon is available.[7] [27] [105] [106]
• Same-day discharge after laparoscopic appendicectomy has been shown to be safe and without
increased risk of complications, and may be suitable for certain patients.[7] [107]
• Do not give postoperative antibiotics in adults with uncomplicated acute appendicitis, because there
is no evidence they decrease the rate of surgical infection.[7]
MANAGEMENT

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Acute appendicitis Management

Evidence: Laparoscopic versus open appendicectomy in adults

Evidence shows that laparoscopic appendicectomy compares favourably with open

appendicectomy and is the first choice for most adults. [Evidence B]

• The advantages of laparoscopic compared with open surgery are: [62] [108] [109] [110]

• Better cosmetic outcome

• Shorter length of stay in hospital[27]
• Less postoperative pain[27]
• Lower risk of surgical site infection[109] [111]
• Diagnostic potential if appendix is macroscopically normal.[112] [113]

• However, laparoscopic appendicectomy is a slightly longer procedure and more expensive, and
there is some evidence that it may be associated with an increased risk of an intra-abdominal
abscess.[109] [114]
• In pregnant women, laparoscopic appendicectomy is now thought to be safe in terms of fetal
loss and preterm delivery.[105] [106] [115]

• A systematic review (published 2019, search date unclear) included 22 studies (4694
women; 905 laparoscopic appendicectomies and 3789 open appendicectomies) in a
pooled analysis.[116]

• While overall fetal loss was more common with laparoscopic appendicectomy
(OR 1.72, 95% CI 1.22 to 2.42), this was driven by one large retrospective study
(n=3133) which had high rates of complicated appendicitis (30%). Removing this
study from the analysis resulted in no significant difference in fetal loss (OR 1.16,
95% CI 0.68 to 1.99).
• Laparoscopic appendicectomy was also associated with no difference in preterm
delivery (OR 0.76, 95% CI 0.51 to 1.15), and a reduction in both length of hospital
stay and surgical site infection.

• Patients >65 years have increased perioperative risks due to reduced physiological reserve.

• A laparoscopic approach has been shown to reduce postoperative complications,

mortality, and length of stay in this age group.[117] [118] [119] [120] [121]

Timing of surgery in uncomplicated appendicitis

Refer any patient with suspected or confirmed appendicitis within 24 hours even if they have
uncomplicated appendicitis and are stable.
MANAGEMENT

• Ensure appendicectomy is not delayed unnecessarily. This is to minimise patient discomfort.

Evidence suggests that delaying surgery by up to 24 hours does not increase the risk of
perforation.[85]

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 Acute appendicitis Management
• Surgery might be delayed while you await investigation results, trial conservative management, or
ensure adequate staffing levels.[7]
• Minimise surgical delay for patients >65 years old and those with significant comorbidities; these
patients may be at increased risk of perforation.[122]

Evidence: Timing of surgery

There is ongoing debate around the timing of appendicectomy in uncomplicated appendicitis.

• Immediate surgery may reduce the number of cases of perforated/complicated

appendicitis.[123] However, a strategy of delaying surgery while trialling conservative
management can reduce the number of unnecessary operations (negative appendicectomies) in
patients whose appendicitis will resolve without surgery.[7] [124]
• A prospective multicentre cohort study of 2510 patients found that:[85]

• The risk of developing complicated appendicitis was not related to the timing of
appendicectomy for those patients who had surgery delayed by 12-24 hours (odds ratio
[OR] 0.98) or even >48 hours (OR 0.82)
• Surgery at >48 hours was associated with a higher risk of surgical site infection and 30-
day adverse event rate (OR 2.24 and 1.71, respectively) than surgery at <48 hours.

• It is now accepted that perforation is a separate pathology rather than a progression of

appendicitis.[7] [13] [125]

• In practice, however, it is currently not possible to predict which patients have

uncomplicated (non-perforating) appendicitis and which have appendicitis that will
progress to perforation.[13]
• In certain patient groups (patients >65 years, those with comorbidities, and those with
a delay of more than 12 hours before surgery is performed) there is some evidence of
increased risk of perforation. Minimise surgical delay in these groups.[122]

Conservative management with antibiotics

Consider conservative (non-operative) management with antibiotics for selected patients,
including those who have uncomplicated appendicitis (suspected or confirmed on computed tomographic
scan), and do not wish to have surgery, or are unfit to do so; ensure the patient is aware of the risk of
recurrence of appendicitis.[2] [13] [87] [90] [92][93]

• Do not use a conservative approach for pregnant patients.[7]

• Do not use a conservative approach if an appendicolith is present, because non-operative
management carries a significant failure rate.[2] [7] [126]
• Discuss the risks of conservative management and all other potential treatment options with the
MANAGEMENT

patient so that they are able to make an informed decision.[127]

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Acute appendicitis Management
• Check local protocols and seek advice from microbiology colleagues when prescribing
antibiotics as drug regimens and length of treatment varies. Examples of regimens include
ceftriaxone plus metronidazole, cefotaxime plus metronidazole, or amoxicillin/clavulanate.

Evidence: Conservative management

There is insufficient evidence to support conservative non-operative management, using

antibiotics only, of uncomplicated acute appendicitis, unless the patient does not want, or is
unfit for, surgery. [13] [89] [91]

• More research is needed to establish whether a conservative approach has a role, in particular
with respect to patient selection, recurrence rates, and the risk of missing an important
underlying diagnosis such as malignancy.[89]
• The rationale for a conservative approach is that not every appendicitis will lead to perforation,
and there is a well-recognised group of patients with uncomplicated appendicitis that will resolve
spontaneously.[88] [128] Appendicectomy has been the gold standard treatment for over 100
years.[1] However, surgery comes with risk and potential complications that could be avoided
with a conservative non-surgical approach.[90]
• Conservative management is not associated with any increase in risk of developing a
complication secondary to the appendicitis.[90] [129]
• A 5-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicentre
randomised controlled trial compared appendicectomy with antibiotic therapy. Results
showed that 100 of the 256 patients in the antibiotic group (39.1%) ultimately underwent
appendicectomy during 5 years of follow-up. Most of these patients (70/100, 70%) had their
episode of recurrent appendicitis within 1 year of initial presentation. No patient initially treated
with antibiotics who ultimately developed recurrent appendicitis had any complications directly
related to the delay in surgery. These findings demonstrate the feasibility of treating appendicitis
with antibiotics alone, without surgery. Nearly two-thirds of all patients who initially presented
with uncomplicated appendicitis were successfully treated with antibiotics alone; those who
ultimately developed recurrent appendicitis did not experience any adverse outcomes related to
the delay in appendicectomy.[130]

• The APPAC trial compared open appendicectomy with antibiotic-only therapy for
appendicitis. It involved 530 patients aged 18 to 60 of whom 273 were randomised to
open appendicectomy and 257 to antibiotic therapy.[130]
• It showed a 27% recurrence rate at 1 year following antibiotic-only management. At 5-
year follow-up, the recurrence rate had risen to 39.1%.[130]
• At 5 years, the proportion who had complications (surgical site infection, incisional
hernias, abdominal pain, or obstructive symptoms) was much higher in the surgery group
than in the antibiotic group (24% compared with 6.5%). This may have been partially
related to the use of open rather than laparoscopic surgery.[130]
MANAGEMENT

Uncomplicated appendicitis: children

Seek a decision from a specialist paediatric surgeon regarding whether to proceed with
non-operative management with antibiotics as an alternative to surgery in children.

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 Acute appendicitis Management
Consider conservative (non-operative) management with antibiotics in children, unless an
appendicolith is present. [7]

• Non-operative management with antibiotics is a safe and effective approach in the absence of
appendicolith.[7] The risk of perforation is not increased if surgery is delayed by up to 24 hours.[7]
• The family should be advised that non-operative management may not be successful and that
misdiagnosis can occur.[7]
• Check local protocols and seek advice from microbiology colleagues when prescribing
antibiotics as drug regimens and length of treatment vary. Current evidence supports initial
intravenous antibiotics with subsequent conversion to oral antibiotics.[7] Examples of regimens
include amoxicillin/clavulanate, or ceftriaxone plus metronidazole.
• Failure of medical management may be indicated by persistent fever, unremitting symptoms, or
rising inflammatory markers.

Refer for surgery if an appendicolith is present, because the failure rate of non-operative
management increases in these patients.[2] [94]

If surgery is needed:

• Ensure appendicectomy is not delayed for children with uncomplicated acute appendicitis beyond
24 hours[7]
• Do not give postoperative antibiotics in children with uncomplicated acute appendicitis, because
there is no evidence they decrease the rate of surgical infection[7]
• Laparoscopic appendicectomy is preferred over open appendicectomy provided an appropriately
skilled surgeon is available.[131]
MANAGEMENT

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Acute appendicitis Management

Evidence: Laparoscopic versus open appendicectomy in children

For children with acute appendicitis, if surgery is needed, evidence shows that laparoscopic
appendicectomy compares favourably with open appendicectomy as long as resources and an
appropriately skilled surgeon are available.

The World Society of Emergency Surgery (WSES) 2020 guideline recommends laparoscopic
appendicectomy over open surgery for children with acute appendicitis.[7] This is based on two
systematic reviews published in 2017, one in children and the other from indirect evidence in adults.

• The first systematic review (search date January 2000 to April 2016) included nine studies
(one randomised controlled trial [RCT], one prospective cohort, and seven retrospective cohort
studies) comparing laparoscopic and open surgery in children (aged <18 years) with perforated
acute appendicitis.[132]

• The review authors found that laparoscopic surgery was associated with a lower
incidence of surgical site infection (relative risk [RR] 0.88, 95% CI 0.77 to 1.00) and bowel
obstruction (RR 0.79, 95% CI 0.64 to 0.98).
• However, intra-abdominal abscess was higher with laparoscopic surgery (RR 1.38, 95%
CI 1.20 to 1.59).

• The second systematic review (search date January 2016) included two RCTs and 14
retrospective cohort studies in adults with complicated acute appendicitis.[133]

• Laparoscopic surgery reduced surgical site infection (odds ratio [OR] 0.28, 95% CI 0.25
to 0.31) without increasing the rate of postoperative intra-abdominal abscess (OR 0.79,
95% CI 0.45 to 1.34).
• The operating times with laparoscopic surgery were longer than that with open surgery
groups (weighted mean difference [WMD] 13.78 minutes, 95% CI 8.99 to 18.57), but the
length of hospital stay was significantly shorter with laparoscopic surgery (WMD -2.47
days, 95% CI -3.75 to -1.19), as was the time to oral intake (WMD -0.88 days, 95% CI
-1.20 to -0.55).

A subsequent systematic review (published 2019) in children with complicated appendicitis (six RCTS
and 33 case-control studies) found similar results to the systematic review in adults included in the
WSES guideline.[134]

• Laparoscopic surgery reduced surgical site infections (OR 0.37, 95% CI 0.25 to 0.54) without an
increase in intra-abdominal abscess formation (OR 1.01, 95% CI 0.71 to 1.43).
• Operative time was shorter for open surgery (WMD 12.44 minutes, 95% CI 2.00 to 22.87).
However, laparoscopic surgery also had a shorter length of hospital stay (WMD -0.96 days, 95%
CI -1.47 to -0.45), lower incidences of postoperative ileus or intestinal obstruction, shorter time
to oral intake, and reduced readmission and reoperation rates.
MANAGEMENT

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 Acute appendicitis Management
Complicated appendicitis: adults
Complicated appendicitis occurs in 4% to 6% of patients and is defined as appendicitis with any one
of:[13] [19]

• Gangrenous appendix with or without perforation

• Intra-abdominal abscess
• Peri-appendicular phlegmon
• Purulent-free fluid.

Be aware that complications are more likely in patients who:[135] [136] [137]

• Have longer duration of symptoms

• Are >50 years old
• Are female
• 9
Have a white blood cell count >16 x 10 /L.

Request an immediate surgical review for any patient with confirmed or suspected complicated
appendicitis.

• Patients with a perforated appendix will need urgent appendicectomy. Laparoscopic

appendicectomy is performed in the vast majority of patients in the UK and should be considered
as the treatment of choice for most patients if the expertise is available.[95] [96]
• The optimal management for appendicitis with phlegmon or abscess remains subject to debate.
Latest evidence suggests that laparoscopic appendicectomy is associated with fewer readmissions
and fewer additional interventions than conservative management, provided advanced laparoscopic
expertise is available.[7] [138]
• However, if the patient has an appendiceal abscess/phlegmon, is stable, and laparoscopic
appendicectomy is unavailable, conservative treatment with intravenous antibiotics and
percutaneous image-guided drainage is a reasonable alternative.[7]

• Check local protocols and seek advice from microbiology colleagues when prescribing
antibiotics.
• Interval appendicectomy should be considered if the symptoms do not completely resolve
and/or if symptoms recur.[7] [13]
• Ensure any patient aged >40 years who has conservative management without
interval appendicectomy also has investigations to rule out colon malignancy; these
should include colonoscopy and interval full-dose contrast-enhanced CT scan.[7]
MANAGEMENT

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Acute appendicitis Management

Evidence: Laparoscopic versus open appendicectomy in complicated appendicitis

There is ongoing debate about the optimum approach for the management of complicated
appendicitis in adults. Current evidence suggests a laparoscopic approach may have
advantages compared with open appendicectomy. [96]

• Studies have produced conflicting evidence on the best approach to surgery in complicated
appendicitis.

• A 2017 systematic review of two randomised controlled trials (RCTs) and 14 retrospective
cohort studies comparing open versus laparoscopic appendicectomy for perforated
appendicitis found the laparoscopic approach reduced the risk of surgical site infection
(odds ratio [OR] 0.28) with no increase in risk of intra-abdominal abscess (OR 0.79).[133]
• One retrospective cohort study of 150 patients with perforated appendicitis with abscess
or peritonitis found a laparoscopic approach reduced the incidence of surgical site
infection and repeat surgery and led to a shorter length of stay compared with open
surgery.[139] Another study reported a lower rate of small bowel obstruction after
laparoscopic compared with open surgery (pooled OR 0.44).[96]
• An RCT of 81 patients with complicated appendicitis found no significant difference in
outcomes between laparoscopic and open appendicectomy.[140]
• However, another study found a higher rate of intra-abdominal abscess after laparoscopic
compared with open surgery (6.7 vs. 3.7%).[141]

• The World Society of Emergency Surgery guideline concludes that a laparoscopic approach
may have benefits over open surgery provided the surgeon is experienced in the procedure.[7]

• A 2017 systematic review (3 RCTs and 23 case-control studies) found that laparoscopic
appendicectomy reduced morbidity compared with open appendicectomy in people with
complicated acute appendicitis (surgical site infections: OR 0.30 [95% CI 0.22 to 0.40];
time to oral intake: weighted mean difference -0.98 days [95% CI -1.09 to -0.86 days];
length of hospital stay: weighted mean difference -3.49 days [95% CI -3.70 to -3.29 days];
no significant difference in intra-abdominal abscess rates).[142]
• Operative time was longer with laparoscopic appendicectomy, however this did not reach
statistical significance in the RCT subgroup analysis.

MANAGEMENT

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 Acute appendicitis Management

Evidence: Conservative versus surgical approach for appendiceal abscess/phlegmon

There is ongoing debate about the best approach for patients with an appendiceal abscess/
phlegmon.

In the past, evidence has favoured initial conservative management.

• A 2010 meta-analysis included 17 studies and 1572 patients who had complicated appendicitis
with abscess or phlegmon. It found that conservative treatment, when compared with immediate
surgery, was associated with lower rates of complications (wound infection, abdominal abscess,
bowel obstruction, or need for repeat surgery).[143]
• Similarly, a 2007 systematic review of 61 mainly retrospective studies found immediate surgery
was associated with higher rates of morbidity compared with conservative management (OR
3.3, 95% CI 1.9 to 5.6).[144]

More recent evidence has suggested that early surgery may be preferable, where laparoscopic
expertise is available.

• Data from the US National Inpatient Sample found that of 2209 adults with appendiceal abscess
managed conservatively with drainage, 25.4% required surgery.[145]
• A 2019 systematic review identified 21 studies (17 retrospective, 1 prospective and 3
randomised controlled trials [RCTs]; n=1864) comparing surgical (laparoscopic or open
appendicectomy) versus conservative treatment for complicated appendicitis.[146]

• Overall complications, abdominal/pelvic abscesses, wound infections, and unplanned

procedures were significantly lower in the conservative treatment cohort in the general
analysis.
• However, subgroup analysis of the 3 RCTs (n=140) found no significant difference in
abdominal/pelvic abscesses (OR 0.46, 95% CI 0.17 to 1.29).
• Analysis from the 2 RCTs rated as high quality (assessed using the Newcastle-Ottawa
scale) showed a shorter hospital stay with laparoscopic appendicectomy compared with
conservative treatment (mean difference -0.99 days, 95% CI -1.31 to -0.67 days).
• All the RCTs were published since 2010 and the systematic review authors used a
cumulative meta-analysis to show that, with respect to the outcome of abdominal or pelvic
abscesses, there was a shift towards favouring laparoscopic appendicectomy as it has
become more widespread.
• The most recent of the high-quality RCTs (published 2015) compared 30 patients
who had immediate laparoscopic surgery with 30 who had conservative treatment. It
found that the conservatively managed group required more additional interventions.
These additional interventions were surgery in the conservatively managed group and
percutaneous drainage in the immediate laparoscopic surgery group.[147]
MANAGEMENT

50 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Dec 19, 2023.
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Acute appendicitis Management

Evidence: Role of interval appendicectomy

The role of routine interval appendicectomy remains controversial. The risk of perioperative
morbidity needs to be weighed against the risk of recurrence of appendicitis and the age-
related incidence of underlying malignancy. [7]

• Debate continues as to whether patients with abscess/phlegmon who are initially managed
conservatively need routine 'interval appendicectomy' at a later date (typically at 6 weeks).
• Some experts advocate routine interval appendicectomy to avoid:

• Any risk of recurrence of appendicitis, which has been reported to vary from 7.3% in
one systematic review to as high as 27% at 2 months in one randomised controlled trial
(RCT)[144] [147]
• Missing an underlying malignancy (incidence 6%)[13]

• The incidence of an underlying malignancy increased to 29% in patients over 40

years of age who had a peri-appendicular abscess in one study.[148] However,
interval appendicectomy has been found to carry a morbidity risk of 12.4%.[144]
• In a retrospective study of people who underwent appendicectomy for acute
appendicitis, 3% of those aged ≥60 years had unexpected malignancy compared
with 1.5% of those aged <60 years.[149]
• A 2019 RCT comparing interval appendicectomy versus follow up with MRI was
stopped early when the interim analysis showed a high rate of malignancy (10/60
[17%], all in people aged >40 years).[148]
• The risk of appendiceal neoplasm in patients treated initially with non-operative
management of complicated appendicitis is 11%, increasing to 16% in patients
aged 50 years and older and 43% in patients aged over 80 years.[150][151] [152]

• The World Society of Emergency Surgery’s 2020 Jerusalem guideline recommends:[7]

• Interval appendicectomy for patients with recurrent symptoms

• Colonoscopy and interval full-dose contrast-enhanced CT scan for any patient >40 years
of age who is conservatively managed, to reduce the risk of missing a malignancy.[151]

• The European Association for Endoscopic Surgery 2015 consensus statement concluded
that although there is a rationale for routine interval appendicectomy, data on its benefits are
lacking.[13]
• The 2019 US Eastern Association for the Surgery of Trauma guideline made a conditional
recommendation against routine interval appendicectomy in adults who are otherwise
asymptomatic.[153]

• They identified 3 observational studies, which showed an increased risk of recurrence

without interval appendicectomy (RR 14.16, 95% CI 2.74 to 73.11, quality of evidence
MANAGEMENT

assessed as low using GRADE). This represented an increased risk from 15.8% overall
with non-operative management to 24.3% in those patients who did not have routine
interval appendicectomy.

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 Acute appendicitis Management
• Therefore the guideline panel felt surgery was only required for people with symptoms
of recurrence due to the risk of perioperative complications. They also noted that the
decision should also take into consideration the patient's age (due to the progressive
increased incidence of malignancy in those >40 years), although they felt that in general
the risk of appendiceal malignancy was very low, noting an overall incidence of 0.97 per
100,000 population.

Give postoperative antibiotics to any patient with complicated appendicitis.[7]

• Seek advice from microbiology colleagues on the choice of antibiotic as this will be guided by local
resistance patterns. Examples of regimens include amoxicillin plus metronidazole, piperacillin/
tazobactam, or amoxicillin/clavulanate.
• Continue antibiotics typically for 3 to 5 days; start with intravenous and then switch to oral
administration.
• Discontinue antibiotics based on resolving clinical signs (e.g., fever) and laboratory criteria (e.g.,
leukocytosis).
• Complicated appendicitis is strongly associated with an increased risk of surgical site infection;
the postoperative complication rate is up to 4 times higher in complicated compared with
uncomplicated appendicitis.[13]

Complicated appendicitis: children

Complicated appendicitis occurs in less than 19% of children.[7] It is defined as appendicitis with any one
of:[13] [19]

• Gangrenous appendix with or without perforation

• Intra-abdominal abscess
• Peri-appendicular phlegmon
• Purulent-free fluid.

Have a low threshold of suspicion for considering complicated appendicitis in children, especially in those
of preschool age. This group is less able to articulate their symptoms. They often present with atypical
features, more rapid progression, and higher incidence of complications.[154] [155] [156]

Request an immediate surgical review for any patient with confirmed or suspected complicated
appendicitis.

• Early appendicectomy should be performed within 8 hours.[7]

• Laparoscopic appendicectomy is preferred over open appendicectomy where laparoscopic
equipment and expertise are available.[7] [157] Laparoscopic appendicectomy decreases the
incidence of overall postoperative complications, including wound infection and duration of total
hospital stay.[132] [133]
MANAGEMENT

• The optimal management for appendicitis with phlegmon or abscess remains subject to debate.
Laparoscopic appendicectomy is associated with fewer readmissions and fewer additional
interventions than conservative management, provided advanced laparoscopic expertise is
available.[7] [138]

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Acute appendicitis Management
• However, if the patient with phlegmon or abscess is stable and laparoscopic appendicectomy is
unavailable, conservative treatment with intravenous antibiotics and percutaneous image-guided
drainage is a reasonable alternative.[7]

• Meta-analyses in children with phlegmon or abscess have found that non-operative

management is associated with lower complication and readmission rates and reduced
length of hospital stay.[158] [159]
• Check local protocols and seek advice from microbiology colleagues when prescribing
antibiotics.
• Interval appendicectomy should be considered if the patient has had conservative
management and symptoms persist or recur.[7]

MANAGEMENT

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 Acute appendicitis Management

Evidence: Laparoscopic versus open appendicectomy in children

For children with acute appendicitis, if surgery is needed, evidence shows that laparoscopic
appendicectomy compares favourably with open appendicectomy as long as resources and an
appropriately skilled surgeon are available.

The World Society of Emergency Surgery (WSES) 2020 guideline recommends laparoscopic
appendicectomy over open surgery for children with acute appendicitis.[7] This is based on two
systematic reviews published in 2017, one in children and the other from indirect evidence in adults.

• The first systematic review (search date January 2000 to April 2016) included nine studies
(one randomised controlled trial [RCT], one prospective cohort, and seven retrospective cohort
studies) comparing laparoscopic and open surgery in children (aged <18 years) with perforated
acute appendicitis.[132]

• The review authors found that laparoscopic surgery was associated with a lower
incidence of surgical site infection (relative risk [RR] 0.88, 95% CI 0.77 to 1.00) and bowel
obstruction (RR 0.79, 95% CI 0.64 to 0.98).
• However, intra-abdominal abscess was higher with laparoscopic surgery (RR 1.38, 95%
CI 1.20 to 1.59).

• The second systematic review (search date January 2016) included two RCTs and 14
retrospective cohort studies in adults with complicated acute appendicitis.[133]

• Laparoscopic surgery reduced surgical site infection (odds ratio [OR] 0.28, 95% CI 0.25
to 0.31) without increasing the rate of postoperative intra-abdominal abscess (OR 0.79,
95% CI 0.45 to 1.34).
• The operating times with laparoscopic surgery were longer than that with open surgery
groups (weighted mean difference [WMD] 13.78 minutes, 95% CI 8.99 to 18.57), but the
length of hospital stay was significantly shorter with laparoscopic surgery (WMD −2.47
days, 95% CI −3.75 to −1.19), as was the time to oral intake (WMD −0.88 days, 95% CI
−1.20 to −0.55).

A subsequent systematic review (published 2019) in children with complicated appendicitis (six RCTS
and 33 case-control studies) found similar results to the systematic review in adults included in the
WSES guideline.[134]

• Laparoscopic surgery reduced surgical site infections (OR 0.37, 95% CI 0.25 to 0.54) without an
increase in intra-abdominal abscess formation (OR 1.01, 95% CI 0.71 to 1.43).
• Operative time was shorter for open surgery (WMD 12.44 minutes, 95% CI 2.00 to 22.87).
However, laparoscopic surgery also had a shorter length of hospital stay (WMD -0.96 days, 95%
CI -1.47 to -0.45), lower incidences of postoperative ileus or intestinal obstruction, shorter time
to oral intake, and reduced readmission and reoperation rates.
MANAGEMENT

Give postoperative antibiotics to any child with complicated appendicitis.[7]

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Acute appendicitis Management
• Seek advice from microbiology colleagues on the choice of antibiotic as this will be guided by
local resistance patterns. Examples of regimens include piperacillin/tazobactam and amoxicillin/
clavulanate.
• Continue postoperative antibiotics for less than 7 days; start with intravenous and then switch to
oral administration after 48 hours.
• Discontinue antibiotics based on resolving clinical signs (e.g., fever) and laboratory criteria (e.g.,
leukocytosis).
• Complicated appendicitis is strongly associated with an increased risk of surgical site infection;
the postoperative complication rate is up to 4 times higher in complicated compared with
uncomplicated appendicitis.[13]

MANAGEMENT

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 Acute appendicitis Management

Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

Acute ( summary )
uncomplicated appendicitis: adults

fit for surgery or with 1st supportive treatment

appendicolith

plus appendicectomy

unfit for/does not want 1st supportive treatment

surgery and without
appendicolith

plus antibiotics

uncomplicated appendicitis:
children

with appendicolith 1st supportive treatment

plus appendicectomy

without appendicolith 1st supportive treatment

plus antibiotics

2nd supportive treatment

plus appendicectomy

complicated appendicitis: adults

with free perforation and/ 1st supportive treatment

or acutely unwell

plus emergency appendicectomy

plus postoperative antibiotics

stable with abscess or 1st supportive treatment

phlegmon

plus laparoscopic appendicectomy

plus postoperative antibiotics

2nd supportive treatment

plus antibiotics and percutaneous image-

MANAGEMENT

guided drainage

consider interval appendicectomy

complicated appendicitis: children

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Acute appendicitis Management

Acute ( summary )

with free perforation and/ 1st supportive treatment

or acutely unwell

plus emergency appendicectomy

plus postoperative antibiotics

stable with abscess or 1st supportive treatment

phlegmon

plus laparoscopic appendicectomy

plus postoperative antibiotics

2nd supportive treatment

plus antibiotics and percutaneous image-

guided drainage

consider interval appendicectomy

MANAGEMENT

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 Acute appendicitis Management

Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

Acute
uncomplicated appendicitis: adults

fit for surgery or with 1st supportive treatment

appendicolith
Primary options

» paracetamol: 15 mg/kg (maximum 1000

mg/dose) intravenously every 4-6 hours when
required, maximum 4000 mg/day

OR

» morphine sulfate: 5-10 mg subcutaneously/

intravenously/intramuscularly every 4 hours
initially, adjust dose according to response

» Keep the patient nil by mouth if surgery is

being considered.

• Run intravenous maintenance fluids

for any patient who is being kept nil by
mouth.[27]

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

» Involve obstetric support for any

pregnant woman with appendicitis as
management requires a multidisciplinary
approach.[84]
plus appendicectomy
Treatment recommended for ALL patients in
selected patient group
» Refer any patient with suspected or confirmed
appendicitis within 24 hours.

» Appendicectomy is the standard treatment for

uncomplicated appendicitis.[13]

• Laparoscopic appendicectomy is preferred

MANAGEMENT

over open surgery for most adults

(including pregnant women) provided
an appropriately skilled surgeon is
available.[7] [105] [106] [110]
• Ensure appendicectomy is not delayed
unnecessarily in order to minimise

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Acute appendicitis Management

Acute
patient discomfort. However, evidence
suggests that delaying surgery by up to
24 hours does not increase the risk of
perforation.[85]
• Minimise surgical delay for patients >65
years of age and those with significant
comorbidities as these patients may be at
increased risk of perforation.[122]

» Give all patients prophylactic antibiotics

before surgery to reduce the risk of
postoperative complications.[86] Check local
protocols.

• Patients with uncomplicated appendicitis

require a single preoperative dose only.[7]
[86]
• Do not give postoperative antibiotics
in adults with uncomplicated acute
appendicitis, because there is no evidence
they decrease the rate of surgical
infection.[7]

» Do not use a conservative approach if an

appendicolith is present, because non-operative
management carries a significant failure rate.[7]
[2]
unfit for/does not want 1st supportive treatment
surgery and without
Primary options
appendicolith
» paracetamol: 15 mg/kg (maximum 1000
mg/dose) intravenously every 4-6 hours when
required, maximum 4000 mg/day

OR

» morphine sulfate: 5-10 mg subcutaneously/

intravenously/intramuscularly every 4 hours
initially, adjust dose according to response

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

» Involve obstetric support for any

pregnant woman with appendicitis as
management requires a multidisciplinary
approach.[84]
MANAGEMENT

plus antibiotics
Treatment recommended for ALL patients in
selected patient group
Primary options

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 Acute appendicitis Management

Acute
» ceftriaxone: 1-2 g intravenously every 24
hours
-or-
» cefotaxime: 1 g intravenously every 8-12
hours, may increase to 8-12 g/day given in
3-4 divided doses in severe infections
--AND--
» metronidazole: 500 mg intravenously every
8 hours

OR

» amoxicillin/clavulanate: 1.2 g intravenously

every 8 hours
Dose consists of 1 g of amoxicillin plus 0.2 g
of clavulanate.

» Give conservative management with

antibiotics for selected patients, including
those who have uncomplicated appendicitis
(suspected or confirmed on computed
tomographic scan), and do not wish to have, or
are unfit for, surgery; ensure the patient is aware
of the risk of recurrence of appendicitis.[13] [87]
[90]

• Do not use a conservative approach for

pregnant patients.[7]
• Do not use a conservative approach if
an appendicolith is present, because
non-operative management carries a
significant failure rate.[7] [2]
• Discuss the risks of conservative
management and all other potential
treatment options with the patient so
that they are able to make an informed
decision.[127]
• Check local protocols and seek
advice from microbiology colleagues
when prescribing antibiotics as drug
regimens and length of treatment varies.
Examples of regimens include ceftriaxone
plus metronidazole, cefotaxime plus
metronidazole, or amoxicillin/clavulanate.

uncomplicated appendicitis:
children
MANAGEMENT

with appendicolith 1st supportive treatment

Primary options

» paracetamol: body weight <10 kg: 10 mg/kg

intravenously every 4-6 hours when required,
maximum 30 mg/kg/day; body weight ≥10 kg:

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Acute appendicitis Management

Acute
15 mg/kg intravenously every 4-6 hours when
required, maximum 60 mg/kg/day

OR

» morphine sulfate: consult specialist for

guidance on dose

» Keep the patient nil by mouth if surgery is

being considered.

• Run intravenous maintenance fluids

for any patient who is being kept nil by
mouth.[27]
• For fluid resuscitation in children, see
Volume depletion in children .

» Refer all children with suspected

appendicitis to the paediatric surgery
team on call, if available.Where no paediatric
surgery team is available, joint care should be
managed between paediatrics and surgical
teams.

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

plus appendicectomy
Treatment recommended for ALL patients in
selected patient group
» Refer for surgery if an appendicolith
is present, because the failure rate of non-
operative management increases in these
patients.[7] [2]

• Laparoscopic appendicectomy is
preferred over open surgery provided
an appropriately skilled surgeon is
available.[7]
• Ensure appendicectomy is not delayed
for children with uncomplicated acute
appendicitis beyond 24 hours.[7]

» Give all patients prophylactic antibiotics

before surgery to reduce the risk of
postoperative complications.[7] Check local
MANAGEMENT

protocols.

• Patients with uncomplicated appendicitis

require a single preoperative dose only.[7]

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 Acute appendicitis Management

Acute
» Do not give postoperative antibiotics in children
with uncomplicated acute appendicitis, because
there is no evidence they decrease the rate of
surgical infection.[7]
without appendicolith 1st supportive treatment
Primary options

» paracetamol: body weight <10 kg: 10 mg/kg

intravenously every 4-6 hours when required,
maximum 30 mg/kg/day; body weight ≥10 kg:
15 mg/kg intravenously every 4-6 hours when
required, maximum 60 mg/kg/day

OR

» morphine sulfate: consult specialist for

guidance on dose

» Refer all children with suspected

appendicitis to the paediatric surgery
team on call, if available. Where no paediatric
surgery team is available, joint care should be
managed between paediatrics and surgical
teams.

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

plus antibiotics
Treatment recommended for ALL patients in
selected patient group
Primary options

» amoxicillin/clavulanate: children <3 months

of age: 30 mg/kg intravenously every 12
hours; children ≥3 months of age: 30 mg/kg
intravenously every 8 hours, maximum 1200
mg/dose
Dose consists of amoxicillin plus clavulanate.

OR

» ceftriaxone: children 1 month to 11 years

of age or body weight <50 kg: 50-80 mg/kg
intravenously every 24 hours, maximum 4000
MANAGEMENT

mg/day; children ≥12 years of age or body

weight ≥50 kg: 1-2 g intravenously every 24
hours
-and-
» metronidazole: children 1 month of age:
15 mg/kg intravenously as a loading dose,

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Acute appendicitis Management

Acute
followed by 7.5 mg/kg every 8 hours; children
≥2 months of age: 7.5 mg/kg intravenously
every 8 hours, maximum 500 mg/dose

» Seek a decision from a specialist

paediatric surgeon regarding whether to
proceed with non-operative management
with antibiotics as an alternative to
surgery in children.

» Give conservative management with

antibiotics for selected patients, including
those who have uncomplicated appendicitis
(suspected or confirmed on computed
tomographic scan) .[7]

• Advise that there is a chance of failure

and misdiagnosis of complicated
appendicitis with non-operative
management.[7]
• Check local protocols and seek
advice from microbiology colleagues
when prescribing antibiotics as drug
regimens and length of treatment vary.
• Examples of regimens include amoxicillin/
clavulanate, or ceftriaxone plus
metronidazole.

2nd supportive treatment

Primary options

» paracetamol: body weight <10 kg: 10 mg/kg

intravenously every 4-6 hours when required,
maximum 30 mg/kg/day; body weight ≥10 kg:
15 mg/kg intravenously every 4-6 hours when
required, maximum 60 mg/kg/day

OR

» morphine sulfate: consult specialist for

guidance on dose

» Keep the patient nil by mouth if surgery is

being considered.

• Run intravenous maintenance fluids

for any patient who is being kept nil by
mouth.[27]
• For fluid resuscitation in children, see
MANAGEMENT

Volume depletion in children .

» Give adequate analgesia.[27] [37]

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 Acute appendicitis Management

Acute
• Paracetamol may be used, or give an
opioid (e.g., morphine) if required.

plus appendicectomy
Treatment recommended for ALL patients in
selected patient group
» Refer for surgery if conservative
management fails.

• Failure of medical management may be

indicated by persistent fever, unremitting
symptoms, or rising inflammatory markers.
• Laparoscopic appendicectomy is
preferred over open surgery provided
an appropriately skilled surgeon is
available.[7]
• Ensure appendicectomy, if indicated,
is not delayed for children with
uncomplicated acute appendicitis beyond
24 hours.[7]

» Do not give postoperative antibiotics in children

with uncomplicated acute appendicitis, because
there is no evidence they decrease the rate of
surgical infection.[7]
complicated appendicitis: adults

with free perforation and/ 1st supportive treatment

or acutely unwell
Primary options

» paracetamol: 15 mg/kg (maximum 1000

mg/dose) intravenously every 4-6 hours when
required, maximum 4000 mg/day

OR

» morphine sulfate: 5-10 mg subcutaneously/

intravenously/intramuscularly every 4 hours
initially, adjust dose according to response

» Involve critical care and seek immediate

surgical input for any patient with suspected
perforated appendicitis and signs of
shock or sepsis.

• If the patient has signs of shock, give a

MANAGEMENT

fluid challenge to correct hypotension and/

or tachycardia.[79] See Shock .

• Give 250-500 mL of either normal

saline (0.9% sodium chloride) or
Hartmann’s solution (also known

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Acute appendicitis Management

Acute
as Ringer’s lactate solution),
intravenously over 15 minutes.[79]

• Refer to local guidelines for the

recommended approach at your institution
for prompt assessment and management
of patients with suspected sepsis, or those
at risk.[26] [80] [81] [83] See Sepsis in
adults .

» Keep the patient nil by mouth if surgery is

being considered.

• Run intravenous maintenance fluids

for any patient who is being kept nil by
mouth.[27]

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

» Involve obstetric support for any

pregnant woman with appendicitis as
management requires a multidisciplinary
approach.[84]
plus emergency appendicectomy
Treatment recommended for ALL patients in
selected patient group
» Request an immediate surgical review
for any patient with confirmed or suspected
complicated appendicitis.

» Patients with a perforated appendix will need

urgent appendicectomy.

» Laparoscopic appendicectomy is performed

in the vast majority of patients in the UK and
should be considered as the treatment of choice
for most patients if the expertise is available.[95]
[96]

» Give all patients prophylactic antibiotics before

surgery to reduce the risk of postoperative
complications.[86] Check local protocols.
plus postoperative antibiotics
Treatment recommended for ALL patients in
selected patient group
MANAGEMENT

Primary options

» amoxicillin: 500 mg intravenously every

8 hours, may increase to 1000 mg every 6
hours in severe infections

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 Acute appendicitis Management

Acute
-and-
» metronidazole: 500 mg intravenously every
8 hours

OR

» piperacillin/tazobactam: 4.5 g intravenously

every 8 hours, may increase to 4.5 g every 6
hours in severe infections
Dose consists of 4 g of piperacillin plus 0.5 g
of tazobactam.

OR

» amoxicillin/clavulanate: 1.2 g intravenously

every 8 hours
Dose consists of 1 g of amoxicillin plus 0.2 g
of clavulanate.

» Continue antibiotics postoperatively if

complicated appendicitis is confirmed during
surgery.[86]

• Check local protocols and seek advice

from microbiology colleagues on the
choice of antibiotic as this will be guided
by local resistance patterns. Examples
of regimens include amoxicillin plus
metronidazole, piperacillin/tazobactam, or
amoxicillin/clavulanate.
• Continue antibiotics typically for 3 to 5
days; start with intravenous and then
switch to oral administration.
• Discontinue antibiotics based on resolving
clinical signs (e.g,. fever) and laboratory
criteria (e.g., leukocytosis).

stable with abscess or 1st supportive treatment

phlegmon
Primary options

» paracetamol: 15 mg/kg (maximum 1000

mg/dose) intravenously every 4-6 hours when
required, maximum 4000 mg/day

OR
MANAGEMENT

» morphine sulfate: 5-10 mg subcutaneously/

intravenously/intramuscularly every 4 hours
initially, adjust dose according to response

66 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Dec 19, 2023.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.
Acute appendicitis Management

Acute
» Keep the patient nil by mouth if surgery is
being considered.

• Run intravenous maintenance fluids

for any patient who is being kept nil by
mouth.[27]

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

» Involve obstetric support for any

pregnant woman with appendicitis as
management requires a multidisciplinary
approach.[84]

»
plus laparoscopic appendicectomy
Treatment recommended for ALL patients in
selected patient group
» Laparoscopic appendicectomy is
recommended as the first-line treatment for
a stable patient who has appendicitis with
phlegmon or abscess, provided the expertise is
available.[7]

» In experienced hands, laparoscopic surgery

is associated with fewer readmissions and
fewer additional interventions than conservative
treatment, with a comparable hospital stay.[7]

» Give all patients prophylactic antibiotics before

surgery to reduce the risk of postoperative
complications.[86] Check local protocols.
plus postoperative antibiotics
Treatment recommended for ALL patients in
selected patient group
Primary options

» amoxicillin: 500 mg intravenously every

8 hours, may increase to 1000 mg every 6
hours in severe infections
-and-
MANAGEMENT

» metronidazole: 500 mg intravenously every

8 hours

OR

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 Acute appendicitis Management

Acute
» piperacillin/tazobactam: 4.5 g intravenously
every 8 hours, may increase to 4.5 g every 6
hours in severe infections
Dose consists of 4 g of piperacillin plus 0.5 g
of tazobactam.

OR

» amoxicillin/clavulanate: 1.2 g intravenously

every 8 hours
Dose consists of 1 g of amoxicillin plus 0.2 g
of clavulanate.

» Continue antibiotics postoperatively if

complicated appendicitis is confirmed during
surgery.[86]

• Check local protocols and seek advice

from microbiology colleagues on the
choice of antibiotic as this will be guided
by local resistance patterns. Examples
of regimens include amoxicillin plus
metronidazole, piperacillin/tazobactam, or
amoxicillin/clavulanate.
• Continue antibiotics typically for 3 to 5
days; start with intravenous and then
switch to oral administration.
• Discontinue antibiotics based on resolving
clinical signs (e.g,. fever) and laboratory
criteria (e.g., leukocytosis).

2nd supportive treatment

Primary options

» paracetamol: 15 mg/kg (maximum 1000

mg/dose) intravenously every 4-6 hours when
required, maximum 4000 mg/day

OR

» morphine sulfate: 5-10 mg subcutaneously/

intravenously/intramuscularly every 4 hours
initially, adjust dose according to response

» Give adequate analgesia.[27] [37]

MANAGEMENT

• Give opioids if these are required.

» Involve obstetric support for any

pregnant woman with appendicitis as

68 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Dec 19, 2023.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2024. All rights reserved.
Acute appendicitis Management

Acute
management requires a multidisciplinary
approach.[84]
plus antibiotics and percutaneous image-
guided drainage
Treatment recommended for ALL patients in
selected patient group
Primary options

» amoxicillin: 500 mg intravenously every

8 hours, may increase to 1000 mg every 6
hours in severe infections
-and-
» metronidazole: 500 mg intravenously every
8 hours

OR

» piperacillin/tazobactam: 4.5 g intravenously

every 8 hours, may increase to 4.5 g every 6
hours in severe infections
Dose consists of 4 g of piperacillin plus 0.5 g
of tazobactam.

OR

» amoxicillin/clavulanate: 1.2 g intravenously

every 8 hours
Dose consists of 1 g of amoxicillin plus 0.2 g
of clavulanate.

» If laparoscopic expertise is not available,

conservative treatment with intravenous
antibiotics and percutaneous image-guided
drainage is a reasonable alternative for a stable
patient with an abscess/phlegmon.[7] Check
local protocols and seek advice from
microbiology colleagues when prescribing
antibiotics as drug regimens and length of
treatment varies.

• Continue antibiotics for up to 6 weeks;

consider interval appendicectomy if
symptoms persist or recur.[7] [13]
• Examples of regimens include amoxicillin
plus metronidazole, piperacillin/
tazobactam, or amoxicillin/clavulanate.
MANAGEMENT

consider interval appendicectomy

Treatment recommended for SOME patients in
selected patient group

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 Acute appendicitis Management

Acute
» Interval appendicectomy should be considered
if the patient has had conservative management
and symptoms persist or recur.[7] [13]

» The patient is usually discharged to continue

antibiotics at home and then readmitted for
interval appendicectomy if this is needed.

» Ensure any patient aged >40 years who

has conservative management without
interval appendicectomy also has investigations
to rule out colon malignancy; these should
include colonoscopy and interval full-dose
contrast-enhanced CT scan.[7]
complicated appendicitis: children

with free perforation and/ 1st supportive treatment

or acutely unwell
Primary options

» paracetamol: body weight <10 kg: 10 mg/kg

intravenously every 4-6 hours when required,
maximum 30 mg/kg/day; body weight ≥10 kg:
15 mg/kg intravenously every 4-6 hours when
required, maximum 60 mg/kg/day

OR

» morphine sulfate: consult specialist for

guidance on dose

» Involve critical care and seek immediate

surgical input for any patient with suspected
perforated appendicitis and signs of
shock or sepsis.

• For fluid resuscitation in children, see

Volume depletion in children .
• Refer to local guidelines for the
recommended approach at your institution
for prompt assessment and management
of patients with suspected sepsis, or those
at risk.[26] [80] [81] [83] See Sepsis in
children .

» Keep the patient nil by mouth if surgery is

being considered.[27]

• For fluid resuscitation in children, see

Volume depletion in children .
MANAGEMENT

» Give adequate analgesia.[27] [37]

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Acute appendicitis Management

Acute
• Paracetamol may be used, or give an
opioid (e.g., morphine) if required.

plus emergency appendicectomy

Treatment recommended for ALL patients in
selected patient group
» Request an immediate surgical review
for any child with confirmed or suspected
complicated appendicitis. Children with a
perforated appendix and/or those who are
acutely unwell will need urgent (within 8
hours) appendicectomy.[7]

» Laparoscopic appendicectomy is preferred

over open appendicectomy where laparoscopic
equipment and expertise are available.[7] [157]

» Give all patients prophylactic antibiotics before

surgery to reduce the risk of postoperative
complications.[7] Follow local protocols.
plus postoperative antibiotics
Treatment recommended for ALL patients in
selected patient group
Primary options

» amoxicillin/clavulanate: children <3 months

of age: 30 mg/kg intravenously every 12
hours; children ≥3 months of age: 30 mg/kg
intravenously every 8 hours, maximum 1200
mg/dose
Dose consists of amoxicillin plus clavulanate.

OR

» piperacillin/tazobactam: children 2-11 years

of age: 112.5 mg/kg intravenously every 8
hours, maximum 4500 mg/dose
Dose consists of piperacillin plus tazobactam.

» Give postoperative antibiotics to any child

with complicated appendicitis.[7]

• Seek advice from microbiology colleagues

on the choice of antibiotic as this will
be guided by local resistance patterns.
Examples of regimens include piperacillin/
MANAGEMENT

tazobactam and amoxicillin/clavulanate.

• Continue postoperative antibiotics for less
than 7 days; start with intravenous and

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 Acute appendicitis Management

Acute
then switch to oral administration after 48
hours.
• Discontinue antibiotics based on resolving
clinical signs (e.g., fever) and laboratory
criteria (e.g., leukocytosis).

stable with abscess or 1st supportive treatment

phlegmon
Primary options

» paracetamol: body weight <10 kg: 10 mg/kg

intravenously every 4-6 hours when required,
maximum 30 mg/kg/day; body weight ≥10 kg:
15 mg/kg intravenously every 4-6 hours when
required, maximum 60 mg/kg/day

OR

» morphine sulfate: consult specialist for

guidance on dose

» Keep the patient nil by mouth if surgery is

being considered.

• Run intravenous maintenance fluids

for any patient who is being kept nil by
mouth.[27]
• For fluid resuscitation in children, see
Volume depletion in children .

» Refer all children with suspected

appendicitis to the paediatric surgery
team on call, if available. Where no paediatric
surgery team is available, joint care should be
managed between paediatrics and surgical
teams.

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

plus laparoscopic appendicectomy

Treatment recommended for ALL patients in
selected patient group
» Laparoscopic appendicectomy is
recommended as the first-line treatment for
MANAGEMENT

a stable patient who has appendicitis with

phlegmon or abscess, provided the expertise is
available.[7] [138]

» In experienced hands, laparoscopic surgery

is associated with fewer readmissions and

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Acute appendicitis Management

Acute
fewer additional interventions than conservative
treatment, with a comparable hospital stay.[7]

» Give all patients prophylactic antibiotics before

surgery to reduce the risk of postoperative
complications.[86] Check local protocols.
plus postoperative antibiotics
Treatment recommended for ALL patients in
selected patient group
Primary options

» amoxicillin/clavulanate: children <3 months

of age: 30 mg/kg intravenously every 12
hours; children ≥3 months of age: 30 mg/kg
intravenously every 8 hours, maximum 1200
mg/dose
Dose consists of amoxicillin plus clavulanate.

OR

» piperacillin/tazobactam: children 2-11 years

of age: 112.5 mg/kg intravenously every 8
hours, maximum 4500 mg/dose
Dose consists of piperacillin plus tazobactam.

» Give postoperative antibiotics to any child

with complicated appendicitis.[7]

• Seek advice from microbiology colleagues

on the choice of antibiotic as this will
be guided by local resistance patterns.
Examples of regimens include piperacillin/
tazobactam and amoxicillin/clavulanate.
• Continue postoperative antibiotics for less
than 7 days; start with intravenous and
then switch to oral administration after 48
hours.[7]
• Discontinue antibiotics based on resolving
clinical signs (e.g., fever) and laboratory
criteria (e.g., leukocytosis).

2nd supportive treatment

Primary options

» paracetamol: body weight <10 kg: 10 mg/kg

intravenously every 4-6 hours when required,
MANAGEMENT

maximum 30 mg/kg/day; body weight ≥10 kg:

15 mg/kg intravenously every 4-6 hours when
required, maximum 60 mg/kg/day

OR

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 Acute appendicitis Management

Acute
» morphine sulfate: consult specialist for
guidance on dose

» Refer all children with suspected

appendicitis to the paediatric surgery
team on call, if available. Where no paediatric
surgery team is available, joint care should be
managed between paediatrics and surgical
teams.

» Give adequate analgesia.[27] [37]

• Paracetamol may be used, or give an

opioid (e.g., morphine) if required.

plus antibiotics and percutaneous image-

guided drainage
Treatment recommended for ALL patients in
selected patient group
Primary options

» amoxicillin/clavulanate: children <3 months

of age: 30 mg/kg intravenously every 12
hours; children ≥3 months of age: 30 mg/kg
intravenously every 8 hours, maximum 1200
mg/dose
Dose consists of amoxicillin plus clavulanate.

OR

» piperacillin/tazobactam: children 2-11 years

of age: 112.5 mg/kg intravenously every 8
hours, maximum 4500 mg/dose
Dose consists of piperacillin plus tazobactam.

» If laparoscopic expertise is not available,

conservative treatment with intravenous
antibiotics and percutaneous image-guided
drainage is a reasonable alternative for a stable
patient with an abscess/phlegmon.[7]

» Meta-analyses in children with phlegmon

or abscess have found that non-operative
management is associated with lower
complication and readmission rates and reduced
length of hospital stay.

» Check local protocols and seek advice

from microbiology colleagues when
MANAGEMENT

prescribing antibiotics as drug regimens and

length of treatment vary.

• Continue antibiotics for up to 6 weeks;

consider interval appendicectomy if
symptoms persist or recur.[7]

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Acute appendicitis Management

Acute
• Examples of regimens include piperacillin/
tazobactam and amoxicillin/clavulanate.

consider interval appendicectomy

Treatment recommended for SOME patients in
selected patient group
» Interval appendicectomy should be considered
if the patient has had conservative management
and symptoms persist or recur.[7] The patient
is usually discharged to continue antibiotics
at home and then readmitted for interval
appendicectomy if this is needed.

Patient discussions
Patients can be started on a clear liquid diet on the same day as the operation if there is no nausea or
vomiting and can start a regular diet the next day. Patients are usually advised to take at least 1 week off
work or school. Future level of activity, including driving and return to work, should be determined at the
follow-up appointment. All patients should be advised to contact their doctor if they develop persistent
or increasing pain, vomiting or fevers. If managed operatively, they should be advised to seek medical
advice if they develop swelling or redness at the site of the wound, or drainage from the wound.[168]

MANAGEMENT

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 Acute appendicitis Follow up

Monitoring
Monitoring
FOLLOW UP

Patients are usually discharged from hospital 1 day after the operation for uncomplicated appendicitis.
Complicated appendicitis may require a longer hospital stay depending on the response to treatment.
In some countries, patients are followed up postoperatively regardless of complicated or uncomplicated
appendicitis; for example, 1 week after discharge, with further follow-up visits arranged as needed.

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Acute appendicitis Follow up

Complications

Complications Timeframe Likelihood

FOLLOW UP
perforation short term low

The patient will appear unwell and may have:

• Signs of sepsis or shock.[2] See Shock , Sepsis in adults and Sepsis in children .
• Localised peritonitis with guarding[25]
• Generalised peritonitis; a tense, distended abdomen with guarding or rigidity and absent bowel
sounds[25]

• This is caused by free perforation in the peritoneal cavity[25]

• A palpable mass

• This is due to a peri-appendiceal abscess caused by a perforation that is contained by the

omentum.[7]

Emergency appendicectomy (open or laparoscopic) should be performed in all cases. This can be done
open or laparoscopically.[27]

It is now accepted that perforation is not merely a progression of an appendicitis but rather a completely
different pathology.[7] [13] [125]

• In practice it is currently not possible to predict early in the course of the condition which patients
have uncomplicated (non-perforating) appendicitis and which have appendicitis that will progress to
perforation.[13]
• In certain patient groups (patients >65 years, those with comorbidities, and those with a delay
of more than 12 hours before surgery is performed) there is some evidence of increased risk of
perforation. Minimise surgical delay in these groups.[122]

generalised peritonitis short term low

Large perforation of acutely inflamed appendix results in generalised peritonitis.

Presents with a tense, distended abdomen with guarding or rigidity and absent bowel sounds.[25]

If the diagnosis is suspected as acute appendicitis, emergency appendicectomy should be performed.

If diagnosis is in doubt, exploratory laparotomy should be performed through midline incision, and the
inflamed appendix needs to be removed.[161]

appendicular mass short term low

Usually seen in patients with a relatively long history of symptoms.

Presents with tender right lower quadrant mass. Ultrasonography or computed tomographic scan will show
a mass.

If the patient appears otherwise well, the initial management is conservative treatment with intravenous
fluids and broad-spectrum antibiotics. If there is clinical improvement and the signs and symptoms
are completely resolved, then there is no need for interval appendicectomy.[144] [162] [163] Interval
appendicectomy is performed after 6 weeks if the symptoms are not completely resolved.[164]

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 Acute appendicitis Follow up

Complications Timeframe Likelihood

Ensure any patient >40 years of age who has conservative management without interval
appendicectomy also has investigations to rule out colon malignancy; these should include
FOLLOW UP

colonoscopy and interval full-dose contrast-enhanced CT scan.[7]

appendicular abscess short term low

Usually occurs as a progression of the disease process, particularly after perforation.

Presents with tender right lower quadrant mass, swinging fever, and leukocytosis.

Ultrasonography or computed tomographic (CT) scan will show the abscess.

Initial treatment includes intravenous antibiotics and CT-guided drainage of abscess.

If there is clinical improvement and the signs and symptoms are completely resolved, then there is
no need for interval appendicectomy.[144] [162] [163] Interval appendicectomy is performed after 6
weeks if the symptoms are not completely resolved.[164] There is evidence to suggest that laparoscopic
appendicectomy may be a feasible first-line option over conservative treatment for appendiceal abscess in
adults; however, this is not recommended.[147]

Ensure any patient >40 years of age who has conservative management without interval
appendicectomy also has investigations to rule out colon malignancy; these should include
colonoscopy and interval full-dose contrast-enhanced CT scan.[7]

surgical wound infection short term low

One retrospective cohort study of 150 patients with perforated appendicitis with abscess or peritonitis
found a laparoscopic approach reduced the incidence of surgical site infection and repeat surgery and led
to a shorter length of stay compared with open surgery.[139]

There is also a decreased incidence of a surgical wound infection if prophylactic antibiotics are used.[165]

appendiceal malignancy long term low

The risk of appendiceal neoplasm in patients treated with non-operative management of complicated
appendicitis is 11%, increasing to 16% in patients aged 50 years and older and 43% in patients aged over
80.[150] [151] [152] Mucinous neoplasms are the most common form of appendiceal malignancy (43%),
although the incidence of appendiceal carcinoid appendiceal tumours is rising, particularly in patients
under 40 years of age.[166] [150]

stump appendicitis long term low

A rare complication which occurs in approximately 0.25% of patients following laparoscopic

appendicectomy.[167] Presents with right lower quadrant pain, a median of 292 days following
laparoscopic appendicectomy.[167] Treatment is surgical, with the majority of patients (97%) undergoing
repeat laparoscopic appendicectomy.[167]

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Acute appendicitis Follow up

Prognosis

FOLLOW UP
If patients are treated in a timely fashion, the prognosis is good. Wound infection and intra-abdominal
abscess are potential complications associated with appendicectomy. Laparopscopic appendicectomy has
been shown to decrease the incidence of overall complications.[160]

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 Acute appendicitis Guidelines

Diagnostic guidelines

United Kingdom

Commissioning guide: emergency general surgery (acute abdominal pain)

Published by: Association of Surgeons of Great Britain and Ireland; Last published: 2014
Royal College of Surgeons of England

Europe

Diagnosis and management of acute appendicitis: EAES consensus

development conference 2015
Published by: European Association for Endoscopic Surgery Last published: 2016

Laparoscopic approach to acute abdomen

GUIDELINES

Published by: Società Italiana di Chirurgia Endoscopica e nuove Last published: 2011
tecnologie; Associazione Chirurghi Ospedalieri Italiani; Società Italiana di
Chirurgia; Società Italiana di Chirurgia d'Urgenza e del Trauma; Società
Italiana di Chirurgia nell'Ospedalità Privata; European Association for
Endoscopic Surgery

International

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES

Jerusalem guidelines
Published by: World Society of Emergency Surgery Last published: 2020

North America

Critical issues in the evaluation and management of emergency department

patients with suspected appendicitis
Published by: American College of Emergency Physicians Last published: 2023

ACR appropriateness criteria: right lower quadrant pain - suspected

appendicitis
Published by: American College of Radiology Last published: 2022

ACR appropriateness criteria: acute nonlocalized abdominal pain and fever

Published by: American College of Radiology Last published: 2018

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Acute appendicitis Guidelines

Asia

The practice guidelines for primary care of acute abdomen

Published by: Japanese Society for Abdominal Emergency Medicine; Last published: 2016
Japan Radiological Society; Japanese Society of Hepato-Biliary-
Pancreatic Surgery; Japan Primary Care Association

Treatment guidelines

United Kingdom

Commissioning guide: emergency general surgery (acute abdominal pain)

Published by: Association of Surgeons of Great Britain and Ireland; Last published: 2014
Royal College of Surgeons of England

GUIDELINES
Europe

Adult appendicitis: clinical practice guidelines

Published by: French Society of Digestive Surgery; Society of Last published: 2021
Abdominal and Digestive Imaging

Diagnosis and management of acute appendicitis: EAES consensus

development conference 2015
Published by: European Association for Endoscopic Surgery Last published: 2016

International

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES

Jerusalem guidelines
Published by: World Society of Emergency Surgery Last published: 2020

Guidelines for diagnosis and treatment of acute appendicitis in the elderly

Published by: Italian Society of Surgical Pathophysiology; Italian Last published: 2019
Society of Geriatric Surgery; World Society of Emergency Surgery; Italian
Society of Emergency Medicine

The management of intra-abdominal infections from a global perspective

Published by: World Society of Emergency Surgery Last published: 2017

Oceania

Acute abdominal pain

Published by: Starship Child Health Last published: 2022

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 Acute appendicitis Evidence tables

Evidence tables
For adults and adolescents with suspected appendicitis, how does
EVIDENCE TABLES

laparoscopic appendectomy compare with conventional appendectomy?

This table is a summary of the analysis reported in a Cochrane Clinical Answer that focuses on the
above important clinical question.

View the full source Cochrane Clinical Answer

Evidence B * Confidence in the evidence is moderate or low to moderate where GRADE has
been performed and the intervention may be more effective/beneficial than the
comparison for key outcomes.

Population: Adults and adolescents with suspected appendicitis

Intervention: Laparoscopic appendectomy
Comparison: Conventional appendectomy (open surgery, most using a McBurney/muscle-splitting method)

† ‡
Outcome Effectiveness (BMJ rating) Confidence in evidence (GRADE)

Wound infections (time point Favours intervention Moderate

unclear)

Intra‐abdominal abscess Favours comparison Moderate

(follow‐up range from hospital
discharge to 1 year)

Pain intensity on day 1 Favours intervention Low

postoperatively

Length of hospital stay Favours intervention Low

Time until return to normal Favours intervention Low

activity

Note
The Cochrane Clinical Answer (CCA) notes that intra-abdominal abscesses are more likely to occur with
laparoscopic surgery, but also notes that the Cochrane reviewers did not stratify this in relation to the
pathology of the appendix, resulting in some uncertainty as to which approach is preferable in patients with
complicated appendicitis.

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Acute appendicitis Evidence tables
* Evidence levels
The Evidence level is an internal rating applied by BMJ Best Practice. See the EBM Toolkit for details.

EVIDENCE TABLES
Confidence in evidence

A - High or moderate to high

B - Moderate or low to moderate
C - Very low or low

† Effectiveness (BMJ rating)

Based on statistical significance, which demonstrates that the results are unlikely to be due to chance, but
which does not necessarily translate to a clinical significance.

‡ Grade certainty ratings

High The authors are very confident that the true

effect is similar to the estimated effect.
Moderate The authors are moderately confident that
the true effect is likely to be close to the
estimated effect.
Low The authors have limited confidence in the
effect estimate and the true effect may be
substantially different.
Very Low The authors have very little confidence in
the effect estimate and the true effect is
likely to be substantially different.
BMJ Best Practice EBM Toolkit: What is GRADE?

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 Acute appendicitis References

Key articles
• Di Saverio S, Podda M, de Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020
REFERENCES

update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020 Apr 15;15(1):27. Full text
Abstract

• Gorter RR, Eker HH, Gorter-Stam MA, et al. Diagnosis and management of acute appendicitis:
EAES consensus development conference 2015. Surg Endosc. 2016 Nov;30(11):4668-90. Full text
Abstract

• Association of Surgeons of Great Britain and Ireland; Royal College of Surgeons of England.
Commissioning guide: emergency general surgery (acute abdominal pain). April 2014 [internet
publication]. Full text

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 Acute appendicitis Images

Images
IMAGES

Figure 1: Acute appendicitis - intraoperative specimen

Nasim Ahmed, MBBS, FACS; used with permission

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Acute appendicitis Images

IMAGES
Figure 2: CT abdomen - thickened appendix
Nasim Ahmed, MBBS, FACS; used with permission

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Contributors:

// Expert Advisers:

John Abercrombie, FRCS

General and Colorectal Surgeon
Queen’s Medical Centre, Nottingham, UK
DISCLOSURES: JA is trustee and council member of the Royal College of Surgeons of England.

// Peer Reviewers:

Sarah Richards,
General Surgeon
Royal United Hospitals, Bath NHS Foundation Trust, UK
DISCLOSURES: SR declares that she has no competing interests.

Kokila Lakhoo, PhD, FRCS, FCS (Paediatrics) MRCPCH, MBCHB

Consultant Paediatric Surgeon
Children’s Hospital in Oxford and the University of Oxford, UK
DISCLOSURES: KL declares that she has no competing interests.

// Editors:

Tessa Davis,
Section Editor, BMJ Best Practice
Consultant in Paediatric Emergency Medicine, Royal London Hospital, London, UK
DISCLOSURES: TD declares that she has no competing interests.

Annabel Sidwell,
Section Editor, BMJ Best Practice
DISCLOSURES: AS declares that she has no competing interests.

Jo Haynes,
Head of Editorial, BMJ Knowledge Centre
DISCLOSURES: JH declares that she has no competing interests.

Susan Mayor,
Lead Section Editor, BMJ Best Practice
DISCLOSURES: SM works as a freelance medical journalist and editor, video editorial director and
presenter, and communications trainer. In this capacity, she has been paid, and continues to be paid,
by a wide range of organisations for providing these skills on a professional basis. These include: NHS
organisations, including the National Institute for Health and Care Excellence, NHS Choices, NHS Kidney
Care, and others; publishers and medical education companies, including the BMJ Group, the Lancet
group, Medscape, and others; professional organisations, including the British Thoracic Oncology Group,
the European Society for Medical Oncology, the National Confidential Enquiry into Patient Outcome and
Death, and others; charities and patients’ organisations, including the Roy Castle Lung Cancer Foundation
and others; pharmaceutical companies, including Bayer, Boehringer Ingelheim, Novartis, and others; and
 communications agencies, including Publicis, Red Healthcare and others. She has no stock options or
shares in any pharmaceutical or healthcare companies; however, she invests in a personal pension, which
may invest in these types of companies. She is managing director of Susan Mayor Limited, the company
name under which she provides medical writing and communications services.

Tanna z Aliabadi-Oglesby,
Lead Section Editor, BMJ Best Practice
DISCLOSURES: TAO declares that she has no competing interests.

Julie Costello,
Comorbidities Editor, BMJ Best Practice
DISCLOSURES: JC declares that she has no competing interests.

Adam Mitchell,
Drug Editor, BMJ Best Practice
DISCLOSURES: AM declares that he has no competing interests.

// Acknowledgements:
BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work
is retained in parts of the content:Dileep N. Lobo, MS, DM, FRCS, FACSProfessor of Gastrointestinal
SurgeryNational Institute for Health Research, Nottingham Digestive Diseases Biomedical
Research UnitNottingham University Hospitals and University of Nottingham, Queen's Medical
CentreNottinghamUKDNL declares that he has no competing interests. DNL is an author of an article cited
in the topic.