CLINICAL OVERVIEW

Appendicitis
Elsevier Point of Care (see details)Updated September 25, 2023. Copyright Elsevier BV. All rights reserved.

Synopsis
Urgent Action
 All patients with strongly suspected or confirmed appendicitis require prompt antibiotic
therapy

For uncomplicated appendicitis, common agents are cefoxitin, cefotetan, or cefazolin

o
plus metronidazole 8 9

o For complicated appendicitis, common regimen is ceftriaxone plus metronidazole

 Emergent appendectomy (surgery within several hours of admission) is rarely indicated,
unless patient is unstable or very ill-appearing with generalized peritonitis 4

o Early appendectomy (surgery within about 24 hours of admission) is procedure of

choice for stable patients with acute appendicitis; risk of perforation does not increase
unless significant delay in definitive care occurs

o Emergent operative intervention (appendectomy and peritoneal irrigation within several

hours) is necessary for ill-appearing or unstable patients and patients with generalized
peritonitis2

Key Points
 Appendicitis, or acute inflammation of the vermiform appendix, is the most common
abdominal surgical emergency; lifetime risk approaches about 8% 1 2

 Often presents with periumbilical abdominal pain that localizes to the right lower quadrant;
pain is constant and worse with movement. Vomiting and low-grade fever develop after onset
of abdominal pain, and tenderness develops in the right lower quadrant

 Establishing diagnosis can be challenging and may be aided by biochemical testing, clinical
prediction scoring, serial clinical examinations, imaging, and expert consultation. Definitive
confirmation of diagnosis is based on tissue histopathology 3

 Standard laboratory testing includes CBC, urinalysis, C-reactive protein, and urine β-hCG in
females of childbearing age; mild leukocytosis is nonspecific but common in patients with
appendicitis 4

 Use local or regional algorithms to assist in risk stratification to guide best diagnostic and
imaging approach

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

o Intermediate-risk patients usually require observation with serial clinical examinations

and imaging studies; CT is preferred in nonpregnant adults, and ultrasonography is
preferred in children and pregnant patients5

o High-risk patients require immediate surgical consultation for appendectomy without

further workup

 Start antibiotics promptly at the time of confirmed or highly suspected acute appendicitis 3 6

 Standard treatment of both uncomplicated (simple, nonperforated) and most complicated

(perforated) acute appendicitis is prompt laparoscopic appendectomy 6
  Optimal management strategy for patients with phlegmon and walled-off abscess is not
standardized

o Initial strategy usually involves antibiotics, supportive care, bowel rest, and
percutaneous drainage of significant fluid collections 3 4 7

 Prognosis for most otherwise healthy patients with uncomplicated appendicitis is good.
Patients with perforation are at much higher risk for postoperative complications (20%-30%) 6

Pitfalls
 Maintain a high index of suspicion for appendicitis in patients presenting with abdominal
pain

o Significant delays in diagnosis can lead to increased morbidity secondary to increased

risk for complications (eg, perforation, abscess, peritonitis)

 Diagnosis may be challenging given variability in presentation; manifestations may vary

according to anatomic position of inflamed appendiceal tip 10

o Occasionally, pain from appendicitis may be difficult to localize or it may localize to

atypical positions (eg, right upper quadrant, suprapubic, flank)

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

position 11

 Atypical presentations may occur in very young children, pregnant patients, and older-aged
and immunocompromised people

o Very young children usually present with perforated appendicitis

 o Pregnant patients may present with variations in reported location of pain. Symptoms of
early appendicitis overlap with clinical manifestations of normal pregnancy (eg,
vomiting, physiologic leukocytosis). Febrile response may be blunted

o Older-aged and immunocompromised people may present with muted symptoms and
are at high risk for perforation at presentation

 Consider alternate diagnosis in females of childbearing age because several gynecologic

processes mimic acute appendicitis 5

 Significant practice variation exists in preferred diagnostic, evaluation, and treatment

methods of suspected and confirmed appendicitis; refer to regional and institutional protocols
for guidance

 Pretreatment with antibiotics may alter clinical findings in patients with evolving
appendicitis 12

o Maintain low threshold for specialist consultation; consider advanced imaging in

patients presenting with right lower quadrant pain and tenderness who are receiving
antibiotics

 In children, avoid CT imaging owing to excessive exposure to radiation; first line imaging for
children is ultrasonography to assess for signs of appendicitis

o Consider consultation and transfer to facility with pediatric capabilities (eg, pediatric
imaging protocols, pediatric radiologists, pediatric surgeons) if ultrasonography to
assess for appendicitis is not available
Terminology
Clinical Clarification
 Appendicitis is acute inflammation of the vermiform appendix, the wormlike diverticulum
originating at the base of the cecum 1

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

Classification
 Uncomplicated appendicitis (simple or nonperforated appendicitis)

oInflamed appendix without signs of gangrene, perforation, intra-abdominal abscess,

contained phlegmon, or intra-abdominal purulent fluid 3

 Complicated appendicitis (includes perforated appendicitis)

o Gangrenous inflamed appendix with or without perforation, intra-abdominal abscess,

contained phlegmon, or purulent intra-abdominal fluid3

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

2

Diagnosis
Clinical Presentation


McBurney point. - Surface anatomy representing the base of the appendix.

From Sellars H et al: Acute appendicitis. Surgery. 35(8):432-8, 2017, Figure 1.

 

Appendix positions and corresponding symptoms. - Anterior located appendix floats in an

anterior position in an arc from a common base. When inflamed, appendix tip may affix to
surrounding structures in a subcecal, pelvic, or ileal position. Anterior positioning includes
positions to the right of the diagonal line (positions other than retrocecal/retrocolic).

Data from Quick CRG et al: Appendicitis. In: Quick CRG et al, eds: Essential Surgery:
Problems, Diagnosis and Management. 6th ed. Elsevier; 2020:366-73; Sinha R: Appendix,
colon and rectum. In: Allan PL et al, eds: Clinical Ultrasound. 3rd ed. Elsevier; 2011:388-
410; and Kovler ML et al: Appendicitis. In: Cameron AM et al, eds: Current Surgical
Therapy. 13th ed. Elsevier; 2020:284-9.
History

 Abdominal pain
o Typically the earliest symptom and present in most patients

o Classic description of pain

 Gradual onset of dull periumbilical pain that migrates to right lower quadrant
within 12 to 48 hours 13

 Migration of pain is a strong predictor of appendicitis in both children

(positive likelihood ratio, 1.9-3.1) and adults (positive likelihood ratio,
3.2)14 15

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

in adults (positive likelihood ratio, 7.3-8.5) than in children (likelihood
ratio, 1.2-3.1) 2 14 15

 Pain is commonly exacerbated by movement (eg, bumping during car ride,

walking, coughing)

 Pain usually is constant and progressive rather than intermittent

 Classic presentation is noted in only about half of patients with appendicitis 6 7

o Eventual localization of pain depends on anatomic position of inflamed appendiceal tip

(noninflamed appendix usually floats from a fixed base in an arc through various
anterior positions; inflamed appendiceal tip may become adherent to surrounding
structures in a relatively fixed position)

 Pain at McBurney point (one-third way from right anterior superior iliac spine to
umbilicus): indicative of anterior location of tip of appendix7

 Pain below McBurney point (low pelvic pain) or suprapubic pain: indicative of
tip of appendix located in pelvis16
  Back pain, flank pain, or ill-defined pain: indicative of tip of appendix located in
retrocecal position16

 Periumbilical pain (may persist and increase in intensity rather than migrate to
another position): indicative of tip of appendix located adjacent to terminal ileum
(post- or preileal)

 Right upper quadrant pain: may occur in patients with conditions associated with
altered anatomy (eg, malrotation, third trimester of pregnancy) 5

 Other variable symptoms

o Nausea and vomiting

 Occurs in more than half of patients; presence of vomiting may increase

likelihood of appendicitis by at least 2-fold, and absence diminishes likelihood by
about half 6 14

 Typically develops after onset of pain

 May become bilious with persistent emesis

o Fever

 Usually low grade (lower than 38 °C in adults) unless perforation has occurred 13

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

 Absence of fever does not exclude appendicitis; however, it lowers

likelihood of appendicitis by at least two-thirds 2 14 16

o Anorexia is common

o Diarrhea
  Most often noted in patients with appendix located in pelvic position

o Urinary symptoms (eg, frequency, urgency)

 Most often noted in patients with appendix located in pelvic position

o Tenesmus and constipation may develop

 Symptoms suggestive of perforation

o Localized right lower quadrant pain that suddenly improves then gradually worsens,
becoming generalized and diffuse

o Associated symptoms may include abdominal bloating, firmness, and high fever
(above 38 °C ) with chills
17

o Longer duration of pain (more than 48 hours from onset) is typical in patients
6

presenting with perforated compared with nonperforated appendicitis 17

Physical examination

 General appearance

o Gait is often guarded, hunched, and associated with a slight limp favoring right side

o Patients move tentatively and prefer to remain still

o Patients are more comfortable lying in the right lateral recumbent position

o Right leg may be flexed at hip to decrease peritoneal stretch

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

o Overall, one-half of patients with appendicitis have fever; lack of 13

fever diminishes likelihood of appendicitis by about two-thirds 2

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

 Abdominal examination may show signs of ileus, location of inflamed appendix, or

peritonitis

o Abdominal distention suggests perforation, ileus, or bowel obstruction

o Bowel sounds may be hyperactive or normal early in illness and become hypoactive as
disease progresses

 Absent or decreased bowel sounds is associated with appendicitis in children

(positive likelihood ratio, 3.1) 15

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

 Voluntary guarding may occur near area of maximal tenderness

 May reflect anatomic position of appendix

 Periumbilical tenderness may indicate tip of appendix adjacent to terminal

ileum (post- or preileal appendix)

 Right lower quadrant tenderness at McBurney point is consistent with

anterior position of appendix

 Minimal tenderness may indicate tip of appendix positioned in pelvis

(pelvic appendix)
  Delayed, inconsistent, or absent tenderness may occur when tip of appendix
is behind cecum (retrocecal appendix)

 Pregnant patients may present with variable tenderness due to displacement

of appendix by gravid uterus

 Mass in right lower quadrant suggests phlegmon or localized abscess

o Psoas or obturator sign also may indicate anatomic location of appendix

 Neither sign is associated with severity of disease or perforation

 Psoas sign—elicitation of pain with passive right hip extension or active right
thigh flexion—is consistent with appendix in retrocecal location

 Obturator sign—elicitation of pain with internal rotation of right hip—is

consistent with appendix in pelvic location

 Positive psoas (positive likelihood ratio: 2 [in adults] or 3.2 [in children]) and
obturator (positive likelihood ratio, 3.5 in children) signs appear to be strong
predictors of appendicitis, when present 14 15

o Peritoneal signs

 Rovsing sign (right lower quadrant pain elicited with palpation of left lower
quadrant) suggests peritoneal irritation

 Positive likelihood ratio of 3.5 for appendicitis in children 15

  Rebound tenderness (elicited by gentle tapping on abdomen or rapid release of
pressure from abdomen) suggests peritoneal irritation

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

o Involuntary guarding and abdominal wall rigidity

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

o Cervical motion tenderness with absence of purulent cervical discharge may be noted,
particularly in patients with pelvic location of appendiceal tip

o Right adnexal tenderness may be appreciable

o Right adnexal mass may be noted in patients with inflammatory mass (eg, abscess,
phlegmon)

Causes and Risk Factors

Causes

 Appendicitis is caused by obstruction of appendiceal lumen, resulting in distention and

venous congestion. Intraluminal bacterial overgrowth and subsequent bacterial invasion of
the appendix wall occur; appendiceal ischemia and necrosis may ensue

o Obstruction

 Localized lymphoid hyperplasia obstruction is the most common cause of

appendicitis in children and accounts for one-half of occurrences overall
  Fecalith obstruction is the most common cause of appendicitis in adults and
accounts for one-third of occurrences overall

 Foreign body (eg, intestinal worms, food seeds, intestinal calculi, inspissated
barium) causes obstruction in less than 5% of cases 19

 Obstructive neoplasms (eg, carcinoid tumor, metastatic spread to appendix,

primary appendiceal carcinoma) account for less than 1% of acute appendicitis
cases 20

 Incidence of appendicular neoplasms is higher with complicated

appendicitis (3%-17%) in adults older than 40 years 4

o Bacteria

 Most common bacteria include typical fecal flora (eg, Escherichia

coli, Bacteroides fragilis, Pseudomonas)
 Bacterial invasion and ensuing inflammation can eventually result in perforation
with contamination of peritoneal cavity
Risk factors and/or associations
Age

 Peak occurrence is in patients aged 15 to 25 years 5

 Incidence steadily increases in children with advancing age

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

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

o Most common in children aged 10 years or older 6

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

Sex
  Male to female ratio is 1.4 to 1 until age 30 years; in patients older than 30 years, the
prevalence is equal in both sexes 21

Genetics

 Positive family history imparts a nearly 3-fold increased risk for developing appendicitis 6

Other risk factors/associations

 Appendicitis overall is most common in summer months 22

 Perforated appendicitis

o Occurs more frequently in fall and winter 2

o More common in younger children (90% in children younger than 3-4

years) than older children (20% in children aged 10-17 years)
6 2 14

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

16

o More common in males than females

Diagnostic Procedures


Imaging in appendicitis. - A, Ultrasonogram showing a thickened appendix wall (arrow),
with an appendicolith at its tip. B, CT showing an appendix mass (arrow). C, CT showing an
inflamed appendix, with a tiny appendicolith as its cause (arrow).

From Grant LA et al: Colon. In: Grant LA et al, eds: Grainger and Allison's Diagnostic
Radiology Essentials. 2nd ed. Elsevier; 2019:292-311.

Ultrasonogram of dilated appendix (thick arrow pointing to wall of appendix) with

appendicolith (thin arrow) measuring 2.7 cm in diameter.

From Monroe BJ et al: A case of appendicitis with appendicolith diagnosed with ultrasound
in the emergency department. J Emerg Med. 48(6):727-8, 2015, Figure 2.


Transverse section of appendix. - Appendicitis in ultrasonogram is identified as a well-

circumscribed echogenic round structure surrounded by hypoechoic soft tissue collection.

From Barai A: Abdominal pain in a 15-year-old boy. Visual J Emerg Med. 6:26-7, 2017,
Figure 1.


Longitudinal section of appendix (A) which appears to be a blind-ended loop attached to the
cecal pole lying on psoas major muscle (M). - Point of care ultrasonography showed a well-
circumscribed swollen echogenic appendix lying on the psoas major muscle lateral to the
common iliac vessels and it was not compressible.

From Barai A: Abdominal pain in a 15-year-old boy. Visual J Emerg Med. 6:26-7, 2017,
Figure 2.


Transvers and longitudinal color Doppler ultrasonagrams of inflamed appendix. - A,

Transverse ultrasonogram shows inflamed appendix with enlarged diameter and wall
thickening and hyperechogenicity of periappendiceal fat. B, Longitudinal color Doppler
ultrasonogram shows inflamed appendix with hyperemic wall.

From Raposo Rodriguez L et al: Usefulness of ultrasonography in children with right iliac
fossa pain. Radiology. 54(2):137-48, 2012, Figure 2.


Contrast-enhanced axial CT image shows an abnormal appendix (arrows) with mild luminal
distention and abnormal mural enhancement and thickening. - No significant
periappendiceal inflammatory stranding is present.

From Wenzke DR et al: Diseases of the appendix. In: Gore RM et al, eds: Textbook of
Gastrointestinal Radiology. 4th ed. Saunders; 2015:955-83, Figure 56-17.


Unenhanced sagittal multiplanar reconstruction CT image shows a fluid-filled dilated

appendix (arrow) with multiple appendicoliths (arrowheads) and periappendiceal
inflammatory changes.

From Patel NB et al: Evaluating the patient with right lower quadrant pain. Radiol Clin
North Am. 53(6):1159-70, 2015, Figure 3.


Unenhanced coronal multiplanar reconstruction CT image shows a fluid-filled dilated

appendix (circled) with periappendiceal inflammatory changes.

From Patel NB et al: Evaluating the patient with right lower quadrant pain. Radiol Clin
North Am. 53(6):1159-70, 2015, Figure 4.


A 23-year-old man with acute appendicitis. - Axial (A) and coronal contrast-enhanced
abdominopelvic CT (B) show enlarged appendix with a diameter of 10 mm medial to iliac
vessels (white arrows) and fat stranding around the dilated appendix (arrow head). Appendix
also shows wall enhancement. C, cecum.

From Toprak H et al: Mimics of acute appendicitis--alternative diagnoses at sonography,

CT, and MRI; specific imaging findings that can help in differential diagnosis. Clin Imaging.
48:90-105, 2018, Figure 1.

These 3 CT scans show differing presentations for appendicitis. - A, The appendix (arrow) is
enlarged and has a thickened wall. There are no inflammatory changes such as
periappendiceal fat stranding seen on this study. B, The appendix (arrow) is enlarged, and
there is free fluid and inflammatory changes medially indicating likely perforation. C, The
patient presented with a 1-week history of pain and the appendix has perforated with the
development of 2 abscesses (asterisks). In addition, a fecalith is seen medially (dotted
arrow). This patient was initially managed nonoperatively with drainage of the abscesses and
intravenous antibiotics. She underwent laparoscopic interval appendectomy 10 weeks after
the initial admission.

From St. Peter SD et al: Appendicitis. In: Holcomb GW et al, eds: Holcomb and Ashcraft's
Pediatric Surgery. 7th ed. Elsevier; 2020:664-78, Figure 42.3.
 

This sagittal CT image depicts 3 appendicoliths (arrow) and an enlarged appendix.

From St. Peter SD et al: Appendicitis. In: Holcomb GW et al, eds: Holcomb and Ashcraft's
Pediatric Surgery. 7th ed. Elsevier; 2020:664-78, Figure 42.4.

Primary diagnostic tools

 Suspect diagnosis based on history and physical examination

o Consider diagnosis in all patients who have abdominal pain and tenderness on
examination; a significant percentage of appendicitis cases are initially missed on
presentation (up to 20% of all cases) 5
 o Note that prior treatment with antibiotics may alter clinical findings and decrease
confidence in examination findings; lower threshold for imaging and surgical
consultation may be warranted in patients pretreated with antibiotics 12

 Laboratory testing

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

o Interpret laboratory studies with caution in patients with suspected appendicitis. Use
these studies to support increased or decreased likelihood of appendicitis rather than
definitively prove or exclude diagnosis 4

 Combined test performance of WBC count more than 10,000/mm³ and C-reactive
protein more than 8 mg/L is associated with positive likelihood ratio of 23 and
negative likelihood ratio of 0.03 for diagnosis of acute appendicitis

 Among pediatric patients, C-reactive protein more than 10 mg/L and leukocytosis
(greater than 16,000 cells/mL) are strong predictors of acute appendicitis 4

 Establishing diagnosis can be challenging and may be aided by laboratory testing, clinical
prediction scoring, serial clinical examinations, imaging, and expert consultation; definitive
confirmation of diagnosis is based on histopathologic changes 3

o Use local or regional algorithms to assist in risk stratification to guide best diagnostic
and imaging approach

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

by clinical presentation, laboratory findings, and clinical prediction scoring tools

 Clinical prediction rules (Alvarado score, Pediatric Appendicitis Score, Pediatric

Appendicitis Risk Calculator) can aid in identifying pediatric patients at low risk
 of appendicitis but should not be the sole criteria used to exclude need for
advanced imaging for diagnosis of appendicitis 23

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

imaging in adult patients

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

 Low risk: further evaluation includes:

 Assess and treat alternate causes of abdominal pain

 Early appendicitis is possible; provide clear instructions to return for

further evaluation if pain persists or worsens to assess for evolving
appendicitis

 Discharge with close follow-up without specific imaging studies to

further evaluate for appendicitis. If patient has right lower quadrant
pain or tenderness, follow-up for repeated abdominal examination in
12 to 24 hours

 Intermediate risk: patients often require imaging studies, observation with

serial clinical assessments, and possibly surgical consultation 5

 High risk: patients often move straight to surgery consultation for possible
surgical intervention without imaging 24

 Significant regional and institutional practice variation exists in preferred

diagnostic and evaluation measures 2 6

o Consider early consultation with an appropriate specialist (eg, general surgeon for
adults, pediatric surgeon for children) to aid in diagnostic evaluation
  Consider early transfer to care facility that has experts available for special
populations (eg, pediatric radiologists, pediatric surgeons, high-risk obstetricians)
before imaging when appropriate specialty resources are lacking 2

 Imaging

o Preferred imaging for acute appendicitis

 Nonpregnant adults

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

modality to diagnose appendicitis and exclude alternative diagnoses 25 26

 Based on a 2019 Cochrane review, sensitivity is 95% (95%

confidence interval, 0.93-0.96) and specificity is 94% (95%
confidence interval, 0.92-0.95); positive predictive value is 92%
(95% confidence interval, 0.90-0.94) 25

 Sensitivity and specificity of low-dose CT are comparable to

standard-dose CT

 MRI is a highly accurate radiation-free modality that may be used to

diagnose appendicitis in all age groups 27

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

ultrasonography)

 May be used when other studies are not available or contraindications

exist

 Children
  Abdominal ultrasonography is recommended first line imaging modality to
evaluate for appendicitis in children4 15 23 28

 If ultrasonography is inconclusive or appendix is not visualized, next

options include secondary imaging strategies (repeat
ultrasonography/MRI with contrast/CT), admission for a period of
observation with serial clinical examinations, or diagnostic
laparoscopy 4 6

 Some data suggest that the diagnostic accuracy of ultrasonography

approaches that of CT and MRI in children; however, acute
appendicitis cannot be reliably excluded unless a normal appendix is
visualized 29

 A meta-analysis of accuracy of imaging studies in pediatric

patients showed area under receiver operating characteristic
curve data: MRI (0.995), ultrasonography (0.987), CT (0.982) 29

 Pregnant patients

 Graded compression transabdominal ultrasonography is first line imaging

modality 4

 Ultrasonographic evaluation in pregnancy has been shown to have

low sensitivity (77.6%) and specificity (75.3%); therefore,
consideration for follow-up imaging in a different modality should be
considered in a patient with negative or uncertain ultrasonogram
findings 30

 MRI without contrast enhancement is preferred second line option 16 27 31

 American College of Obstetricians and Gynecologists recommends

avoiding exposure to gadolinium in pregnant patients 32

o Abdominal radiograph
  Often ordered during evaluation for appendicitis; however, study usually does not
aid in diagnosis6

 Most helpful to assess for complications such as small bowel obstruction or free
air and for alternate causes of abdominal pain (eg, lower lobe pneumonia,
constipation)

Laboratory


o


o
o

o

o
o

Imaging


o
o

 
o



o

o

o



o



o


o


o


o


o
 



o



o


o


o
o

o



 o

Other diagnostic tools


o



o
o
o

o




























 


















 
















 







































 


 View full size
Appendicitis risk stratification and initial management strategy.
Supplemental Risk for
Typical clinical manifestations Typical initial management strategy
evaluation appendicitis

Low likelihood of appendicitis

Appendicitis
Inflammatory Response:
0 to 4

Adult Appendicitis
Score: 0 to 10

Assess for and treat alternate causes of

Presence of few signs and abdominal pain. Provide clear
symptoms with lack of right lower Alvarado score: 3 or instructions for return for continued Roughly 5%
quadrant tenderness, no fever, less evaluation if symptoms worsen. to 6%
and soft abdomen Discharge with close follow-up (establish
physician follow-up in 12-24 hours)

Pediatric Appendicitis
Score: 3 or less

WBC count, absolute

neutrophil count, and C-
reactive protein (if
obtained): within
reference range
 Supplemental Risk for
Typical clinical manifestations Typical initial management strategy
evaluation appendicitis

Moderate likelihood of appendicitis

Appendicitis
Inflammatory Response:
5 to 8

Adult Appendicitis
Score: 11 to 15

Presence of some signs and Further evaluation includes observation

symptoms of appendicitis (eg, with serial abdominal examinations,
mild right lower quadrant imaging to assess for appendicitis Roughly
Alvarado score: 4 to 6
tenderness or right lower (ultrasonography in children and 26% to 66%
quadrant pain with movement, pregnant patients, CT in nonpregnant
vomiting, low grade fever) adults), and possibly surgical consultation

Pediatric Appendicitis
Score: 4 to 7

WBC count, absolute

neutrophil count, and C-
reactive protein: may be
within reference range
or elevated

High likelihood of appendicitis

 Supplemental Risk for
Typical clinical manifestations Typical initial management strategy
evaluation appendicitis

Appendicitis
Inflammatory Response:
9 to 12

Adult Appendicitis
Score: 16 or higher

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

Pediatric Appendicitis
Score: 8 or more

WBC count, absolute

neutrophil count, and/or
C-reactive protein:
typically elevated
Caption: Prior treatment with antibiotics may alter presentation pattern. Maintain a lower threshold
for surgical consultation and/or imaging in patients with prior treatment with antibiotics.
Differential Diagnosis
Most common
 Mesenteric adenitis
 o Inflammation of lymph nodes in the intestinal mesentery; may be primary without
associated acute inflammatory process or secondary to another underlying condition
(eg, Crohn, infectious colitis, ascending diverticulitis, lymphoma) 61

o Most common alternative diagnosis in children. Typically presents after a viral upper
respiratory tract infection
62

o Difficult to differentiate on clinical grounds alone; may be associated with longer

duration of symptoms, higher fever, and absence of rebound tenderness or percussion
tenderness on examination

o Usually diagnosed by radiographic (eg, abdominal CT or ultrasonography) findings or

at the time of operative exploration

 Gastroenteritis (Related: Gastroenteritis in Children)

d1

o Presents similarly with abdominal pain, vomiting, and fever

o Diarrhea is usually a prominent feature in patients with gastroenteritis. Diarrhea may be

present in patients with appendicitis but is often less prominent than in those with
gastroenteritis

o Abdominal pain is characteristically more diffuse and intermittent (crampy) in patients

with gastroenteritis rather than constant and progressive as in patients with appendicitis

o Patients with gastroenteritis usually lack focal tenderness, guarding, or rebound on

examination. Children with gastroenteritis do not resist movement, whereas in those
with appendicitis, movement exacerbates pain
  A notable exception is gastroenteritis caused by Yersinia enterocolitica,
which sometimes causes focal abdominal pain and tenderness virtually
indistinguishable from appendicitis
o Differentiation is usually based on clinical presentation. Diagnosis of gastroenteritis is
clinical and its cause is determined by stool testing (eg, bacterial culture), when
indicated

 Intussusception
o Presents similarly with abdominal pain and vomiting; commonly affects infants and
young children 63

o Pain is often more colicky than the constant and progressive pain typically associated
with appendicitis; fever is much less common in patients with intussusception than in
those with appendicitis

o Differentiating features include sausage-shaped right upper quadrant mass, blood in

stool, and propensity for mental status depression in children presenting with
intussusception

o Differentiate based on clinical presentation and radiographic findings; ultrasonography

is about 90% sensitive and specific for diagnosis of intussusception 63

o Air contrast enema is gold standard for confirming diagnosis and is preferred initial
treatment option in stable patients without signs of perforation 63

 Urinary tract infection (Related: Urinary Tract Infection in Children)

o Presents similarly with abdominal pain, vomiting, and fever

o Abdominal pain and tenderness is often suprapubic and/or flank in patients with urinary
tract infection as opposed to periumbilical migrating to right lower quadrant
 o Sterile pyuria may occur with appendiceal inflammation; however, bacteriuria is not
expected in patients with appendicitis 64

o Differentiate based on presenting features and urinalysis (showing nitrate positivity

with dipstick testing and/or bacteria with microscopy)

o Diagnosis is based on signs of inflammation in urine (eg, pyuria) and culture positive
for a uropathogen

 Functional constipation 65

o Presents similarly with abdominal pain and sometimes vomiting; pain is often colicky

o Manifestations are often more insidious and chronic in patients with constipation;
history of fecal soiling, large volume hard stools, and withholding behaviors may be
elicited

o Rectal examination is usually notable for substantial stool burden, and abdominal
examination may show palpable, mobile masses of stool and lack of focal right lower
quadrant tenderness

o Differentiate by clinical presentation; large stool burden on abdominal radiograph

suggests constipation

o Constipation is usually a clinical diagnosis

 Pneumonia (Related: Community-Acquired Pneumonia in Children (Older

Than 3 Months))
o May present similarly with abdominal pain, fever, and vomiting, particularly in
children with pneumonia involving right lower lobe
 o Cough and difficulty breathing are usually presenting features in children with
pneumonia, but occasionally these manifestations are subtle or lacking

o Tachypnea, focal diminished breath sounds, and lower than normal oxygen saturation
values are often clues to presence of pneumonia

o Abdominal tenderness is either mild and diffuse or lacking in children with pneumonia

oDiagnose pneumonia by clinical presentation (cough, tachypnea) and confirm with

supportive chest radiography findings when indicated (eg, admission requirement,
suspicion of complications) 66

 Testicular torsion (Related: Testicular Torsion)

o May present similarly with abdominal pain and often vomiting; most common in first
year of life and around puberty 67

o Pain is usually acute at onset. Examination is significant for scrotal swelling, abnormal
horizontal testicular lie, high position of testicle in scrotum, and lack of cremasteric
reflex

o Differentiate by clinical presentation and abnormal findings on genital examination

Diagnose testicular torsion with ultrasonography and confirm at time of surgical

o
exploration 67

 Renal colic (Related: Nephrolithiasis)

o Right-sided ureteral or renal calculus may present similarly with abdominal pain and
vomiting
 o Quality and progression of pain are somewhat different than with appendicitis. Patients
often describe pain beginning in flank then radiating down to right lower quadrant, and
pain is intermittent and colicky rather than constant and progressive

o Urolithiasis is frequently associated with hematuria, either gross hematuria or

microscopic hematuria; focal right lower quadrant tenderness is not a typical finding in
patients with urolithiasis

oDifferentiate based on clinical presentation, urinalysis, and CT or ultrasonography (eg,

normal appendix and visualization of calculus and/or dilated ureter or renal collecting
system) 68

 Ovarian cysts
o Most commonly occur in postmenarchal adolescents. Hemorrhage or rupture of ovarian
cyst causes severe pain

o Presentation may be clinically indistinguishable from appendicitis when right sided

with abdominopelvic pain and sometimes vomiting; guarding and rebound tenderness
may be evident on examination

o In contrast to patients with acute appendicitis, fever is uncommon

o Imaging is often required to differentiate. Ultrasonography is the imaging modality of

choice, but ovarian cyst may be diagnosed using CT

o Ruptured hemorrhagic cyst may mimic appendicitis on imaging with fat stranding and
free fluid in pelvis. Absence of free air noted in some patients with ruptured
appendicitis may help to differentiate conditions68
 Crohn disease (Related: Crohn Disease)
o Terminal ileitis associated with Crohn disease can present with right lower quadrant
pain and signs suggestive of systemic inflammation (eg, fever, increased C-reactive
protein level, leukocytosis)

o Historic manifestations suggestive of Crohn disease include weight loss, chronic

diarrhea with blood and/or mucus, unexplained fever, perianal disease, and
extraintestinal symptoms (eg, rashes, arthritis)

o CT findings consistent with Crohn disease include mucosal hyperenhancement and

bowel wall thickening in discrete lesions (skip lesions) throughout the gastrointestinal
tract. Complications (eg, abscesses, strictures, fistula) may be identified
61

o Differentiate based on clinical presentation and radiographic findings consistent with

Crohn disease; histopathology may be required to definitively exclude Crohn disease
from acute appendicitis in some patients

oDiagnosis of Crohn disease is based on a combination of clinical, endoscopic,

radiologic, histologic, and pathologic findings showing some degree of focal,
asymmetrical, and transmural granulomatous inflammation of the luminal
gastrointestinal tract 69

 Meckel diverticulitis (Related: Diverticulitis)

o Congenitally derived ileal diverticulum that, when inflamed, can produce symptoms
and a clinical picture indistinguishable from acute appendicitis 70

o Patients may have a history of painless gastrointestinal bleeding

 o Occasionally differentiated based on radiologic findings; however, appearance can bear
striking resemblance to appendicitis on imaging (enlarged tubular mass surrounded by
inflammatory changes) 68

o Diagnosis usually confirmed at time of operative procedure

 Ovarian torsion
o Symptoms may closely mimic appendicitis and include nausea and right lower quadrant
pain (with right ovarian involvement)

o Onset and severity of pain is acute and severe compared with progressive nature of pain
in patients with appendicitis. Adnexal mass may be found on examination

o Fever is unusual unless associated with significant ovarian necrosis

o Differentiate by clinical presentations and ultrasonography findings (no Doppler flow

to ovary) 68

 Ectopic pregnancy (Related: Ectopic Pregnancy)

d9 71

o Presents similarly with abdominal pain and vomiting

o Fetus implanting in right side of pelvis causes right-sided abdominal pain and
tenderness developing over hours or days; β-hCG test result is positive

o As opposed to appendicitis, ectopic pregnancy is frequently associated with vaginal

bleeding

o Differentiate based on clinical presentation and positive β-hCG test result. Confirm
diagnosis by using transvaginal ultrasonography to show absence of intrauterine
pregnancy. Also may be detected by MRI and CT 68
 Pelvic inflammatory disease and/or tubo-ovarian abscess (Related: Pelvic
Inflammatory Disease)
o Presents similarly with progressive abdominal pain, nausea, vomiting, and fever

o Pain is usually more suprapubic, bilateral, and longer lasting than in appendicitis;
development of tubo-ovarian abscess leads to lateralization of pain

o History of unprotected sexual activity may be elicited and patient may report vaginal
discharge and possibly urinary symptoms (eg, dysuria); characteristic onset of pain is
during or shortly after menses

o Differentiate by clinical presentation and pelvic examination findings consistent with

pelvic inflammatory disease (eg, purulent cervical discharge, cervical motion
tenderness, adnexal tenderness) with or without abscess

o Pelvic inflammatory disease is a clinical diagnosis; cause is determined by culture or

polymerase chain reaction confirmation of chlamydia or gonorrhea in genital tract

o Tubo-ovarian abscess diagnosis usually is confirmed with transvaginal

ultrasonography 68

 Spontaneous bacterial peritonitis (Related: Spontaneous Bacterial

Peritonitis)
o Presents similar to perforated appendicitis with abdominal pain, fever, and abdominal
tenderness

o Classically occurs in preadolescent girls or patients with nephrotic syndrome or

cirrhosis6
 o Differentiate by clinical presentation and imaging; ultrasonography with diffuse ascites,
coupled with visualization of normal appendix, suggests diagnosis

o Diagnosis is based on analysis of ascitic fluid; cause is confirmed by microbiologic

culture 72

 Epiploic appendagitis
o Benign and self-limiting condition. Develops secondary to torsion, ischemia, or
infarction of lobulated, fat-filled omental appendages on the antimesenteric surface of
the colon; inflammation then results 6

o Presents similarly when process involves right lower quadrant with acute and subacute,
localized, right lower quadrant pain; right lower quadrant tenderness may be present but
fever is usually lacking

o Differentiate based on clinical presentation and findings on imaging (eg,

ultrasonography, CT); definitive diagnosis is usually based on imaging 61 68

Treatment
 

Algorithm shows suggested clinical management pathway for emergency department

patients with possible appendicitis.

From Cole MA et al: Acute appendicitis. In: Walls RM et al, eds: Rosen's Emergency
Medicine: Concepts and Clinical Practice. 9th ed. 2018:1121-8.e2, Figure 83.2.

Goals
 Treat and contain infection and inflammation with antibiotics and prompt
appendectomy (standard treatment of acute appendicitis) 6

 Provide fluid resuscitation and supportive care with IV fluids; prepare for potential surgery
by establishing NPO status

 Prevent infectious complications and sepsis 6

  Provide symptomatic care with pain relief, fever control, and treatment of nausea and
vomiting

Disposition
Admission criteria

Most patients with appendicitis require admission for treatment; however, some patients with
uncomplicated appendicitis may be taken directly to surgery and then discharged home without an inpatient
stay
Criteria for ICU admission

 Sepsis with hemodynamic compromise (eg, in cases of suppurative appendicitis with

perforation and peritoneal contamination)
Recommendations for specialist referral

 Consult a general surgeon for further diagnostic and management considerations when there
is a moderate or strong clinical suspicion of appendicitis in adults

 Consult early with an obstetrician for diagnosis and management considerations when the
patient is pregnant and there is suspicion of appendicitis. The general surgeon manages
surgical issues and performs appendectomy 7

 Crucial to consult with a pediatric surgeon for diagnosis and management of young children
given high rate of complicated appendicitis in very young age groups 7

Treatment Options
Initial resuscitation, stabilization, and supportive care 73

 Fluids, electrolytes, and nutrition

 o Place patient on NPO status

o Replace fluid deficits with normal saline or Ringer lactate solution as indicated;
continue maintenance IV fluids while patient on NPO status

o Correct any electrolyte abnormalities before surgery

 Antiemetics

o Use antiemetics when indicated. Ondansetron is preferred when contraindications are

lacking; promethazine is an option for adults

o Nasogastric tube decompression is only necessary for patients with bowel obstruction
or persistent emesis

 Analgesia

o Manage pain with parenteral opioid analgesics as needed

o Opioid analgesia does not adversely affect diagnostic accuracy or interfere with
surgical decision making in patients with an abdominal condition that may require
surgery; may be used unless otherwise contraindicated 6 73

 Antibiotic therapy

o Promptly begin IV antibiotic therapy (broad spectrum with activity against aerobic
gram-negative and anaerobic bacteria) when diagnosis of appendicitis has been
reasonably established or is highly suspected regardless of whether operative or
nonoperative treatment is anticipated 74
  Refer to community-acquired intra-abdominal infection guidelines for detailed
guidance 75

o Antibiotic prophylaxis is required for patients who are scheduled for appendectomy or
for those in whom delayed surgical management is anticipated 3 6 76

 Antibiotics reduce rates of postoperative wound infections and intra-abdominal

abscesses

 Follow institutional clinical practice pathway for preferred antibiotic prophylaxis,

when available 5

 Uncomplicated appendicitis: routine perioperative antibiotic prophylaxis

for gastrointestinal surgery is appropriate 5

 Common antibiotic choices include single dose of cefoxitin,

cefotetan, and cefazolin or ceftriaxone plus metronidazole 4 8 9

 Clindamycin plus gentamicin or metronidazole plus gentamicin

are options for patients with β-lactam allergy 9 77

 Give single dose IV 30 to 60 minutes before incision 4 78 79

 Consider redosing intraoperatively if the procedure exceeds 2

half-lives of the antibiotic or excessive blood loss occurs 9

 Single-dose prophylaxis is usually sufficient and postoperative

antibiotics are unnecessary9

 Complicated appendicitis: broad coverage for facultative and anaerobic

colonic flora 5 80

 Common antibiotic choices include ertapenem, imipenem-cilastatin,

moxifloxacin, or piperacillin-tazobactam monotherapy or combined
therapy (eg, ceftriaxone plus metronidazole, cefotaxime plus
metronidazole) 2 76 81
  Perforated appendicitis requires ongoing antibiotic therapy after
appendectomy; total duration is usually about 3 to 7 days; however
2 days may be sufficient 82 4 80

 Once source control is achieved, outcomes after 3 to 5 days are

similar to those with prolonged course of antibiotics

Patient may transition to oral antibiotics to complete the


course 6 78

o If planning to manage nonoperatively, initially administer a long-acting parenteral

antibiotic, such as ertapenem or ceftriaxone, plus high-dose, once-daily metronidazole 74

 Can be followed by oral regimens, such as metronidazole plus advanced-

generation cephalosporin or fluoroquinolone

 Use ciprofloxacin plus metronidazole or moxifloxacin monotherapy for patients

with serious β-lactam allergy 75

 Antipyretics

o Administer antipyretics for fever 6

o Most experts recommend avoiding preoperative NSAIDs (postoperative NSAIDs are

appropriate)

Management of uncomplicated appendicitis (simple or nonperforated appendicitis)

 Either operative or nonoperative management can be considered as first line therapy for
selected patients 4 76 83 84
 o Patients who are fit for surgery and have no high-risk CT findings (appendicolith,
presence of a mass, dilated appendix) are candidates for either appendectomy or
antibiotics alone

o Appendectomy is recommended for patients who are fit for surgery and have high-risk
findings on CT

o Antibiotics-first approach is recommended for patients who are not fit for surgery and
have no high-risk CT findings

o Benefits and risks of alternative treatment options should be discussed with patient and
approach should be individualized based on clinical and radiographic findings and
patient preferences

 Operative management (appendectomy)

o Standard of care and definitive treatment for most patients

 Overwhelming majority of patients undergo appendectomy when there are no

contraindications62

 Early appendectomy (surgery within 24 hours of admission) is recommended for

acute appendicitis, including pediatric cases
2 4

 Emergent appendectomy (surgery within several hours of admission) is not

necessary for stable patients with acute appendicitis
4

 No differences are noted among patients treated with early appendectomy

versus emergent appendectomy in rates of gangrenous or perforated
 appendixes, operative length, readmission, postoperative complications, or
hospital stay85

 Avoid delaying operative intervention for more than 24 hours. A delay of

up to 24 hours does not appear to significantly increase odds of complicated
appendicitis with appropriate and timely antibiotic administration4 86 87

 Operative delay beyond 48 hours is associated with increased risk for

surgical site infection and postoperative complications86

 Removal of normal-appearing appendix is recommended by the 2020 World

Society of Emergency Surgery guideline due to variability in accuracy of visual
assessment by surgeons, although it is a weak recommendation based on low-
quality evidence

 Nonoperative management

o Entails treatment with antibiotics and initial observation without appendectomy;

appendectomy is reserved for refractory or recurrent cases

o Appropriate alternative to appendectomy in patients with uncomplicated appendicitis

with no signs of diffuse peritonitis or high-risk CT findings
74

o Feasible and safe approach; however, risk of recurrence is higher than operative
treatment and patients should discuss risks/benefits in detail with surgical team4

o Systematic reviews and meta-analyses, as well as publication of long-term outcomes of

randomized controlled trials, determined that antibiotic-first approach can be used
safely for nonpregnant adults and children with uncomplicated acute appendicitis

 Not recommended for pregnant patients 88

o American College of Surgeons 2020 guidelines for managing patients presenting with
surgical emergencies in the early part of the COVID-19 pandemic states that antibiotics
are an acceptable first line treatment for uncomplicated acute appendicitis, with
appendectomy offered for those with worsening or recurrent symptoms 84

o Patients must be carefully selected to meet the following conditions:

 Clinical diagnosis of localized appendicitis without signs of diffuse peritonitis on

examination 74

 Hemodynamically stable without severe sepsis or septic shock 74

 On imaging the appendix is fully visualized and intact with none of the
following: 6 89

 Suppuration (ie, abscess or phlegmon)

 Findings suggestive of perforation (significant limitation of

ultrasonography and CT is lack of high sensitivity for
detection of perforation ) 28

 Presence of an appendicolith

 Not pregnant or immunocompromised 74

 No history of inflammatory bowel disease

 For adult patients, the following criteria are associated with 89% chance of
recovery with nonoperative management: 90

 C-reactive protein less than 60 mg/L

 WBC count less than 12 × 10⁹/L

  Age younger than 60 years

 For pediatric patients:

Patient must be old enough to reliably describe symptoms (age older than 7
years) 89

 Appendiceal diameter smaller than 1.1 cm 89

 WBC count higher than 5 × 10⁹/L and less than 18 × 10⁹/L 6 89

o Antibiotic therapy

 First line antibiotic regimens include metronidazole plus either ceftriaxone or

cefotaxime, or ertapenem 75

 For those with β-lactam allergy, guidelines recommend ciprofloxacin plus

metronidazole or moxifloxacin monotherapy 75

 IV antibiotics are recommended for 48 hours followed by outpatient oral

antibiotics for total antibiotic duration of 5 to 10 days 2 6 49 74 75

 Optimal duration of admission and parenteral therapy is not definitively known

 Adult patients discharged on oral antibiotics within 24 hours of diagnosis

and first administration of IV antibiotics had no greater risk of
complications or appendectomy than those who remained in hospital for
more than 24 hours before discharge on oral antibiotics 91

o Outcomes

 1-year treatment failure rate is approximately 27.4% to 40% with antibiotic-first

approach, with an increased complication rate compared to surgical
approach 92 93 94 95
  Antibiotic-first treatment group has a 5-year treatment failure rate of 39% and
reduced overall complication rate and health care costs 96

 The following factors are associated with increased risk of antibiotic

treatment failure within 30 days: 97

 Female sex (odds ratio 1.53; 95% confidence interval, 1.01-2.31)

 Radiographic finding of wider appendiceal diameter (odds ratio per

1-mm increase, 1.09; 95% confidence interval, 1.00-1.18)

 Presence of appendicolith (odds ratio, 1.99; 95% confidence interval,

1.28-3.10)

 Among pediatric patients specifically, failure rate is 14% 98

 Higher level of reported pain at presentation was associated with an

increased risk of in-hospital treatment failure (relative risk, 2.1 [95%
confidence interval, 1.0-4.4]) 99

 Data regarding complication rates are mixed. Data from a high-quality meta-
analysis show increased complication rate after antibiotic-first approach,
93

while results from the APPAC (Appendicitis Acuta) randomized controlled trial
did not show increased rates of intra-abdominal abscess or other major
complications with this strategy 94

 Among adults and children, nonoperative approach was associated with reduced
overall complication rate and health care costs 96 98

o The necessity of antibiotics in management of uncomplicated appendicitis has not been

definitively established
  APPAC III clinical trial found no statistical superiority in patient outcomes with
antibiotic-first versus no-antibiotic strategy for patients with uncomplicated
appendicitis 100 101

 Further study is warranted to further determine whether antibiotics are

necessary for nonoperative management

Management of complicated appendicitis (includes perforated appendicitis)

 All patients should receive prompt surgical evaluation. The 2020 World Society of
Emergency Surgery guideline provides recommended operative strategies
4

 Management depends on patient status (stable or unstable), type of perforation (contained or

free) if any, and whether an abscess or phlegmon has formed

o Patients who are septic or unstable and those with a free perforation or generalized
peritonitis (noncontained, free-floating, purulent fluid in peritoneal cavity) require
emergency appendectomy with drainage and irrigation of peritoneal cavity 4 7

o Immediate appendectomy in patients with a phlegmon or abscess often requires

extensive dissection and may lead to injury of adjacent organs and complications such
as a postoperative abscess or enterocutaneous fistula 102

 Initial nonoperative management to allow local inflammation to subside and

interval (delayed) appendectomy carries lower risk of complications

 Specific clinical scenarios

o Stable patients with acute appendicitis with perforation

 Some controversy exists regarding optimal initial management strategy 2

 Appendectomy at time of presentation (early or up-front appendectomy) is usual

treatment for patients with perforated appendicitis without known significant
abscess or phlegmon in preoperative period 2

 Antibiotics, with or without interval appendectomy (6-8 weeks after acute

inflammatory process has subsided), are an alternative 2 6

o Stable patients with periappendiceal, walled-off (contained), well-defined abscess

or phlegmon (inflammatory mass) 3 7

 Some controversy exists regarding optimal management strategy 2

 Standard initial management includes antibiotics, supportive care, bowel rest, and
percutaneous drainage of significant fluid collections when accessible 3 4 7

 Failure to improve clinically with nonoperative management indicates need

for prompt appendectomy 6

 Early primary appendectomy, along with antibiotics and percutaneous

drainage, is an alternative 2

Operative approach and considerations

 Laparoscopic surgical appendectomy

o Gold standard; preferred over open laparotomy for both

acute simple and perforated appendicitis
103 6 4 7 16 103 104

o Associated with faster recovery, diminished risk for wound infection, decreased pain,
and improved cosmesis compared with open appendectomy 73

o Associated with reduced pain, decreased incidence of wound infections, shorter length
of stay (1 day), and shorter recovery time in adults; however, also associated with 65%
higher rate of intra-abdominal abscess formation compared to open procedure (odds
ratio, 1.65; 95% confidence interval, 1.12-2.43) based on a 2018 Cochrane review 103
 o Among children, laparoscopic approach has shown lower rates of complications
including lower rate of postoperative wound infections and reduced length of stay (0.8
days), as compared with the open approach 103 105

 Open surgical appendectomy

o Conversion to open approach may be required in some patients. Most common reasons
include technical difficulties during laparoscopic approach secondary to presence of
adhesions or complications of perforation73

 Interval appendectomy 7

o Performed 4 to 8 weeks after initial medical management, after nonoperative

management for perforated appendicitis or phlegmon 4

o Rate of recurrence ranges from 12% to 24%; however, nonoperative treatment with
recurrence of appendiceal phlegmon has similar mortality to appendectomy

o Current guidelines recommend against routine interval appendectomy for adults

younger than 40 years and children with complicated appendicitis

o Guidelines recommend consideration of interval appendectomy for recurrent symptoms

after nonoperative management of acute appendicitis

o Proponents cite procedure eliminates risk of recurrence and excludes underlying

medical conditions (eg, malignancy, carcinoid) 3 7

o Opponents caution that most patients will not develop recurrence after perforation
3

owing to belief that most appendiceal lumens become obliterated after perforation
process7

Postoperative care
 Follow institutional protocol for postoperative care 2

 Postoperative antibiotics

o No postoperative antibiotics are required after appendectomy for nonperforated acute

appendicitis 73

o Postoperative IV antibiotics are indicated for patients with perforated appendicitis in

consultation with a surgeon; current recommendations include a short course (3-7
days), starting with IV and transitioning to oral as tolerated 4 75 78 80 82

 Diet

oAdvance diet as soon as clinically feasible in postoperative period 7

 Pain management

o Optimal management and standardized approach are lacking

o Treatment often consists of multimodal approach with short-duration IV opiate in

combination with NSAID and acetaminophen as tolerated

 Monitor for complications

o Obtain imaging to assess for intra-abdominal abscess in patients not improving on

anticipated clinical trajectory (eg, prolonged fever, ileus, inability to tolerate oral
intake, persistent pain)

oIf patient requires more than 6 days of inpatient care after perforated appendicitis,
evaluate for intra-abdominal abscess 2

 Discharge
 o General discharge criteria include:

 Ability to tolerate diet and oral medications

 Lack of fever

 Ability to ambulate

 Pain under control with oral pain medications

o Patients are usually discharged within 24 hours after laparoscopic appendectomy for
uncomplicated acute appendicitis 73

o Continue antibiotics for patients with perforated appendicitis until fevers subside and
patients can tolerate diet 2

Drug therapy

 Antibiotics for surgical prophylaxis 9

o Cephalosporins

 Cefotetan

 Cefotetan Disodium Solution for injection; Infants†, Children†, and

Adolescents†: 40 mg/kg/dose (Max: 2 g/dose) IV as a single dose within 30
to 60 minutes prior to the surgical incision; consider intraoperative redosing
6 hours from the first preoperative dose. May continue 40 mg/kg/dose
(Max: 2 g/dose) IV every 12 hours for no more than 24 hours post-
operatively if necessary.
  Cefotetan Disodium Solution for injection; Adults: 1 to 2 g IV as a single
dose within 30 to 60 minutes prior to the surgical incision; consider
intraoperative redosing 6 hours from the first preoperative dose. May
continue 1 to 2 g IV every 12 hours for no more than 24 hours post-
operatively if necessary.

 Cefoxitin

 Cefoxitin Sodium Solution for injection; Infants 1 to 2 months†: 40

mg/kg/dose IV as a single dose within 30 to 60 minutes prior to the surgical
incision; consider intraoperative redosing 2 hours from the first
preoperative dose. May continue 40 mg/kg/dose IV every 6 hours for no
more than 24 hours post-operatively if necessary.

 Cefoxitin Sodium Solution for injection; Infants, Children, and Adolescents

3 months to 17 years: 30 to 40 mg/kg/dose (Max: 2 g/dose) IV as a single
dose within 30 to 60 minutes prior to the surgical incision; consider
intraoperative redosing 2 hours from the first preoperative dose. May
continue 30 to 40 mg/kg/dose (Max: 2 g/dose) IV every 6 hours for no
more than 24 hours post-operatively if necessary.

 Cefoxitin Sodium Solution for injection; Adults: 2 g IV as a single dose

within 30 to 60 minutes prior to the surgical incision; consider
intraoperative redosing 2 hours from the first preoperative dose. May
continue 2 g IV every 6 hours for no more than 24 hours post-operatively if
necessary.
 Cefazolin (in combination with metronidazole)

 Cefazolin Sodium Solution for injection; Infants and Children 1 month to 9

years†: 30 mg/kg (Max: 2 g/dose) IV/IM as a single dose within 60 minutes
prior to the surgical incision; consider intraoperative redosing 4 hours from
the first preoperative dose. May continue 30 mg/kg (Max: 2 g/dose) IV/IM
every 6 to 8 hours for no more than 24 hours post-operatively if necessary.

 Cefazolin Sodium Solution for injection; Children and Adolescents 10 to 17

years weighing less than 50 kg: 1 g IV/IM as a single dose within 30 to 60
minutes prior to the surgical incision; consider intraoperative redosing 4
hours from the first preoperative dose. May continue 500 mg to 1 g IV/IM
every 6 to 8 hours for no more than 24 hours post-operatively if necessary.

 Cefazolin Sodium Solution for injection; Children and Adolescents 10 to 17

years weighing 50 kg or more: 2 g IV as a single dose within 30 to 60
minutes prior to the surgical incision; consider intraoperative redosing 4
hours from the first preoperative dose. May continue 500 mg to 1 g IV/IM
every 6 to 8 hours for no more than 24 hours post-operatively if necessary.

 Cefazolin Sodium Solution for injection; Adults weighing less than 120 kg:
1 g IV/IM or 2 g IV as a single dose within 30 to 60 minutes prior to the
surgical incision; consider intraoperative redosing 4 hours from the first
preoperative dose. May continue 500 mg to 1 g IV/IM or 2 g IV every 6 to
8 hours for no more than 24 hours post-operatively if necessary.
  Cefazolin Sodium Solution for injection; Adults weighing 120 kg or more:
3 g IV/IM as a single dose within 30 to 60 minutes prior to the surgical
incision; consider intraoperative redosing 4 hours from the first
preoperative dose. May continue 3 g IV/IM every 6 to 8 hours for no more
than 24 hours post-operatively if necessary.

 Ceftriaxone (in combination with metronidazole)

 Ceftriaxone Sodium Solution for injection; Infants†, Children†, and

Adolescents†: 50 to 75 mg/kg/dose (Max: 2 g/dose) IV as a single dose
within 60 minutes prior to the surgical incision; no intraoperative redosing
is necessary.

 Ceftriaxone Sodium Solution for injection; Adults: 2 g IV as a single dose

within 60 minutes prior to the surgical incision; no intraoperative redosing
is necessary.

o Nitroimidazoles

 Metronidazole (as part of a combination regimen)

 Metronidazole Solution for injection; Infants†, Children†, and

Adolescents† weighing less than 80 kg: 30 mg/kg/dose (Max: 1 g/dose) IV
as a single dose within 60 minutes prior to the surgical incision; no
intraoperative redosing is necessary. May continue 15 mg/kg/dose (Max:
500 mg/dose) IV every 8 hours for no more than 24 hours post-operatively
if necessary.
  Metronidazole Solution for injection; Children† and Adolescents†
weighing 80 kg or more: 30 mg/kg/dose (Max: 1.5 g/dose) IV as a single
dose within 60 minutes prior to the surgical incision; no intraoperative
redosing is necessary. May continue 15 mg/kg/dose (Max: 500 mg/dose) IV
every 8 hours for no more than 24 hours post-operatively if necessary.

 Metronidazole Solution for injection; Adults: 500 mg to 1.5 g as a single

dose within 60 minutes prior to the surgical incision; no intraoperative
redosing is necessary. May continue 500 mg IV every 6 to 12 hours for no
more than 24 hours post-operatively if necessary.

o For patients with β-lactam allergy

 Clindamycin (in combination with gentamicin)

 Clindamycin Solution for injection; Infants, Children, and Adolescents: 10

mg/kg (Max: 900 mg/dose) IV as a single dose within 60 minutes prior to
the surgical incision; consider intraoperative redosing 6 hours from the first
preoperative dose. May continue 10 mg/kg (Max: 900 mg/dose) every 8
hours for no more than 24 hours post-operatively if necessary.

 Clindamycin Solution for injection; Adults: 900 mg IV as a single dose

within 60 minutes prior to the surgical incision; consider intraoperative
redosing 6 hours from the first preoperative dose. May continue 900 mg IV
every 8 hours for no more than 24 hours post-operatively if necessary.

 Gentamicin (in combination with clindamycin or metronidazole)

  Gentamicin Sulfate Solution for injection; Infants, Children, and
Adolescents: 2.5 mg/kg/dose IV as a single dose within 60 minutes prior to
the surgical incision; no intraoperative redosing is necessary.

 Gentamicin Sulfate Solution for injection; Adults: 5 mg/kg/dose IV as a

single dose within 60 minutes prior to the surgical incision; no
intraoperative redosing is necessary.

 Antibiotics for uncomplicated (simple) appendicitis as part of nonoperative management

o Combination regimens

 Cephalosporins

 Ceftriaxone (in combination with metronidazole)

 Ceftriaxone Sodium Solution for injection; Infants, Children, and

Adolescents: 50 to 75 mg/kg/day (Max: 2 g/day) IV/IM divided every
12 to 24 hours for at least 48 hours, followed by oral step-down
therapy for a total treatment duration of 5 to 10 days.

 Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV/IM

every 12 to 24 hours for at least 48 hours, followed by oral step-down
therapy for a total treatment duration of 5 to 10 days.

 Cefuroxime (as step-down therapy with metronidazole)

  Cefuroxime Axetil Oral suspension; Infants, Children, and
Adolescents: 10 to 15 mg/kg/dose (Max: 500 mg/dose) PO every 12
hours for a total treatment duration of 5 to 10 days as step-down
therapy after initial parenteral therapy.

 Cefuroxime Axetil Oral tablet; Adults: 250 mg PO every 12 hours for

a total treatment duration of 5 to 10 days as step-down therapy after
initial parenteral therapy.

 Nitroimidazoles

 Metronidazole (as part of combination therapy)

 IV dosing

 Metronidazole Solution for injection; Infants†, Children†, and

Adolescents†: 22.5 to 40 mg/kg/day (Max: 1.5 g/day) IV
divided 8 hours every 8 hours for at least 48 hours, followed by
oral step-down therapy for a total treatment duration of 5 to 10
days.

 Metronidazole Solution for injection; Adults: 500 mg IV every

6 to 12 hours or 1.5 g IV every 24 hours for at least 48 hours,
followed by oral step-down therapy for a total treatment
duration of 5 to 10 days.

 Oral dosing as step-down therapy

  Metronidazole Oral tablet; Infants†, Children†, and
Adolescents†: 10 mg/kg/dose (Max: 500 mg/dose) PO every 8
hours for a total treatment duration of 5 to 10 days as step-
down therapy after initial parenteral therapy

 Metronidazole Oral tablet; Adults: 500 mg PO every 6 hours

for a total treatment duration of 5 to 10 days as step-down
therapy after initial parenteral therapy.

 Fluoroquinolones (for patients with β-lactam allergy)

 Ciprofloxacin (in combination with metronidazole)

 IV dosing

 Ciprofloxacin Solution for injection; Infants, Children, and

Adolescents: 10 to 15 mg/kg/dose (Max: 400 mg/dose) IV
every 12 hours for at least 48 hours, followed by oral step-
down therapy for a total treatment duration of 5 to 10 days.

 Ciprofloxacin Solution for injection; Adults: 400 mg IV every

12 hours for at least 48 hours, followed by oral step-down
therapy for a total treatment duration of 5 to 10 days as part of
combination therapy.

 Oral dosing as step-down therapy

  Ciprofloxacin Oral suspension; Infants, Children, and
Adolescents: 10 to 20 mg/kg/dose (Max: 500 mg/dose) PO
every 12 hours for a total treatment duration of 5 to 10 days as
step-down therapy after initial parenteral therapy.

 Ciprofloxacin Hydrochloride Oral tablet; Adults: 500 mg PO

every 12 hours for a total treatment duration of 5 to 10 days as
step-down therapy after initial parenteral therapy.

o Single-agent therapy

 Carbapenems

 Ertapenem

 Ertapenem Solution for injection; Infants and Children: 15

mg/kg/dose IV every 12 hours (Max: 1 g/day) for at least 48 hours,
followed by oral step-down therapy for a total treatment duration of 5
to 10 days.

 Ertapenem Solution for injection; Adolescents: 1 g IV every 24 hours

for at least 48 hours, followed by oral step-down therapy for a total
treatment duration of 5 to 10 days.

 Ertapenem Solution for injection; Adults: 1 g IV every 24 hours for at

least 48 hours, followed by oral step-down therapy for a total
treatment duration of 5 to 10 days.
  Fluoroquinolones (for patients with β-lactam allergy)

 Moxifloxacin

 IV dosing

 Moxifloxacin Hydrochloride Solution for injection; Adults: 400

mg IV every 24 hours for at least 48 hours, followed by oral
step-down therapy for a total treatment duration of 5 to 10 days.

 Oral dosing as step-down therapy

 Moxifloxacin Hydrochloride Oral tablet; Adults: 400 mg PO

every 24 hours for a total treatment duration of 5 to 10 days as
step-down therapy after initial parenteral therapy.

 Antibiotics for complicated appendicitis (suppurative appendicitis with abscess, perforation)

o Combination regimens

 Cephalosporins

 Cefotaxime (in combination with metronidazole) 75

 Cefotaxime Sodium Solution for injection; Infants, Children, and

Adolescents weighing less than 50 kg: 150 to 200 mg/kg/day IV
divided every 6 to 8 hours (Max: 2 g/dose) for 3 to 7 days.
  Cefotaxime Sodium Solution for injection; Children and Adolescents
weighing 50 kg or more: 1 to 2 g IV every 6 to 8 hours for 3 to 7
days.

 Cefotaxime Sodium Solution for injection; Adults: 1 to 2 g IV every

6 to 8 hours for 3 to 7 days.

 Ceftriaxone (in combination with metronidazole) 75

 Ceftriaxone Sodium Solution for injection; Infants, Children, and

Adolescents: 50 to 75 mg/kg/day (Max: 2 g/day) IV/IM divided every
12 to 24 hours for 3 to 7 days

 Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV/IM

every 12 to 24 hours for 3 to 7 days.

 Nitroimidazoles

 Metronidazole (as part of combination therapy) 75

 Metronidazole Solution for injection; Infants†, Children†, and

Adolescents† weighing less than 80 kg: 30 mg/kg/dose (Max: 1
g/dose) IV every 24 hours for 3 to 7 days.

 Metronidazole Solution for injection; Children† and Adolescents†

weighing 80 kg or more: 30 mg/kg/dose (Max: 1.5 g/dose) IV every
24 hours for 3 to 7 days.

 Metronidazole Solution for injection; Adults: 500 mg IV every 6 to

12 hours or 1.5 g IV every 24 hours for 3 to 7 days.
  Fluoroquinolones 75

 Increasing resistance to Escherichia coli; check susceptibility

 For patients with serious β-lactam allergies

 Ciprofloxacin (in combination with metronidazole)

 Ciprofloxacin Solution for injection; Infants†, Children†, and

Adolescents†: 10 to 15 mg/kg/dose (Max: 400 mg/dose) IV
every 12 hours for 3 to 7 days.

 Ciprofloxacin Solution for injection; Adults: 400 mg IV every 8

to 12 hours for 3 to 7 days.

o Single-agent therapy

 β-Lactam plus β-lactam inhibitor

 Piperacillin-tazobactam 75

 Piperacillin Sodium, Tazobactam Sodium Solution for injection;

Infants younger than 2 months†: 200 to 300 mg/kg/day piperacillin
component (225 to 337.5 mg/kg/day piperacillin; tazobactam) IV
divided every 6 to 8 hours for 3 to 7 days.

 Piperacillin Sodium, Tazobactam Sodium Solution for injection;

Infants, Children, and Adolescents 2 months to 17 years: 200 to 300
mg/kg/day piperacillin component (225 to 337.5 mg/kg/day
piperacillin; tazobactam) IV divided every 6 to 8 hours for 3 to 7
days.
  Piperacillin Sodium, Tazobactam Sodium Solution for injection;
Adults: 3.375 g (3 g piperacillin and 0.375 g tazobactam) IV every 4
to 6 hours or 4.5 g (4 g piperacillin and 0.5 g tazobactam) IV every 6
hours for 3 to 7 days.

 Carbapenems

 Ertapenem 75

 Ertapenem Solution for injection; Infants 1 to 2 months†: 15

mg/kg/dose IV every 12 hours for 3 to 7 days.

 Ertapenem Solution for injection; Infants and Children 3 months to

12 years: 15 mg/kg/dose IV every 12 hours (Max: 1 g/day) for 3 to 7
days.

 Ertapenem Solution for injection; Adolescents: 1 g IV every 24 hours

for 3 to 7 days.

 Ertapenem Solution for injection; Adults: 1 g IV every 24 hours for 3

to 7 days.

 Imipenem-cilastatin

 Imipenem, Cilastatin Sodium Solution for injection; Infants 1 to 2

months: 25 mg/kg/dose IV every 6 hours for 3 to 7 days.

 Imipenem, Cilastatin Sodium Solution for injection; Infants,

Children, and Adolescents 3 months to 17 years: 15 to 25 mg/kg/dose
 IV every 6 hours (Max: 2 g/day for fully susceptible organisms; 4
g/day for moderately susceptible organisms). Treat for 3 to 7 days.

 Imipenem, Cilastatin Sodium Solution for injection; Adults: 500 mg

IV every 6 hours or 1 g IV every 8 hours for fully susceptible
organisms and 1 g IV every 6 hours for organisms with intermediate
susceptibility. Treat for 3 to 7 days.

 Cephalosporins

 Cefoxitin

 Cefoxitin Sodium Solution for injection; Infants 1 to 2 months†: 80 to

160 mg/kg/day IV/IM divided every 6 to 8 hours for 3 to 7 days.

 Cefoxitin Sodium Solution for injection; Infants, Children, and

Adolescents 3 months to 17 years: 80 to 160 mg/kg/day IV/IM
divided every 4 to 8 hours (Max: 12 g/day) for 3 to 7 days.

 Cefoxitin Sodium Solution for injection; Adults: 1 to 2 g IV every 6

hours for 3 to 7 days.

 Fluoroquinolones

 Moxifloxacin

 Moxifloxacin Hydrochloride Solution for injection; Adults: 400 mg

IV every 24 hours for 3 to 7 days.
Comorbidities

 Chronic appendicitis

o Diagnosis and management of condition is controversial; represents a diagnosis of

exclusion

Many exhibit findings of dilated appendix, thickened appendix, or appendicolith

o
without acute periappendiceal inflammation on imaging 7 16

o Appendectomy may relieve symptoms; histopathology may show findings consistent

with chronic inflammation in some patients 16

o Elective appendectomy in select patients with concern for chronic appendicitis may be
warranted 7

 Limited data suggest a subset of patients with chronic, persistent, localized, right
lower quadrant pain without systemic manifestations of inflammation (eg, no
fever, normal laboratory findings) may benefit from appendectomy 7

 Immunocompromised status 16

o Appendicitis often manifests atypically in people who are immunocompromised, given

body's inability to mount immune response (eg, lack of fever, lack of leukocytosis, lack
of peritonitis). Imaging may show a blunted level of inflammation compared with
nonimmunosuppressed patients

o High index of suspicion, low threshold for imaging, and early aggressive treatment are
recommended
Special populations

 Pregnant patients
o Appendicitis affects 1 in 500 to 2000 pregnancies; highest incidence
7

is in the second and third trimesters 16

o Results in preterm labor in at least 4% of patients with uncomplicated appendicitis and

11% of patients with complicated appendicitis 106

o Risk of fetal loss is about 2% in patients without perforation and 6% in patients with
complicated appendicitis 106

o Delay in diagnosis is not uncommon

 Clinical manifestations that occur with normal pregnancy overlap with

manifestations of appendicitis (eg, nausea, vomiting, physiologic leukocytosis,
mild elevation in C-reactive protein) and febrile response to illness may be
blunted in pregnancy

 Displacement of the appendix by the gravid uterus results in variations in

reported location of pain

o Imaging 107 108

 Ultrasonography is the imaging test of choice, particularly during the first

trimester when fetal ionizing radiation exposure risks from CT imaging are
greatest

 MRI without gadolinium is next test of choice for patients with inconclusive
ultrasonography

 CT may be necessary if diagnosis cannot be reliably excluded through clinical

evaluation, ultrasonography, or MRI
 o Consult obstetrician early with concern for appendicitis to aid in diagnosis and
management; consult anesthesiologist soon after diagnosis for aid in surgical matters 7

o Operative treatment

 Surgical management is usually straightforward in the first trimester of pregnancy

but may be challenging due to altered anatomy in the second and third
trimesters88

 Higher risk of perioperative complications in second and third trimesters

compared to nonpregnant patients

Laparoscopic appendectomy can be performed in all


trimesters; conversion to open approach may be required
7 16 4

 Laparoscopic appendectomy is the standard approach up to 20 weeks of

gestation or while the uterine fundus is below the level of the umbilicus 88

 Beyond 20 weeks of gestation, or when the uterine fundus is above the

level of the umbilicus, laparoscopic or open appendectomy may be
performed depending on preference and expertise of surgeon 88

o Nonoperative approach is not recommended for pregnant patients 4

 Infants and small children 7

o Very young children, infants, and neonates often present with perforation

o Early consultation with a pediatric surgeon is important to reduce risk of becoming a

complicated appendicitis

 Older patients 16

o Appendicitis often manifests atypically (eg, muted symptoms), and diagnosis may be
challenging in patients with underlying dementia
 o Perforation rate at presentation is higher than general population, and presence of
various medical problems results in higher overall morbidity than other age groups

o High index of suspicion, low threshold for imaging, and early aggressive treatment are
recommended

o Laparoscopic appendectomy recommended over open appendectomy 4

 View full size

Examples of commonly used antibiotics for appendicitis.
Appendicitis type Definition Antibiotics Duration

Inflamed appendix
without signs of Cefoxitin, cefotetan,
Uncomplicated
gangrene, perforation, cefazolin plus Single dose of preoperative IV
appendicitis (simple,
intra-abdominal abscess, metronidazole, or antibiotics 30 to 60 minutes before
nonperforated):
contained phlegmon, or ceftriaxone plus incision
surgical prophylaxis
purulent intra-abdominal metronidazole
fluid

Inflamed appendix
Uncomplicated without signs of Ertapenem, ceftriaxone
IV antibiotics are recommended for 48
appendicitis (simple, gangrene, perforation, plus metronidazole,
hours followed by outpatient oral
nonperforated): intra-abdominal abscess, cefotaxime plus
antibiotics for total
nonoperative contained phlegmon, or metronidazole, or
antibiotic duration of 5 to 10 days
management purulent intra-abdominal moxifloxacin
fluid

Complicated Gangrenous inflamed Ceftriaxone plus Total duration of IV/PO antibiotic

appendicitis appendix with or without metronidazole, cefotaxime course is usually about 3 to 7 days
(perforated) perforation, intra- plus metronidazole, and based on clinical response.
abdominal abscess, piperacillin-tazobactam, Continue IV antibiotics until patient is
Appendicitis type Definition Antibiotics Duration

afebrile for 24 hours or more, is

contained phlegmon, or
imipenem-cilastatin, tolerating diet, has WBC count within
purulent intra-abdominal
moxifloxacin, or ertapenem reference range, and is ready for
fluid
discharge
Caption: Follow institutional clinical practice pathway for preferred antibiotic selection. Begin
antibiotics in any patient when diagnosis of acute appendicitis is established or highly suspected.
 View full size
Standard management for appendicitis.
Type of appendicitis Typical management strategy

Supportive and symptomatic care (NPO, IV resuscitation and

All patients maintenance IV fluids, electrolyte correction [when indicated if
abnormality noted], vomiting and fever control, analgesia, antibiotics)

Uncomplicated appendicitis (simple or Early laparoscopic appendectomy (surgery within about 8 hours of
nonperforated appendicitis) admission)

Early laparoscopic appendectomy (surgery within about 24 hours of

Stable patients with acute appendicitis with
admission). Alternate options include antibiotics with or without interval
perforation without obvious abscess or
appendectomy (4-8 weeks after acute inflammatory process is quelled)
phlegmon noted in preoperative assessment
and antibiotics only

Antibiotics, supportive care, bowel rest, and percutaneous drainage of

Stable patients with periappendiceal, walled-
significant fluid collections when accessible with or without interval
off (contained), well-defined abscess
appendectomy. Alternate option includes early appendectomy along
or phlegmon (inflammatory mass)
with antibiotics and percutaneous drainage

Ill-appearing or unstable patients and Emergent appendectomy (surgery within several hours of admission)
patients with generalized peritonitis with drainage and irrigation of the peritoneal cavity
Type of appendicitis Typical management strategy

(noncontained, free-floating, purulent fluid in

peritoneal cavity)
Caption: Nonoperative management (antibiotics, observation, and supportive care only) for early
uncomplicated appendicitis may be an option for select patients in consultation with a surgeon.
Monitoring
 Postoperative monitoring

o Monitor clinically for postoperative complications (eg, ileus, infection, obstruction)

o Monitor clinically for presence of discharge criteria (eg, pain under control, tolerating
oral diet and fluids, ability to ambulate, lack of fever)
7

o Obtain imaging to assess for intra-abdominal abscess (ultrasonography and/or CT) by

day 5 to 7 if prolonged ileus and failure to progress on predicted improvement
trajectory develops (eg, persistent fever, WBC count higher than 12,000/mm³, inability
to tolerate PO, uncontrolled pain) 2 109

Complications and Prognosis

Complications
 Appendiceal perforation

o More common when duration of illness extends beyond 48 to 72 hours 6

 Time from onset of symptoms may be the most important determinant related to
increased risk for perforation 110 111
 o Rates of perforation at presentation are variably reported

 Perforation rates for children younger than 3 years are greater than 85% 7

 Perforation rates for children aged 10 to 17 years are less than 20% 62

 Perforation rates for adults range from 17% to 32% 15

o Highest perforation rates occur in young children, older adults, and patients with 3 or
more comorbidities 15

o Perforation may be discovered at the time of appendectomy because ability to detect

perforation by preoperative imaging (eg, ultrasonography, CT) is not optimal

o May result in development of local complications (eg, appendiceal abscess or

phlegmon) or more of a diffuse process (eg, peritonitis); untreated perforation can lead
to sepsis and death

 After appendectomy

o Postoperative complications may include: 73

 Early

 Surgical site infection (eg, wound infection, intra-abdominal abscess)

 Bleeding

 Bowel injury

 Prolonged postoperative ileus

 Bowel obstruction
  Visceral or cutaneous fistula

 Wound dehiscence

 Late

 Stump appendicitis

 Infertility (in females)

 Small bowel obstruction secondary to intra-abdominal adhesions

 Incisional hernia

o Risk for postoperative complications is much higher following perforated appendicitis

than simple (nonperforated) appendicitis 73

 About 20% of children with perforated appendicitis and 0.8% with nonperforated
appendicitis develop postoperative intra-abdominal abscess 2

 Negative appendectomy rate

o Negative appendectomy means that a normal appendix is found during surgery

o Despite continually improving imaging techniques, negative appendectomy rates may

reach up to about 20% in some institutions, depending on population 5 6

o Females of childbearing age, young children, and older people are among the highest
groups with negative appendectomy rates 5
 o Current guidelines recommend removal of normal-appearing appendix in patients with
signs and symptoms of appendicitis due to variability in ability of surgeons to visually
identify appendiceal inflammation 4

Prognosis
 Morbidity and mortality largely depend on patient age, existing comorbidity, and appendix
status (perforated or nonperforated)

o Mortality

Overall, most pediatric and adult age mortality rates are low (less than 1%) in
developed nations; higher with advanced age and in low- and middle-income
countries (1%-4%) 112 6

 Estimates are higher overall for patients with perforation (about 1.7%) 1

o Morbidity

Previously healthy patients without perforation usually rapidly return to normal


activities after appendectomy with negligible risk of postoperative complications
(about 3%) 6

 Patients with perforation are at much higher risk for postoperative complications
(20%-30%), prolonged hospital stay, need for prolonged antibiotic therapy,
increased postoperative use of CT, and longer time to return to normal activities 6

 Course of illness

o Spontaneous resolution may occur in a small minority of patients without treatment 11 113

o About 40% of children overall present with perforation; about 90% of children younger
than 3 years present with perforation 6

o Average postoperative length of stay: 6

  For patients with simple appendicitis is about 24 hours

 For patients with perforated appendicitis is about 4 to 5 days

 Incidental appendicolith

o Incidence of incidental appendicolith (calcification in appendiceal lumen without signs

of appendicitis) noted on imaging (abdominal radiograph, CT, ultrasonography)
obtained for reasons other than concern for appendicitis may be as high as 10% 6

o Patients with and without incidental appendicolith have the same risk for developing
appendicitis 6

o Clinical follow-up is only measure usually indicated 6

Screening and Prevention

Screening
At-risk populations

 Adults 40 years or older with complicated appendicitis have an increased incidence of

appendicular neoplasms (3%-17%). For patients treated nonoperatively, international
guidelines recommend screening colonoscopy and full-dose contrast-enhanced CT after
resolution of acute infection 4

Prevention
 Incidental appendectomy

o Appendectomy performed at time of abdominal surgery for a different indication

without evidence of acute appendicitis 114
  Although once common practice, this procedure is now controversial 16

 May be considered in surgical procedures requiring right lower quadrant incision

(eg, Meckel diverticulectomy, intussusception reduction) 2

 Rationale includes eliminating risk for future appendicitis and for complications
occurring in the setting of potential diagnostic uncertainty (eg, Crohn disease)
7

 Benefits must be weighed against risks of appendectomy (eg, wound infection,

appendiceal stump leakage, adhesions) and loss of appendix for subsequent
gastrointestinal or urogenital reconstructive procedures
7

 Therefore, avoid in patients at risk for bowel or bladder incontinence

o Indications for incidental appendectomy are individualized to patient and determined

by surgeon

 Some experts suggest that indications may be best reserved for patients in whom
future appendicitis may pose a diagnostic dilemma or future appendectomy is
predicted to be unusually challenging 7

References
[Link] D et al: Appendicitis. BMJ Clin Evid. 2007:0408, 2007
View In Article|Cross Reference
[Link] RM et al: Pediatric appendicitis. Surg Clin North Am. 97(1):93-112, 2017
View In Article|Cross Reference
[Link] RR et al: Diagnosis and management of acute appendicitis. EAES Consensus
Development Conference 2015. Surg Endosc. 30(11):4668-90, 2016
View In Article|Cross Reference
[Link] Saverio S et al: Diagnosis and treatment of acute appendicitis: 2020 update of
the WSES Jerusalem guidelines. World J Emerg Surg. 15(1):27, 2020
View In Article|Cross Reference
[Link] CD et al: Appendicitis. In: Bennett J et al, eds: Mandell, Douglas, and Bennett's
Principles and Practice of Infectious Diseases. 9th ed. Elsevier; 2020:1059-63.e2
View In Article
[Link] JJ: Acute appendicitis. In: Kliegman RM et al, eds: Nelson Textbook of
Pediatrics. 21st ed. Elsevier; 2020:2048-55.e1
View In Article
[Link] ML et al: Appendicitis. In: Cameron AM et al, eds: Current Surgical Therapy.
13th ed. Elsevier; 2020:284-9
View In Article
[Link] TR et al: Surgical site infections and antimicrobial prophylaxis. In: Bennett JE
et al, eds: Mandell, Douglas, and Bennett's Principles and Practice of Infectious
Diseases. 9th ed. Elsevier; 2020:3743-56.e3
View In Article
[Link] DW et al: Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Surg Infect (Larchmt). 14(1):73-156, 2013
View In Article|Cross Reference
[Link] V: Laparoscopic management of acute appendicitis in situs inversus. J
Minim Access Surg. 2(4):220-1, 2006
View In Article|Cross Reference
[Link] DJ et al: Acute appendicitis. BMJ. 333(7567):530-4, 2006
View In Article|Cross Reference
[Link] RJ et al: Delayed diagnosis of appendicitis in children treated with
antibiotics. Pediatr Surg Int. 22(6):541-5, 2006
View In Article|Cross Reference
[Link] B: Evidence-based emergency medicine/rational clinical examination
abstract. Does this adult patient have appendicitis? Ann Emerg Med. 52(3):301-3,
2008
View In Article|Cross Reference
[Link] DG et al: Does this child have appendicitis? JAMA. 298(4):438-51, 2007
View In Article|Cross Reference
[Link] MJ et al: Acute appendicitis: efficient diagnosis and management. Am Fam
Physician. 98(1):25-33, 2018
View In Article|Cross Reference
[Link] B: The appendix. In: Townsend CM Jr et al, eds: Sabiston Textbook of
Surgery. 20th ed. Elsevier; 2017:1296-311
View In Article
[Link] LE et al: Impact of time in the development of acute appendicitis. Dig
Surg. 25(5):394-9, 2008
View In Article|Cross Reference
[Link] SG et al: Clinical features of misdiagnosed appendicitis in children. Ann
Emerg Med. 20(1):45-50, 1991
View In Article|Cross Reference
[Link] JH et al: Acute appendicitis caused by foreign body ingestion. Ann Surg Treat
Res. 89(3):158-61, 2015
View In Article|Cross Reference
[Link] R et al: Two concurrent appendiceal neoplasms in an elderly patient: a case
report. Int J Surg Case Rep. 40:124-6, 2017
View In Article|Cross Reference
[Link]-Omran M et al: Epidemiologic features of acute appendicitis in Ontario, Canada.
Can J Surg. 46(4):263-8, 2003
View In Article|Cross Reference
[Link] M et al: Evolution and current trends in the management of acute
appendicitis. Surg Clin North Am. 98(5):1005-23, 2018
View In Article|Cross Reference
[Link] College of Emergency Physicians Clinical Policies Subcommittee
(Writing Committee) on Appendicitis et al: Clinical Policy: Critical issues in the
evaluation and management of emergency department patients with suspected
appendicitis: approved by ACEP Board of Directors February 1, 2023. Ann Emerg
Med. 81(6):e115-52, 2023
View In Article|Cross Reference
[Link] R et al: Cost-effectiveness of imaging protocols for suspected
appendicitis. Pediatrics. 145(2):e20191352, 2020
View In Article|Cross Reference
[Link] B et al: Computed tomography for diagnosis of acute appendicitis in adults.
Cochrane Database Syst Rev. 11:CD009977, 2019
View In Article|Cross Reference
[Link] Panel on Gastrointestinal Imaging et al: ACR Appropriateness Criteria®
right lower quadrant pain: 2022 update. J Am Coll Radiol. 19(11S):S445-61, 2022
View In Article|Cross Reference
27.D'Souza N et al: Magnetic resonance imaging (MRI) for diagnosis of acute
appendicitis. Cochrane Database Syst Rev. 12:CD012028, 2021
View In Article|Cross Reference
[Link] Panel on Pediatric Imaging et al: ACR Appropriateness Criteria suspected
appendicitis--child. J Am Coll Radiol. 16(5S):S252-63, 2019
View In Article|Cross Reference
[Link] H et al: Ultrasound, computed tomography or magnetic resonance
imaging--which is preferred for acute appendicitis in children? A meta-analysis.
Pediatr Radiol. 47(2):186-96, 2017
View In Article|Cross Reference
[Link] MN et al: Diagnostic accuracy of ultrasound in diagnosing acute
appendicitis in pregnancy: a systematic review and meta-analysis. Emerg Radiol.
ePub, 2022
View In Article|Cross Reference
[Link] M et al: Pregnancy and appendicitis: a systematic review and meta-analysis
on the clinical use of MRI in diagnosis of appendicitis in pregnant women. World J
Emerg Surg. 14:37, 2019
View In Article|Cross Reference
[Link] College of Obstetricians and Gynecologists Committee on Obstetric
Practice: Committee Opinion No. 723: guidelines for diagnostic imaging during
pregnancy and lactation. Obstet Gynecol. 130(4):e210-16, 2017
View In Article|Cross Reference
[Link]-Abed YA et al: Diagnostic markers in acute appendicitis. Am J Surg.
209(6):1043-7, 2015
View In Article|Cross Reference
[Link] ID et al: Current status of imaging of the gastrointestinal tract: imaging
techniques and radiation issues. In: Adam A et al, eds: Grainger and Allison's
Diagnostic Radiology. 6th ed. Elsevier; 2015:593-609.e1
View In Article
[Link] HM et al: The diagnostic performance of reduced-dose CT for suspected
appendicitis in paediatric and adult patients: a systematic review and diagnostic
meta-analysis. Eur Radiol. 28(6):2537-48, 2018
View In Article|Cross Reference
[Link] SJ et al: Comparison of low- and standard-dose CT for the diagnosis of acute
appendicitis: a meta-analysis. AJR Am J Roentgenol. 208(6):W198-207, 2017
View In Article|Cross Reference
[Link] Group: Low-dose CT for the diagnosis of appendicitis in adolescents and
young adults (LOCAT): a pragmatic, multicentre, randomised controlled non-
inferiority trial. Lancet Gastroenterol Hepatol. 2(11):793-804, 2017
View In Article|Cross Reference
[Link] M et al: The appendicitis inflammatory response score: a tool for the
diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg.
32(8):1843-9, 2008
View In Article|Cross Reference
[Link] JM et al: Clinical policy: critical issues in the evaluation and management
of emergency department patients with suspected appendicitis. Ann Emerg Med.
55(1):71-116, 2010
View In Article|Cross Reference
[Link] K et al: Suspected appendicitis in children: diagnostic importance of
normal abdominopelvic CT findings with nonvisualized appendix. Radiology.
250(2):531-7, 2009
View In Article|Cross Reference
[Link] JD et al: Accuracy of computed tomography in predicting appendiceal
perforation. J Pediatr Surg. 45(1):231-4, 2010
View In Article|Cross Reference
[Link] T et al: New CT criterion for acute appendicitis: maximum depth of
intraluminal appendiceal fluid. AJR Am J Roentgenol. 188(5):1313-9, 2007
View In Article|Cross Reference
[Link] MK et al: Campaigns against ionizing radiation and changed practice
patterns for imaging use in pediatric appendicitis. JAMA Pediatr. 169(8):720-1, 2015
View In Article|Cross Reference
[Link] AS et al: US or CT for diagnosis of appendicitis in children and adults? A
meta-analysis. Radiology. 241(1):83-94, 2006
View In Article|Cross Reference
[Link] TP et al: Benchmarking the value of ultrasound for acute appendicitis in
children. J Pediatr Surg. 51(12):1939-43, 2016
View In Article|Cross Reference
[Link] RG et al: The effect of abdominal pain duration on the accuracy of
diagnostic imaging for pediatric appendicitis. Ann Emerg Med. 60(5):582-90.e3, 2012
View In Article|Cross Reference
[Link] N et al: Appendicitis: evaluation of sensitivity, specificity, and predictive
values of US, Doppler US, and laboratory findings. Radiology. 230(2):472-8, 2004
View In Article|Cross Reference
[Link] S et al: Diagnostic accuracy of MRI versus CT for the evaluation of acute
appendicitis in children and young adults. AJR Am J Roentgenol. 209(4):911-9, 2017
View In Article|Cross Reference
[Link] Saverio S et al: WSES Jerusalem guidelines for diagnosis and treatment of
acute appendicitis. World J Emerg Surg. 11:34, 2016
View In Article|Cross Reference
[Link] R et al: The Alvarado score for predicting acute appendicitis: a systematic
review. BMC Med. 9:139, 2011
View In Article|Cross Reference
[Link] A et al: Evaluation of appendicitis risk prediction models in adults
with suspected appendicitis. Br J Surg. 107(1):73-86, 2020
View In Article|Cross Reference
[Link] Castro SM et al: Evaluation of the appendicitis inflammatory response score for
patients with acute appendicitis. World J Surg. 36(7):1540-5, 2012
View In Article|Cross Reference
[Link] M et al: Randomized clinical trial of Appendicitis Inflammatory
Response score-based management of patients with suspected appendicitis. Br J
Surg. 104(11):1451-61, 2017
View In Article|Cross Reference
[Link] S et al: Evaluation of scoring systems in predicting acute appendicitis
in children. Surgery. 160(6):1599-604, 2016
View In Article|Cross Reference
[Link] Appendicitis Score: Adult Appendicitis Score website. Accessed September
15, 2023. [Link]
View In Article|Cross Reference
[Link] A: A practical score for the early diagnosis of acute appendicitis. Ann
Emerg Med. 15(5):557-64, 1986
View In Article|Cross Reference
[Link] R et al: The use of the clinical scoring system by Alvarado in the decision
to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med.
25(5):489-93, 2007
View In Article|Cross Reference
[Link] JJ et al: The Alvarado score should be used to reduce emergency
department length of stay and radiation exposure in select patients with abdominal
pain. J Trauma Acute Care Surg. 84(6):946-50, 2018
View In Article|Cross Reference
[Link] M: Pediatric appendicitis score. J Pediatr Surg. 37(6):877-81, 2002
View In Article|Cross Reference
[Link] DM et al: Does this child have appendicitis? A systematic review of clinical
prediction rules for children with acute abdominal pain. J Clin Epidemiol. 66(1):95-
104, 2013
View In Article|Cross Reference
[Link] NB et al: Evaluating the patient with right lower quadrant pain. Radiol Clin
North Am. 53(6):1159-70, 2015
View In Article|Cross Reference
[Link] VK et al: Diagnosis and management of pediatric appendicitis,
intussusception, and Meckel diverticulum. Surg Clin North Am. 92(3):505-26, vii, 2012
View In Article|Cross Reference
[Link] CJ: Intussusception. Paediatr Child Health. 28(5):222-6, 2018
View In Article|Cross Reference
[Link] GJ et al: Sterile pyuria. N Engl J Med. 372(11):1048-54, 2015
View In Article|Cross Reference
[Link] PL et al: Constipation: beyond the old paradigms. Gastroenterol Clin North Am.
47(4):845-62, 2018
View In Article|Cross Reference
[Link] SE et al: Pediatric community-acquired pneumonia in the United States:
changing epidemiology, diagnostic and therapeutic challenges, and areas for future
research. Infect Dis Clin North Am. 32(1):47-63, 2018
View In Article|Cross Reference
[Link] MM et al: Acute scrotal emergencies. Emerg Med Clin North Am.
37(4):593-610, 2019
View In Article|Cross Reference
[Link] H et al: Mimics of acute appendicitis--alternative diagnoses at sonography,
CT, and MRI; specific imaging findings that can help in differential diagnosis. Clin
Imaging. 48:90-105, 2018
View In Article|Cross Reference
[Link] GR et al: ACG clinical guideline: management of Crohn's disease in
adults. Am J Gastroenterol. 113(4):481-517, 2018
View In Article|Cross Reference
[Link] T et al: The significance of Meckel's diverticulum in appendicitis--a
retrospective analysis of 233 cases. World J Surg. 29(4):455-8, 2005
View In Article|Cross Reference
[Link] E et al: Complications in early pregnancy. Emerg Med Clin North Am.
37(2):219-37, 2019
View In Article|Cross Reference
[Link] JN: Spontaneous bacterial peritonitis. Hosp Med Clin. 3(3):e350-61, 2014
View In Article|Cross Reference
[Link] MA et al: Acute appendicitis. In: Walls RM et al, eds: Rosen's Emergency
Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2018:1121-8.e2
View In Article
[Link] DA et al: Treatment of acute uncomplicated appendicitis. N Engl J Med.
385(12):1116-23, 2021
View In Article|Cross Reference
[Link] JE et al: The Surgical Infection Society revised guidelines on the
management of intra-abdominal infection. Surg Infect (Larchmt). 18(1):1-76, 2017
View In Article|Cross Reference
[Link] D et al: Diagnosis and management of acute appendicitis in adults: a
review. JAMA. 326(22):2299-311, 2021
View In Article|Cross Reference
[Link] Society of Health-System Pharmacists: Therapeutic Guidelines. Clinical
Practice Guidelines for Antimicrobial Prophylaxis in Surgery. ASHP website. Accessed
September 15, 2023.
[Link]
[Link]?
la=en&hash=27EF2BB2D87067F5DBA9B9FB37C219D368F30152
View In Article|Cross Reference
[Link] SL et al: Antibiotics and appendicitis in the pediatric population: an American
Pediatric Surgical Association outcomes and clinical trials committee systematic
review. J Pediatr Surg. 45(11):2181-5, 2010
View In Article|Cross Reference
[Link] CN et al: Timing of antimicrobial prophylaxis and infectious complications in
pediatric patients undergoing appendectomy. J Pediatr Surg. 53(3):449-51, 2018
View In Article|Cross Reference
[Link] JS et al: Diagnosis and management of complicated intra-abdominal
infection in adults and children: guidelines by the Surgical Infection Society and the
Infectious Diseases Society of America. Surg Infect (Larchmt). 11(1):79-109, 2010
View In Article|Cross Reference
[Link] LM et al: Peritonitis and intraperitoneal abscesses. In: Bennett JE et al, eds:
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th
ed. Elsevier; 2020:1009-36.e5
View In Article
[Link] Wijkerslooth EML et al: 2 days versus 5 days of postoperative antibiotics for
complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority
randomised trial. Lancet. 401(10374):366-76, 2023
View In Article|Cross Reference
[Link] KM et al: American Association for the Surgery of Trauma emergency
general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis,
acute diverticulitis, acute pancreatitis, and small bowel obstruction. Trauma Surg
Acute Care Open. 4(1):e000281, 2019
View In Article|Cross Reference
[Link] College of Surgeons: COVID-19 Guidelines for Triage of Emergency
General Surgery Patients. ACS website. Updated December 8, 2020. Accessed
September 15, 2023. [Link]
guidance/elective-case/emergency-surgery
View In Article|Cross Reference
[Link] M et al: Emergent vs urgent appendectomy in children: a study of
outcomes. J Pediatr Surg. 40(12):1912-5, 2005
View In Article|Cross Reference
[Link] Kingdom National Surgical Research Collaborative et al: Safety of short, in-
hospital delays before surgery for acute appendicitis: multicentre cohort study,
systematic review, and meta-analysis. Ann Surg. 259(5):894-903, 2014
View In Article|Cross Reference
[Link] DB et al: Time to appendectomy for acute appendicitis: a systematic
review. J Pediatr Surg. 53(3):396-405, 2018
View In Article|Cross Reference
[Link] M et al: EAES rapid guideline: systematic review, meta-analysis, GRADE
assessment, and evidence-informed European recommendations on appendicitis in
pregnancy. Surg Endosc. 36(12):8699-712, 2022
View In Article|Cross Reference
[Link] PC et al: Effectiveness of patient choice in nonoperative vs surgical
management of pediatric uncomplicated acute appendicitis. JAMA Surg. 151(5):408-
15, 2016
View In Article|Cross Reference
[Link] J et al: A model to select patients who may benefit from antibiotic
therapy as the first line treatment of acute appendicitis at high probability. J
Gastrointest Surg. 18(5):961-7, 2014
View In Article|Cross Reference
[Link] Group for the CODA Collaborative et al: Analysis of outcomes associated
with outpatient management of nonoperatively treated patients with appendicitis.
JAMA Netw Open. 5(7):e2220039, 2022
View In Article|Cross Reference
[Link] Collaborative et al: A randomized trial comparing antibiotics with
appendectomy for appendicitis. N Engl J Med. 383(20):1907-19, 2020
View In Article|Cross Reference
[Link] JC et al: Antibiotics versus surgical therapy for uncomplicated
appendicitis: systematic review and meta-analysis of controlled trials (PROSPERO
2015: CRD42015016882). Ann Surg. 265(5):889-900, 2017
View In Article|Cross Reference
[Link] P et al: Antibiotic therapy vs appendectomy for treatment of
uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA.
313(23):2340-8, 2015
View In Article|Cross Reference
[Link] Collaborative et al: Antibiotics versus appendectomy for acute
appendicitis--longer-term outcomes. N Engl J Med. 385(25):2395-7, 2021
View In Article|Cross Reference
[Link] P et al: Five-year follow-up of antibiotic therapy for uncomplicated acute
appendicitis in the APPAC randomized clinical trial. JAMA. 320(12):1259-65, 2018
View In Article|Cross Reference
[Link] Group for the CODA Collaborative et al: Patient factors associated with
appendectomy within 30 days of initiating antibiotic treatment for appendicitis. JAMA
Surg. 157(3):e216900, 2022
View In Article|Cross Reference
[Link] R et al: Efficacy and safety of nonoperative treatment for acute
appendicitis: a meta-analysis. Pediatrics. 139(3), 2017
View In Article|Cross Reference
[Link] PC et al: Demographic and clinical characteristics associated with the
failure of nonoperative management of uncomplicated appendicitis in children:
secondary analysis of a nonrandomized clinical trial. JAMA Netw Open. 5(5):e229712,
2022
View In Article|Cross Reference
[Link] S et al: A randomised placebo-controlled double-blind multicentre trial
comparing antibiotic therapy with placebo in the treatment of uncomplicated acute
appendicitis: APPAC III trial study protocol. BMJ Open. 8(11):e023623, 2018
View In Article|Cross Reference
[Link] P et al: Antibiotics versus placebo in adults with CT-confirmed
uncomplicated acute appendicitis (APPAC III): randomized double-blind superiority
trial. Br J Surg. 109(6):503-9, 2022
View In Article|Cross Reference
[Link] Almeida Leite RM et al: Delayed operative management in complicated acute
appendicitis--is avoiding extended resection worth the wait? Results from a global
cohort study. J Gastrointest Surg. 26(7):1482-89, 2022
View In Article|Cross Reference
[Link] T et al: Laparoscopic versus open surgery for suspected appendicitis.
Cochrane Database Syst Rev. 11:CD001546, 2018
View In Article|Cross Reference
[Link] T et al: Laparoscopic versus open appendectomy in patients with
suspected appendicitis: a systematic review of meta-analyses of randomised
controlled trials. BMC Gastroenterol. 15:48, 2015
View In Article|Cross Reference
[Link] S et al: Laparoscopic versus open appendicectomy for complicated
appendicitis in children: a systematic review and meta-analysis. J Pediatr Surg.
57(3):394-405, 2022
View In Article|Cross Reference
[Link] ML et al: Negative appendectomy in pregnant women is associated with
a substantial risk of fetal loss. J Am Coll Surg. 205(4):534-40, 2007
View In Article|Cross Reference
[Link] LP et al: MRI for clinically suspected appendicitis during pregnancy. AJR
Am J Roentgenol. 183(3):671-5, 2004
View In Article|Cross Reference
[Link] P et al: Surgical management of acute right lower-quadrant pain in
pregnancy: a prospective cohort study. J Am Coll Surg. 211(4):490-4, 2010
View In Article|Cross Reference
[Link] KT et al: Utility of standardized discharge criteria after appendectomy
to identify pediatric patients requiring intervention after postoperative imaging.
Surgery. 164(6):1204-8, 2018
View In Article|Cross Reference
[Link] W et al: Appendicitis in preschool aged children: regression analysis of
factors associated with perforation outcome. J Pediatr Surg. 50(9):1569-73, 2015
View In Article|Cross Reference
[Link] K et al: Effects of timing to diagnosis and appendectomy in pediatric
appendicitis. Pediatr Emerg Care. 31(11):753-8, 2015
View In Article|Cross Reference
[Link] A et al: Acute appendicitis: modern understanding of pathogenesis,
diagnosis, and management. Lancet. 386(10000):1278-87, 2015
View In Article|Cross Reference
[Link] RE: The natural history and traditional management of appendicitis
revisited: spontaneous resolution and predominance of prehospital perforations imply
that a correct diagnosis is more important than an early diagnosis. World J Surg.
31(1):86-92, 2007
View In Article|Cross Reference
[Link] JB et al: Incidental appendectomy: 18-year pathologic survey and cost
effectiveness in the nonmanaged-care setting. J Am Coll Surg. 205(2):298-306, 2007
View In Article|Cross Reference
 Icon Name - Icon description
 Icon Name - Icon description
  Icon Name - Icon description
 Icon Name - Icon description

 Icon Name - Icon description

 Contact Us
 Resource Center
 Registered User Agreement
 Help
 Terms & Conditions
 Privacy Policy
 Accessibility

We use cookies to help provide and enhance our service and tailor content. By continuing you agree to the Pengaturan
Cookie.
All content on this site: Copyright © 2024 Elsevier Inc., its licensors, and contributors. All rights are reserved, including
those for text and data mining, AI training, and similar technologies. For all open access content, the Creative Commons
licensing terms apply.