Acute Appendicitis

Acute appendicitis
Straight to the point of care
Last updated: Jun 11, 2021

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Etiology 4
Pathophysiology 4
Case history 5
Diagnosis 6
Approach 6
History and exam 8
Risk factors 9
Investigations 11
Differentials 13
Criteria 15
Management 20
Approach 20
Treatment algorithm overview 22
Treatment algorithm 24
Emerging 30
Patient discussions 30
Follow up 31
Monitoring 31
Complications 32
Prognosis 33
Guidelines 34
Diagnostic guidelines 34
Treatment guidelines 34
Evidence tables 35
References 37
Images 47
Disclaimer 49
Acute appendicitis Overview
Summary
Acute appendicitis is an acute inflammation of the vermiform appendix.
Typically presents as acute abdominal pain starting in the mid-abdomen and later localizing to the right lower
OVERVIEW
quadrant.
Associated with fever, anorexia, nausea, vomiting, and elevation of the neutrophil count.
Diagnosis is usually made clinically. If investigation is required, computed tomography scan or

ultrasonography may show dilatation of the appendix outer diameter to more than 6 mm.
Definitive treatment is surgical appendectomy. A nonoperative, antibiotic-only approach may be feasible in

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

Nasim Ahmed, MBBS, FACS; used with permission
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 11, 2021.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
3
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Use of this content is subject to our) . © BMJ Publishing Group Ltd 2021. All rights reserved.
Acute appendicitis Theory
Epidemiology
Acute appendicitis is one of the most common acute surgical abdominal emergencies.[4] More than 250,000
appendectomies are performed each year in the US; however, the incidence is lower in populations where a
THEORY
high-fiber diet is consumed.[5] [6] The overall lifetime risk of developing acute appendicitis is 8.6% for males
and 6.7% for females; lifetime risk of appendectomy is around 12% in males and 23% in females.[7] [8]
Globally, the pooled incidence of appendicitis or appendectomy is around 100 per 100,000 person
years.[9] Data suggest a rapid increase in incidence in newly industrialized countries.[9] Acute appendicitis
most commonly occurs between the ages of 10 and 30, with the highest incidence in children and
adolescence.[10] [11] There is a slight male to female predominance (1.3:1).
Etiology
Obstruction of the lumen of the appendix is the main cause of acute appendicitis. Fecalith (a hard mass
of fecal matter), normal stool, or lymphoid hyperplasia are the main causes for obstruction. Retrospective
appendectomy data suggest fecalith prevalence of 14% to 18% (among patients with a clinical indication/
clinical syndrome of appendicitis or emergency appendectomy patients, respectively).[12] [13] In emergency
appendectomy patients, fecalith prevalence was 39.4% in perforated appendicitis, but only 14.6% in
nonperforated appendicitis.[12]
There is evidence suggesting a neuroimmune etiology in some cases, but this is still being investigated.[14]
Pathophysiology
The lumen distal to the appendiceal obstruction starts to fill with mucus and acts as a closed-loop
obstruction. This leads to distension and an increase in intraluminal and intramural pressure. As the condition
progresses, the resident bacteria in the appendix rapidly multiply. The most common bacteria in the appendix
are Bacteroides fragilis and Escherichia coli .[15]
Distension of the lumen of the appendix causes reflex anorexia, nausea and vomiting, and visceral pain
around the umbilicus, based on the embryonic origins of the appendix.
As the pressure of the lumen exceeds the venous pressure, the small venules and capillaries become
thrombosed but arterioles remain open, which leads to engorgement and congestion of the appendix. The
inflammatory process soon involves the serosa of the appendix, hence the parietal peritoneum in the region,
which causes classical right lower quadrant pain at McBurney point.
Once the small arterioles are thrombosed, the area at the antimesenteric border becomes ischemic, and
infarction and perforation ensue. Bacteria leak out through the walls and pus forms (suppuration) within and
around the appendix. Perforations are usually seen just beyond the obstruction rather than at the tip of the
appendix.[16]
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 11, 2021.
Acute appendicitis Theory
Case history
Case history #1
THEORY
A 22-year-old male presents to the emergency room with abdominal pain, anorexia, nausea, and low-
grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant
of the abdomen. The pain is steady in nature and aggravated by coughing. Physical examination reveals
a low-grade fever (100.5°F [38°C]), pain on palpation at right lower quadrant (McBurney sign), and
leukocytosis (12,000/microliter) with 85% neutrophils.
Case history #2
A 12-year-old girl presents with sudden-onset severe generalized abdominal pain associated with nausea,
vomiting, and diarrhea. On exam she appears ill and has a temperature of 104°F (40°C). Her abdomen is
tense with generalized tenderness and guarding. No bowel sounds are present.
Other presentations
Atypical appendiceal anatomy, such as retrocecal or long appendix, may present with back, hip, or left-
sided abdominal pain that is confused with an alternate intra-abdominal diagnosis. Older patients are less
likely to have classical symptoms and may present with nonspecific abdominal pain without associated
features, or confusion. The delay in presentation or diagnosis in this group results in increased risk of
morbidity and mortality. The diagnosis of acute appendicitis during pregnancy is often delayed, as the
location of the pain is affected by displacement of the appendix by the uterus, and symptoms such as
nausea and vomiting are frequently associated with pregnancy itself.[3]
5
Acute appendicitis Diagnosis
Approach
History and physical examination form the initial approach in the evaluation of a patient with possible
appendicitis.[2] It is routine practice in the US to request a computed tomography (CT) scan for patients
presenting to the emergency room with features of acute appendicitis.[26]
Validated clinical decision tools such as the Alvarado score demonstrate high sensitivities and are useful for
excluding appendicitis, but lack specificity.[27] [28] [29]
Ultrasound or magnetic resonance imaging (MRI) of the abdomen are recommended if the patient is
pregnant.[10] [30] Women of childbearing age should have a pelvic examination to rule out other pelvic
pathology.[31]
History
Abdominal pain is the main presenting complaint. Pain typically starts at the mid-abdominal region
and later (1 to 12 hours) shifts to the right lower quadrant. Pain is usually constant in nature and with
intermittent abdominal cramps and is usually worse on movement and coughing.
Location of the pain may vary depending upon the position of the appendix:
• Retrocecal appendix may cause flank or back pain

• Retroileal appendix may cause testicular pain due to irritation of the spermatic artery or ureter
• Pelvic appendix may cause suprapubic pain
• A long appendix with tip inflammation in the left lower quadrant may cause pain to that region.
Anorexia is another important symptom almost always associated with acute appendicitis.[32] Without
anorexia the diagnosis of acute appendicitis is in question. Nausea and vomiting are also present in 75%
of patients.[32] Absolute constipation is a late feature.
The sequence of presentation in 95% of patients with acute appendicitis usually starts with anorexia,
followed by abdominal pain and then vomiting.[32] However, in pregnant patients, the only features
shown to be significantly associated with a diagnosis of appendicitis are nausea, vomiting, and local
DIAGNOSIS
peritonitis.[33]
Complicated appendicitis (perforation or intra-abdominal abscess) is more likely the greater the duration
of symptoms and in older patients (>50 years).[34] [35]
Physical exam
Usually, there are no significant changes in vital signs. Patients may have a low-grade fever. In patients
presenting with a high-grade fever, another diagnosis should be considered.[36] Tachycardia may also be
present.[37]
A classic sign is right lower quadrant abdominal tenderness (McBurney sign) and localized rebound
tenderness, if appendix is anterior. There may also be pain in the right lower quadrant after compressing
the left lower quadrant (Rovsing sign).
Pain may be elicited in the right lower quadrant with the patient lying on their left side and slowly
extending the right thigh to cause a stretch in the iliopsoas muscle (psoas sign) or by internal rotation of
the flexed right thigh (obturator sign).
Bowel sounds may be reduced, particularly on the right side compared with on the left.
Classic abdominal findings may not be present if the appendix is in an atypical position.
Patients with perforation may present acutely ill with hypotension, tachycardia, and a tense, distended
abdomen with generalized guarding and absent bowel sounds.
A palpable mass may be felt with appendiceal perforation that has been contained by the omentum,
resulting in a periappendiceal abscess.
In children, pain with coughing and hopping can support the diagnosis.[38] Analgesia may be useful to
facilitate abdominal exam if pain limits the examination. Analgesia does not lead to missed diagnoses in
children.[39] [40]
Investigation
All patients with abdominal discomfort should have a complete blood count taken. Mild leukocytosis
(10,000 to 18,000/microliter) with increased neutrophils is usually present. In children, CRP level on
admission ≥10 mg/L and leukocytosis ≥16,000/microliter are strong predictive factors for appendicitis.[10]
Some form of imaging is usually warranted. Most nonpregnant patients presenting to the emergency room
with abdominal pain suggestive of appendicitis will have a CT scan of the abdomen and pelvis.[30] [10]
Preoperative imaging with a CT scan of the abdomen (ultrasound or MRI for pregnant women) now forms
the usual standard of care. Women and children, in particular, may benefit from preoperative imaging.[26]
[41] [38]
Choice of imaging modality
Although CT scan has greater sensitivity and specificity than ultrasound in diagnosing appendicitis,
the latter is readily available, rapid, and able to be performed at the bedside.[42] [43] [44] In children,
ultrasound may be preferred over CT scan in order to limit radiation exposure. There is evidence to
suggest enhanced sensitivity and specificity of ultrasound in children compared with adults.[41] [45]
[46] If, on ultrasound, a normal appendix is visualized in its full length, then acute appendicitis can be
DIAGNOSIS
excluded. However, this is rarely the case, and the greatest utility for ultrasound is to detect an alternative
cause of abdominal pain that excludes appendicitis.[47]
Appendiceal CT scan is increasingly used as the initial diagnostic test for acute appendicitis, and it is
routine practice in the US to request a CT for patients presenting to the emergency room with features of
acute appendicitis.[26] A CT is also indicated in atypical presentations.[30] [48] However, delayed surgery
subsequent to CT scan for presumed appendicitis is associated with an increased rate of appendiceal
perforation.[49] Intravenous contrast-enhanced CT scan with or without oral contrast has up to 100%
sensitivity compared with 92% sensitivity in nonintravenous contrast-enhanced CT scan.[50] [51]
7
CT abdomen - thickened appendix.

In pregnant women presenting with features of appendicitis, an abdominal sonogram should be

performed to identify the appendix. If the sonogram examination is inconclusive, an abdominal MRI
(particularly in early pregnancy) may be appropriate.[31] [30] However, a negative or inconclusive MRI
does not exclude appendicitis and surgery should still be considered if clinical suspicion is high.[10]
In children, point-of-care ultrasound is the most appropriate first-line diagnostic tool, if an imaging
investigation is indicated based on clinical assessment. In children with inconclusive ultrasound
results, a second-line imaging technique (CT or MRI) can be chosen based on local availability and
DIAGNOSIS
expertize.[10] Low-dose CT is preferred in young people if they have a negative ultrasound.[10]
Tests to exclude other causes

A urinalysis should be performed to exclude possible urinary tract infection or renal colic. Sexually active
women of childbearing age should have a urinary pregnancy test.
History and exam

Key diagnostic factors
abdominal pain (common)
• Constant mid-abdominal pain which later (1 to 12 hours) shifts to right lower quadrant. Usually worse
on movement and coughing.
anorexia (common)
• An important symptom almost always associated with acute appendicitis.[32] Without anorexia the
diagnosis of acute appendicitis is in question.
right lower quadrant tenderness (common)

• A classic sign is right lower quadrant abdominal tenderness (McBurney sign). There may be localized
rebound tenderness, especially if the appendix is anterior. Compressing the left lower quadrant may
also elicit pain in the right lower quadrant (Rovsing sign). Pain may also be elicited with the patient
lying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle
(psoas sign) or by internal rotation of the flexed right thigh (obturator sign).
Other diagnostic factors

age of occurrence (common)
• Most commonly occurs between the ages of 10 and 30, with the highest incidence in children and
adolescence.[10] [11]
nausea (common)
• Nausea and vomiting are present in 75% of patients.[32]
fever (common)
• Low-grade, usually 1.8°F (1°C) increase in body temperature.
diminished bowel sounds (common)

• Bowel sounds may be reduced, particularly on the right side compared with the left.
tachycardia (common)
• Tachycardia may be present, particularly in patients with perforation.[37]
vomiting (uncommon)
• Nausea and vomiting are present in 75% of patients.[32]
DIAGNOSIS
Rovsing sign (uncommon)
• Pressing the left side of the abdominal cavity elicits pain in right lower quadrant.
psoas sign (uncommon)

• Extending the right thigh on left lateral position elicits pain in right lower quadrant.
obturator sign (uncommon)

• Pain is elicited in the right lower quadrant of abdomen by internal rotation of the flexed right thigh.
Risk factors
Weak
9
<6 months of breast feeding
• Affects immunologic responses to certain microbial organisms. Children who received <6 months of
breastfeeding had a higher incidence of acute appendicitis compared with those who received >6
months of breastfeeding.[17] [18]
low dietary fiber

• Known to cause constipation. Children with appendectomies have low fiber in their diet compared with
controls.[6] [19] However, this theory is controversial.[20]
improved personal hygiene

• A higher incidence of acute appendicitis in Western society may be related to the living conditions and
improved personal hygiene.[21]
• A balance of gastrointestinal microbial flora is important for prevention of infection, for digestion, and
providing important nutrients.[22] Frequent use of antibiotics and improved hygienic conditions lead to
decreased exposure and/or imbalance of gastrointestinal microbial flora that may eventually lead to a
modified response to viral infection and thereby trigger appendicitis.[23]
smoking
• Children exposed to passive smoking have significantly increased incidence of acute appendicitis.[24]
There is also an increased incidence of acute appendicitis in adult patients who smoke compared with
adults who never smoked.[24] [25]
DIAGNOSIS
Investigations
1st test to order
Test Result
CBC mild leukocytosis (10,000
• Increased polymorphonuclear leukocytes (>75%). High discriminatory to 18,000/microliter)
power when combined with history.[52]
• Leukocytosis ≥16,000/microliter and CRP level on admission ≥10 mg/
L are strong predictive factors for appendicitis in children.[10]
CRP there is no clear cut-off
value for a raised CRP in
• C-reactive protein is likely to be elevated.[38]
children, CRP likely to be
• CRP level on admission ≥10 mg/L and leukocytosis ≥16,000/
elevated
microliter are strong predictive factors for appendicitis in children
abdominal and pelvic CT scan abnormal appendix
(diameter >6 mm)
• Wall thickening, wall enhancement, and inflammatory changes in
identified or calcified
the surrounding tissues are additional findings seen in a CT scan of
appendicolith seen
abdomen and pelvis.[53]
in association with
periappendiceal
inflammation, fat
stranding
DIAGNOSIS
CT abdomen - thickened appendix.
• Appendiceal CT scan is increasingly used as the initial diagnostic
test for acute appendicitis, and it is routine practice in the US to
request a CT for patients presenting to the emergency room with
features of acute appendicitis.[26] A CT is also indicated in atypical
presentations.[30] [48]
• Intravenous contrast-enhanced CT scan with or without oral
contrast has up to 100% sensitivity compared with 92% sensitivity in
nonintravenous, contrast-enhanced CT scan.[50] [51]
• In pregnant women presenting with features of appendicitis, an
abdominal sonogram should be performed to identify the appendix.
If the sonogram examination is inconclusive, abdominal MRI
(particularly in early pregnancy) may be appropriate.[30] [48]
urinary pregnancy test negative
• If positive, the possibility of ectopic pregnancy should be considered.
11
Other tests to consider
Test Result
abdominal ultrasound aperistaltic or
noncompressible
• In children, point-of-care ultrasound is the most appropriate first-
structure with outer
line diagnostic tool, if an imaging investigation is indicated based on
diameter >6 mm, fluid
clinical assessment.
collection if perforated, fat
• Sensitivity and specificity of ultrasound may be higher in children
stranding, appendicolith
compared with adults.[43] [45] [46]
• In children with inconclusive ultrasound results, a second-line imaging
technique (CT or MRI) can be chosen based on local availability and
expertize.[10]
urinalysis negative
• If positive for red cells, white cells, or nitrates, an alternative diagnosis
such as renal colic or urinary tract infection should be considered.
abdominal and pelvic MRI in pregnancy abnormal appendix
(diameter >6 mm)
• In pregnant women presenting with features of appendicitis, an
identified and evidence
abdominal sonogram should be performed to identify the appendix.
of periappendicial
If the sonogram examination is inconclusive, abdominal MRI
(particularly in early pregnancy) may be appropriate.[30] [48] inflammatory changes,
appendicolith, fat
• A negative or inconclusive MRI does not exclude appendicitis and
stranding
surgery should still be considered if clinical suspicion is high.[10]
DIAGNOSIS
Differentials
Condition Differentiating signs / Differentiating tests

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

by viruses, bacteria, or toxin. to typhoid ( Salmonella
• Characterized by profuse typhi from stool or blood will
watery diarrhea, nausea, confirm the diagnosis).
and vomiting.
• Crampy abdominal pain
often precedes the diarrhea,
and no localizing signs are
present.
• If caused by typhoid fever,
intestinal perforation
may cause localized
abdominal pain and/or
generalized and rebound
tenderness. In this scenario,
associated maculopapular
rash, inappropriate
DIAGNOSIS
bradycardia, and leukopenia
will differentiate from
appendicitis.
Meckel diverticulitis • Usually asymptomatic. • Technetium pertechnetate

• Clinical presentation of scan may show the
diverticulitis is similar to enhancement of diverticulum
acute appendicitis. if gastric mucosa is present.
Intussusception • Occurs in young children • Barium enema may

(age <2 years). demonstrate the
• Sudden onset of colicky intussusception with a coil-
pain; between episodes of spring sign at the point of
pain the child is calm. bowel invagination.
• A sausage-shaped mass
may be palpable in the right
lower quadrant.
Crohn disease • Young adult with fever, • CT scan may show intra-
nausea, vomiting, diarrhea, abdominal abscess.
right lower quadrant pain, • Contrast study of the small
and localized tenderness. bowel and colon may show
13

symptoms
stricture or a series of ulcers
and fissures (cobblestone
appearance) of mucosa.
Peptic ulcer disease • May or may not have a • Erect chest x-ray and
history of peptic ulcer abdominal x-ray may show
disease. free air under the diaphragm
• Pain is abrupt, severe
in intensity, and may be
localized to right lower
quadrant.
Right-sided ureteric stone • Pain is usually colicky • Urinalysis positive for blood.
in nature and severe in • Leukocytosis usually absent.
intensity. May be referred • Abdominal x-rays or
to the labia, scrotum, or tomogram may show
penis and associated with calcified stone.
hematuria. • Pyelography and CT
• Fever usually absent. scan without oral and
intravenous contrast confirm
the diagnosis.
Cholecystitis • Pain and tenderness are • Abdominal ultrasound shows

usually in the right upper thick wall with pericholecystic
quadrant. In one third of collection, and tenderness
patients the gallbladder can is present over gallbladder
be palpable.[54] area (Murphy sign).
• Hepatobiliary iminodiacetic
acid scan will show
nonvisualization of
gallbladder at >4 hours.
Urinary tract infection • Pain and tenderness is • Urine microscopy and culture
usually in suprapubic area confirm presence of bacteria.
DIAGNOSIS
associated with burning

micturition.
• Acute right-sided
pyelonephritis may present
with fever, chills, and
tenderness at the right
costovertebral angle.
Primary peritonitis • Most patients present with • CT scan may show fluid in
abrupt abdominal pain, fever, the abdomen.
distension, and rebound • Peritoneal fluid shows
tenderness. >500/microliter count and
• History of advanced cirrhosis >25% polymorphonuclear
or nephrosis. leukocytosis.
Pelvic inflammatory • Occurs in females usually • Endocervical swab

disease aged between 20 and 40 may confirm the pelvic
years. inflammatory disease due to
• Presents with bilateral lower Chlamydia trachomatis .[55]
quadrant tenderness, usually
within 5 days of the last
menstrual period.

symptoms
• Purulent discharge from
cervical os.
Ruptured Graafian follicle • Midmenstrual cycle, brief • Clinical diagnosis. No

(mit telschmerz) period of lower abdominal investigation indicated.
pain not usually associated
with nausea and vomiting
and fever.
• Tenderness is usually
diffuse, not localized.
Ectopic pregnancy • Female within childbearing • Human chorionic

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

quadrant pain. Occasionally ovarian cyst and decreased
presents with mass in the blood flow.
right lower quadrant.
Criteria
There are multiple validated decision tools utilized in the diagnosis of appendicitis. These include the Adult
Appendicitis Score (AAS), Alvarado, Appendicitis Inflammatory Response (AIR), and RIPASA scoring
systems. These scoring systems involve a combination of history, examination findings, and investigation
DIAGNOSIS
results.
The Alvarado score is commonly used and has undergone the most validation studies. The AIR score
performed well in one systematic review of clinical prediction rules. It showed high sensitivity (92%) and
specificity (63%) in predicting acute appendicitis.[28] The RIPASA score was more sensitive than the
Alvarado score, with improved diagnostic odds ratio, but lower specificity.[28] [29]
The Alvarado score can be used to rule out appendicitis but should not be used to confirm a diagnosis of
appendicitis.[10]
The AIR score and the AAS seem currently to be the best performing clinical prediction scores and have the
highest discriminating power in adults with suspected acute appendicitis. The AIR and AAS scores decrease
negative appendectomy rates in low-risk groups and reduce the need for imaging studies and hospital
admissions in both low- and intermediate-risk groups.[10]
Scoring systems can be used to determine the likelihood or rule out the diagnosis of appendicitis in order to
guide further investigations and management.[10]
• The AIR score or the AAS can be used to determine whether a patient is at high, intermediate or low
risk of having appendicitis.
15
• High-risk patients who are aged <40 years, and have strong symptoms and signs of
appendicitis, may go straight to surgery without imaging. However, local protocols should be
checked as this varies in practice.
• Intermediate-risk patients may undergo further imaging and observation.
• Low-risk patients may be safely discharged without diagnostic imaging, as long as they have
appropriate safety-netting.
Adult Appendicitis Score (AAS)[56]

The higher the score, the greater the chance of having acute appendicitis. This scoring system reliably
reduces the need for imaging studies and hospital admissions in both low- and intermediate-risk groups.[10]
[57]
Pain in right lower quadrant = 2 points.
Pain relocation = 2 points.
Right lower quadrant tenderness
• Women, aged 16-49 years = 1 point.

• All other patients = 3 points.
Guarding
• Mild = 2 points.
• Moderate or severe = 4 points.
Blood leukocytes (×10⁹/L)
• ≥7.2 and <10.9 = 1 point.

• ≥10.9 and <14.0 = 2 points.
• ≥14.0 = 3 points.
DIAGNOSIS
Proportion of neutrophils %
• ≥62 and <75 = 2 points.

• ≥75 and <83 = 3 points.
• ≥83= 4 points.
CRP (mg/L), symptoms <24 hours
• ≥4 and <11 = 2 points.

• ≥11 and <25 = 3 points.
• ≥25 and <83 = 5 points.
• #83 = 1 point.
CRP (mg/L), symptoms >24 hours
• ≥12 and <53 = 2 points.

• ≥53 and <152 = 2 points.
• ≥152 = 1 point.
Sum ≥16 = high risk.
Sum 11 to 15 = intermediate risk.
Sum 0 to 10 = low risk (further investigation not needed).[10]
Alvarado (MANTRELS) score[27]

Score is based on clinical characteristics of the patients. The higher the score out of a possible total of 10,
the greater the chance of having acute appendicitis.
M: Migration of pain to right lower quadrant = 1 point.
A: Anorexia = 1 point.
N: Nausea and vomiting = 1 point.
T: Tenderness in right lower quadrant = 2 points.
R: Rebound tenderness = 1 point.
E: Elevated temperature = 1 point.
L: Leukocytosis = 2 points.
S: Shift of WBC count to left = 1 point.
Appendicitis Inflammatory Response (AIR) score[58]

Vomiting = 1 point.
Pain in right inferior fossa = 1 point.
DIAGNOSIS
Rebound tenderness: light = 1 point; medium = 2 points; strong = 3 points.
Body temperature ≥38.5 = 1 point.
Polymorphonuclear leukocytes: 70% to 84% = 1 point; ≥85% = 2 points.
WBC count: 10.0 to 14.9 ×10⁹/L = 1 point; ≥15.0 ×10⁹/L = 2 points.
CRP concentration: 10 mg/L to 49 mg/L = 1 point; ≥50 = 2 points.
(Maximum 12 points.)
Sum 0 to 4 = low probability. Outpatient follow-up if unaltered general condition.
Sum 5 to 8 = indeterminate group. In-hospital active observation with rescoring/imaging or diagnostic

laparoscopy according to local traditions.
Sum 9 to 12 = high probability. Surgical exploration is proposed.
RIPASA Score for Acute Appendicitis[59]

17
The higher the score out of a possible total of 16, the greater the chance of having acute appendicitis. The
scoring system was developed for Asian populations.
Female = 0.5 points.
Male = 1 point.
Age <39.9 years = 1 point.
Age >40 years = 0.5 points.
Right iliac fossa (RIF) pain = 0.5 points.
Migration of pain to RIF = 0.5 points.
Anorexia = 1 point.
Nausea and vomiting = 1 point.
Duration of symptoms <48 hours = 1 point.
Duration of symptoms >48 hours = 0.5 points.
RIF tenderness = 1 point.
Guarding = 2 points.
Rebound tenderness = 1 point.
Rovsing sign = 2 points.
Fever = 1 point.
Raised WBC = 1 point.

DIAGNOSIS
Negative urine analysis = 1 point.
(Maximum 16 points.)
Acute Physiology and Chronic Health Evaluation II (APACHE II)

score[60]
The APACHE score is commonly used to establish illness severity in the intensive care unit (ICU) and predict
the risk of death. There is a high risk of death if the score is 25 or above.
There are several other models that have been developed for use in the ICU, including APACHE III, Mortality
in Emergency Department Sepsis score, Simplified Acute Physiology Score, Sepsis-related Organ Failure
Assessment, and Mortality Probability Model II.[61] [62] [63]
Early diagnosis remains challenging in children due to atypical clinical features and the difficulty of obtaining
a reliable history and physical examination. In children with suspected acute appendicitis, scoring tools
such as the Alvarado score and Samuel’s Pediatric Appendicitis Score (PAS) are useful to exclude
appendicitis.[10] The PAS includes similar clinical findings to the Alvarado score in addition to a sign more
relevant in children: right lower quadrant pain with coughing, hopping, or percussion. However, diagnosis
should not be based on clinical scores alone.[10]
DIAGNOSIS
19
Acute appendicitis Management
Approach
The usual standard of care for the management of uncomplicated appendicitis in adults continues to be
operative.
There is emerging evidence to suggest that a nonoperative, antibiotic-only approach may be feasible in
select patient populations. The evidence supporting nonoperative management of appendicitis continues to
be conflicting, and further research is warranted. There is more evidence to support a nonoperative approach
in children than in adults.[10] [66] [67] [68] [69] [70] [71] [72] [73]
Uncomplicated presentation
Once the diagnosis of acute appendicitis is made, patients should be given nothing by mouth.
Intravenous fluids, such as lactated Ringer solution, should be started.
Adults
Prompt appendectomy remains the treatment of choice in international guidelines and should be
recommended in most cases. A single preoperative dose of broad-spectrum antibiotic such as cefoxitin
should be given to patients with uncomplicated appendicitis undergoing appendectomy. Postoperative
antibiotics are not indicated.[10]
An antibiotic-only approach may be reasonable for select groups with uncomplicated appendicitis
(suspected or confirmed on computed tomographic scan), where patients understand the risk of recurrent
appendicitis.[10] [73] [71]
An antibiotic-only approach is not recommended if an appendicolith is present since nonoperative

management carries a significant failure rate.[10] [74] A conservative approach should be avoided in
pregnant patients.[10]
Children
Guidance from the World Society of Emergency Surgery supports nonoperative management as feasible,
safe, and effective as initial treatment unless an appendicolith is present.[10] However, in the US the
usual standard of care for the management of uncomplicated appendicitis in children continues to be
operative. Postoperative antibiotics are not indicated in children with uncomplicated acute appendicitis
since there is no evidence they decrease the rate of surgical infection.[10]
Appendicectomy should not be delayed for children with uncomplicated acute appendicitis needing
surgery beyond 24 hours from admission. Surgery performed within this time is not associated with
increased risk of adverse outcomes such as perforation, complications, or operating time in children
who receive timely administration of antibiotics and undergo appendectomy less than 24 hours after
diagnosis.[10]
As for adults, surgery is not recommended in children with appendicoliths since the failure rate of
MANAGEMENT
nonoperative management increases in these cases.[10]
Complicated presentation
Adults
Complications of acute appendicitis occur in 4% to 6% of patients and include gangrene with subsequent
perforation or intra-abdominal abscess.[16]
Initial management includes keeping the patient nothing by mouth and starting intravenous fluids. Patients
who are in shock should be given a bolus of intravenous fluid, such as lactated Ringer solution, in order to
maintain a stable pulse rate and BP.[75] [76]
Intravenous antibiotics (e.g., cefoxitin or piperacillin/tazobactam) should be started immediately and

continued until the patient becomes afebrile and the leukocytosis is corrected. For more severe infections,
a carbapenem antibiotic may be used as a single agent. Combination antibiotic regimens may also be
used based on local sensitivities and protocols.[16]
In patients with acute peritonitis, appendectomy should be performed without delay. Patients presenting
with right lower quadrant abscess should be managed with intravenous antibiotics and drainage either
by interventional radiology (computed tomography-guided drainage) or by operative drainage. If there is
clinical improvement and the signs and symptoms are completely resolved, interval appendectomy may
be unnecessary.[10] [77] [78] [79] [80]
Interval appendectomy is associated with a non-negligible rate of morbidity.[79]
Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved.[10] [11]
Adoption of a wait-and-see approach, reserving appendectomy for patients with recurrent symptoms, is
the most cost-effective strategy compared with routine interval appendectomy.[10]
The incidence of appendicular neoplasms is high (3% to 17%) in patients ≥40 years old with complicated
appendicitis. Any patient ages ≥40 years who has conservative management without interval
appendicectomy should also undergo screening with colonoscopy and interval full-dose contrast-
enhanced CT scan.[10]
The optimal management for appendicitis with phlegmon or abscess remains subject to debate.[10]
Latest evidence suggests that laparoscopic appendectomy is associated with fewer readmissions and
fewer additional interventions than conservative management, provided advanced laparoscopic expertize
is available.[10] However, nonoperative management with antibiotics and, if available, percutaneous
image-guided drainage is a reasonable alternative if the patient is stable and laparoscopic appendectomy
is unavailable, although there is a lack of evidence for its use on a routine basis.[10]
Children
As with adults, initial management includes keeping the patient nothing by mouth and starting intravenous
fluids and intravenous antibiotics. Early appendectomy within 8 hours should be performed in case of
complicated appendicitis.[10] Laparoscopic appendectomy is preferred over open appendectomy in
children where laparoscopic equipment and expertize are available.[10] Postoperative antibiotics for less
than seven days seems to be safe and is not associated with an increased risk of complications. These
can be switched from intravenous to oral form after 48 hours in children with complicated appendicitis with
an overall length of therapy shorter than seven days.[10]
MANAGEMENT
As per management of adults with phlegmon or abscess, nonoperative management (antibiotics and, if
available, percutaneous image-guided drainage) is a reasonable alternative if the patient is stable and
laparoscopic appendectomy is unavailable. Nonoperative management has been associated with better
21
results in terms of complication rate and readmission rate in children but evidence does not support its
routine use.[81]
Surgical options
There are 2 operative options for appendectomy: open and laparoscopic. Most procedures are now
undertaken laparoscopically.
In adults, the choice of appendectomy generally depends upon the experience of the surgeon. Studies
have shown laparoscopic appendectomy to have better cosmetic results, shorter length of hospital stay,
reduced postoperative pain, and reduced risk of wound infection, compared with open appendectomy.[82]
[Evidence B] Laparoscopic appendectomy is recommended for uncomplicated appendicitis, as well as
complicated and perforated appendicitis.[83] [84] It is also considered the safest approach in obese
patients.[10] [85]
In children, laparoscopic appendectomy decreases the incidence of overall postoperative complications,

including wound infection and duration of total hospital stay.[86] [87] [82] [88] [89]
In pregnant patients, laparoscopic appendectomy should be preferred to open appendectomy when

surgery is indicated and where expertize of laparoscopy is available. It is safe in terms of risk of fetal
loss and preterm delivery. Compared to open surgery during pregnancy, laparoscopic appendectomy is
associated with shorter length of hospital stay and lower incidence of surgical site infection. Laparoscopy
is technically safe and feasible during pregnancy.[10] [91]
Antibiotic-only therapy
Antibiotics alone for the treatment of uncomplicated appendicitis can be successful in selected patients
who wish to avoid surgery, and who accept the risk of up to 39% recurrence. In such cases, it is
recommended that the diagnosis of uncomplicated appendicitis is confirmed by imaging, and that patient
expectations are managed via a shared decision-making process.[10] [92] [71] [73] An antibiotic-only
approach is not recommended in pregnant patients or if an appendicolith is present.[10] [74]
Outpatient laparoscopic appendectomy

Some patients may be discharged safely after laparoscopic appendectomy without hospitalization. This
outpatient approach is suitable for patients with uncomplicated appendicitis, provided that an ambulatory
pathway with well-defined ERAS (Enhanced Recovery After Surgery) protocols and patient information/
consent are locally established.[10] ERAS implementation after laparoscopic appendectomy carries
similar rates of morbidity and readmissions compared with conventional care.[93] Its potential benefits
include earlier recovery after surgery and lower hospital and social costs.[10]
Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
MANAGEMENT
Acute ( summary )
uncomplicated acute appendicitis
1st appendectomy + supportive care
adjunct intravenous antibiotic therapy
2nd antibiotic-only therapy
ill with perforation or abscess
1st intravenous antibiotic therapy +

supportive care
perforation plus appendectomy
abscess plus drainage ± interval appendectomy
MANAGEMENT
23
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
MANAGEMENT
Acute
uncomplicated acute appendicitis
1st appendectomy + supportive care
» Once the diagnosis of acute appendicitis

is made, patients should be given nothing by
mouth.
» Intravenous fluids, such as lactated Ringer

solution, should be started.
» Appendectomy should be performed without

delay, as early appendectomy reduces the
chances of perforation and intra-abdominal
abscess.
Acute appendicitis - intraoperative specimen.

Nasim Ahmed, MBBS,
FACS; used with permission
» There are 2 operative options for

appendectomy: open and laparoscopic. In
adults, the choice of appendectomy generally
depends upon the experience of the surgeon.
» Studies have shown laparoscopic

appendectomy to have better cosmetic results,
shorter length of hospital stay, reduced
postoperative pain, and reduced risk of
wound infection, when compared with open
appendectomy. [Evidence B] [82]
» Laparoscopic appendectomy is recommended

for uncomplicated appendicitis.[83] It is also
considered the safest approach in obese
patients.[85]
» In pregnant patients, laparoscopic

appendectomy should be preferred to open
appendectomy when surgery is indicated and
MANAGEMENT
where expertize of laparoscopy is available. It

is safe in terms of risk of fetal loss and preterm
delivery. Compared to open surgery during
pregnancy, laparoscopic appendectomy is
associated with shorter length of hospital stay
25
Acute
and lower incidence of surgical site infection.
Laparoscopy is technically safe and feasible
during pregnancy.[10] [91]
» In children, nonoperative management is

feasible, safe, and effective as initial treatment
unless an appendicolith is present.[10] However,
in the US the usual standard of care for the
management of uncomplicated appendicitis in
children continues to be operative.
» Laparoscopic appendectomy decreases the

incidence of overall postoperative complications,
including wound infection and duration of total
hospital stay.[86] [87] [82] [88] [89] [94]
» Some patients with uncomplicated appendicitis

may be discharged safely after laparoscopic
appendectomy without hospitalization, provided
that an ambulatory pathway with well-defined
ERAS (Enhanced Recovery After Surgery)
protocols and patient information/consent are
locally established.[10] ERAS implementation
after laparoscopic appendectomy carries similar
rates of morbidity and readmissions compared
with conventional care.[93] Its potential benefits
include earlier recovery after surgery and lower
hospital and social costs.[10]
» Patients with higher APACHE (Acute

Physiology and Chronic Health Evaluation)
scores seem to be at higher risk of development
of postoperative complications.
adjunct intravenous antibiotic therapy
Treatment recommended for SOME patients in
selected patient group
Primary options
» cefoxitin: 2 g intravenously as a single dose

30-60 minutes before surgery
» A single preoperative dose of broad-

spectrum antibiotic such as cefoxitin should
be given to patients with uncomplicated
appendicitis undergoing appendectomy.
Postoperative antibiotics are not indicated for
these patients.[10]
2nd antibiotic-only therapy
» Antibiotics alone for the treatment of

MANAGEMENT
uncomplicated appendicitis can be successful in

selected patients who wish to avoid surgery, and
who accept the risk of up to 39% recurrence.
In such cases, it is recommended that the
diagnosis of uncomplicated appendicitis
be confirmed by imaging, and that patient
Acute
expectations be managed via a shared decision-
making process.[95] [92] [71] [73]
» An antibiotic-only approach is not

recommended if an appendicolith is present
since nonoperative management carries a
significant failure rate.[10] [74]
» A conservative approach should be avoided in

pregnant patients.[10]
ill with perforation or abscess
ill with perforation or abscess 1st intravenous antibiotic therapy +

supportive care
Primary options
» cefoxitin: 1-2 g intravenously every 8 hours
OR
» piperacillin/tazobactam: 3.375 g
intravenously every 6 hours
Dose consists of 3 g piperacillin plus 0.375 g
tazobactam.
OR
» meropenem: 1 g intravenously every 8

hours
» These patients have evidence of perforation,

mass, or abscess.
» Initial management includes keeping

the patient nothing by mouth and starting
intravenous fluids. Patients who are in shock
should be given a bolus of intravenous fluid,
such as lactated Ringer solution, in order
to maintain a stable pulse rate and blood
pressure.[75] [76] Following on, maintenance
intravenous fluids should be given until the
condition of the patient improves and an oral diet
can be tolerated.
» Intravenous antibiotics (e.g., cefoxitin or

piperacillin/tazobactam) should be started
immediately. For more severe infections, a
carbapenem antibiotic may be used as a single
agent. Combination antibiotic regimens may
also be used based on local sensitivities and
MANAGEMENT
protocols.[16]
» Antibiotics should be continued until the patient

becomes afebrile and leukocytosis is corrected.
» Patients with higher APACHE (Acute

Physiology and Chronic Health Evaluation)
27
Acute
scores seem to be at higher risk of development
of postoperative complication.
perforation plus appendectomy
Treatment recommended for ALL patients in
» There are 2 operative options for
appendectomy: open and laparoscopic. In
adults, the choice of appendectomy generally
depends upon the experience of the surgeon.
» Studies have shown laparoscopic

appendectomy to have better cosmetic results,
shorter length of hospital stay, reduced
postoperative pain, and reduced risk of
wound infection, when compared with open
appendectomy.[82] [Evidence B]
» Laparoscopic appendectomy is recommended

for complicated and perforated appendicitis.[84]
It is also considered the safest approach
in obese patients.[85] In pregnant patients,
laparoscopic appendectomy should be preferred
to open appendectomy when surgery is
indicated and where expertize of laparoscopy is
available. It is technically feasible and is safe in
terms of risk of fetal loss and preterm delivery.
Compared to open surgery during pregnancy,
laparoscopic appendectomy is associated
with shorter length of hospital stay and lower
incidence of surgical site infection.[10] [91]
» In children, laparoscopic appendectomy

decreases the incidence of overall postoperative
complications, including wound infection and
duration of total hospital stay.[86] [87] [82] [88]
[89] [94]
abscess plus drainage ± interval appendectomy
Treatment recommended for ALL patients in
» Abscess usually occurs as a progression of the
disease process, particularly after perforation.
» Presents with tender right lower quadrant

mass, swinging fever, and leukocytosis.
Ultrasonography or computed tomography (CT)
scan will show the abscess.
» Initial treatment includes intravenous

antibiotics and CT-guided or operative drainage
MANAGEMENT
of the abscess.
» If there is clinical improvement and the signs

and symptoms are completely resolved, interval
appendectomy may be unnecessary.[10]
[77] [78] [79] [80] Interval appendectomy
Acute
is associated with a non-negligible rate of
morbidity.[79] Any patient ages ≥40 years who
has conservative management without interval
appendectomy should also undergo screening
with colonoscopy and interval full-dose contrast-
enhanced CT scan since the incidence of
appendicular neoplasms is high.[10]
» Interval appendectomy is performed after

6 weeks if the symptoms are not completely
resolved.[10] [11] [96] Adoption of a wait-and-
see approach, reserving appendectomy for
patients with recurrent symptoms, is the most
cost-effective strategy compared with routine
interval appendectomy.[10]
» For patients with phlegmon or abscess,

management remains subject to debate.
Latest evidence suggests that laparoscopic
appendectomy is associated with fewer
readmissions and fewer additional interventions
than conservative management, provided
advanced laparoscopic expertize is available.
However, nonoperative management with
antibiotics and, if available, percutaneous image-
guided drainage is a reasonable alternative if the
patient is stable and laparoscopic appendectomy
is unavailable, although there is a lack of
evidence for its use on a routine basis.[10]
MANAGEMENT
29
Emerging
Eravacycline
Eravacycline is a novel antibiotic of the tetracycline class. One clinical trial indicated that it is at least as
effective as ertapenem in treating complicated intra-abdominal infections (cIAIs).[97] Eravacycline may
have a role in the treatment of complicated appendicitis. The Food and Drug Administration (FDA) and the
European Medicines Agency have approved eravacycline (Xerava, Tetraphase Pharmaceuticals) for the
treatment of cIAIs in adults.
Meropenem/vaborbactam
Meropenem/vaborbactam is a carbapenem beta-lactamase inhibitor combination that has demonstrated
higher clinical cure rates, versus best available therapy, for the treatment of carbapenem-resistant
Enterobacteriaceae, among other infections.[98] The Committee for Medicinal Products for Human Use of
the European Medicines Agency has recommended granting authorisation for meropenem/vaborbactam for
the treatment of several types of infection, including cIAIs. Meropenem/vaborbactam is approved by the FDA
for the treatment of complicated urinary tract infections in adults.
Imipenem/cilastatin/relebactam
Imipenem/cilastatin/relebactam is a three-drug combination containing imipenem-cilastatin, a previously
FDA-approved antibiotic, and relebactam, a new beta-lactamase inhibitor. The FDA has approved this
combination to treat adults with complicated urinary tract infections and cIAIs.
Patient discussions
Patients can be started on a clear liquid diet on the same day as the operation if there is no nausea
or vomiting and can start a regular diet the next day. Patients are usually given at least 1 week off
work or school. Future level of activity, driving, or return to work should be determined at the follow-up
appointment.
MANAGEMENT
Acute appendicitis Follow up
Monitoring
Monitoring
FOLLOW UP
Patients are usually discharged from hospital 1 day after surgery for uncomplicated appendicitis.
Complicated appendicitis may require a longer hospital stay depending on the response to treatment.
In some countries, patients are followed up postoperatively regardless of complicated or uncomplicated
appendicitis; for example, 1 week after discharge, with further follow-up visits arranged as needed.
31
Complications
Complications Timeframe Likelihood

FOLLOW UP
perforation short term low
May occur after >12 hours of progressive appendiceal inflammation.
Usually a consequence of a delay in seeking medical treatment.
Presents with more severe abdominal pain, high fever (>101°F [38.3°C]), localized tenderness, and
decreased bowel sounds.
Appendectomy should be performed in all cases. Procedure can be open or laparoscopic. [Evidence B]
generalized peritonitis short term low
Large perforation of acutely inflamed appendix results in generalized peritonitis.
Presents with an acute abdomen (high fever, diffuse abdominal pain, generalized tenderness, and absent
bowel sounds).
If the diagnosis is suspected as acute appendicitis, appendectomy can be performed. If diagnosis is in

doubt, exploratory laparotomy should be performed through midline incision, and the appendix, if inflamed,
should be removed.
appendicular mass short term low
Usually due to delay in medical treatment.
Presents with tender right lower quadrant mass. Ultrasonography or computed tomography scan will show
a mass.
If the patient appears otherwise well, the initial management is conservative treatment with intravenous
fluids and broad-spectrum antibiotics. If there is clinical improvement and the signs and symptoms are
completely resolved, then there is no need for interval appendectomy.[77] [78] [79] Interval appendectomy
is performed after 6 weeks if the symptoms are not completely resolved.[10]
In older patients, carcinoma should be excluded.
appendicular abscess short term low
Usually occurs as a progression of the disease process, particularly after perforation.
Presents with tender right lower quadrant mass, swinging fever, and leukocytosis.
Ultrasonography or computed tomography (CT) scan will show the abscess.
Initial treatment includes intravenous antibiotics and CT-guided drainage of abscess.
The optimal management for appendicitis with phlegmon or abscess remains subject to debate. Latest
evidence suggests that laparoscopic appendectomy is associated with fewer readmissions and fewer
additional interventions than conservative management, provided advanced laparoscopic expertize is
available. However, nonoperative management with antibiotics and, if available, percutaneous image-
Complications Timeframe Likelihood

guided drainage is a reasonable alternative if the patient is stable and laparoscopic appendectomy is
unavailable, although there is a lack of evidence for its use on a routine basis.[10]
FOLLOW UP
surgical wound infection short term low
Decreased incidence if laparoscopic approach and prophylactic antibiotic used.[99] [Evidence B]
Prognosis
If patients are treated in a timely fashion, the prognosis is good. Wound infection and intra-abdominal
abscess are potential complications associated with appendectomy. Laparascopic appendectomy has been
shown to decrease the incidence of overall complications.[83]
33
Acute appendicitis Guidelines
Diagnostic guidelines
International
ACR Appropriateness Criteria: right lower quadrant pain - suspected

appendicitis (ht tp://www.acr.org/Quality-Safety/Appropriateness-Criteria)
[30]
Published by: American College of Radiology Last published: 2018
ACR Appropriateness Criteria: acute nonlocalized abdominal pain and fever

(ht tp://www.acr.org/Quality-Safety/Appropriateness-Criteria) [48]
ACR Appropriateness Criteria: fever without source or unknown origin - child

(ht tp://www.acr.org/Quality-Safety/Appropriateness-Criteria) [64]
GUIDELINES
Critical issues: evaluation and management of emergency department

patients with suspected appendicitis (ht tps://www.acep.org/patient-care/
clinical-policies) [65]
Published by: American College of Emergency Physicians Last published: 2010
WSES Jerusalem guidelines for diagnosis and treatment of acute

appendicitis (ht tps://www.wses.org.uk/guidelines) [10]
Published by: World Society of Emergency Surgery Last published: 2020
Treatment guidelines
International
WSES Jerusalem guidelines for diagnosis and treatment of acute

appendicitis (ht tps://www.wses.org.uk/guidelines) [10]
The management of intra-abdominal infections from a global perspective:

2017 WSES guidelines for management of intra-abdominal infections (ht tps://
www.wses.org.uk/guidelines) [92]
Acute appendicitis Evidence tables
Evidence tables
For adults and adolescents with suspected appendicitis, how does
EVIDENCE TABLES
laparoscopic appendectomy compare with conventional appendectomy?
This table is a summary of the analysis reported in a Cochrane Clinical Answer that focuses on the
above important clinical question.
View the full source Cochrane Clinical Answer (https://www.cochranelibrary.com/cca/

doi/10.1002/cca.2373/full)
Evidence B * Confidence in the evidence is moderate or low to moderate where GRADE has
been performed and the intervention may be more effective/beneficial than the
comparison for key outcomes.
Population: Adults and adolescents with suspected appendicitis

Intervention: Laparoscopic appendectomy
Comparison: Conventional appendectomy (open surgery, most using a McBurney/muscle-splitting method)
† ‡
Outcome Effectiveness (BMJ rating) Confidence in evidence (GRADE)
Wound infections (time point Favors intervention Moderate

unclear)
Intra‐abdominal abscess Favors comparison Moderate

(follow‐up range from hospital
discharge to 1 year)
Pain intensity on day 1 Favors intervention Low

postoperatively
Length of hospital stay Favors intervention Low
Time until return to normal Favors intervention Low

activity
Note
The Cochrane Clinical Answer (CCA) notes that intra-abdominal abscesses are more likely to occur with
laparoscopic surgery, but also notes that the Cochrane reviewers did not stratify this in relation to the
pathology of the appendix, resulting in some uncertainty as to which approach is preferable in patients with
complicated appendicitis.
35
Acute appendicitis Evidence tables
* Evidence levels
The Evidence level is an internal rating applied by BMJ Best Practice. See the EBM Toolkit (https://
bestpractice.bmj.com/info/evidence-tables/) for details.
EVIDENCE TABLES
Confidence in evidence
A - High or moderate to high

B - Moderate or low to moderate
C - Very low or low
† Effectiveness (BMJ rating)

Based on statistical significance, which demonstrates that the results are unlikely to be due to chance, but
which does not necessarily translate to a clinical significance.
‡ Grade certainty ratings
High The authors are very confident that the true

effect is similar to the estimated effect.
Moderate The authors are moderately confident that
the true effect is likely to be close to the
estimated effect.
Low The authors have limited confidence in the
effect estimate and the true effect may be
substantially different.
Very Low The authors have very little confidence in
the effect estimate and the true effect is
likely to be substantially different.
BMJ Best Practice EBM Toolkit: What is GRADE? (https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-
is-grade/)
Acute appendicitis References
Key articles
• Snyder MJ, Guthrie M, Cagle S. Acute appendicitis: Efficient diagnosis and management. Am Fam
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Physician. 2018 Jul 1;98(1):25-33. Full text (https://www.aafp.org/afp/2018/0701/p25.html) Abstract
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• Temple CL, Shirley AH, Temple WJ. The natural history of appendicitis in adults. A prospective
study. Ann Surg. 1995 Mar;221(3):278-81. Full text (http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1234570/pdf/annsurg00049-0078.pdf) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/7717781?
tool=bestpractice.bmj.com)
• Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of acute appendicitis.
Br J Surg. 2004 Jan;91(1):28-37. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/14716790?
• Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated
acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Sep 25;320(12):1259-65. Full
text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233612) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/30264120?tool=bestpractice.bmj.com)
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Acute appendicitis Images
Images
IMAGES
Figure 1: Acute appendicitis - intraoperative specimen.
47
IMAGES Acute appendicitis Images
Figure 2: CT abdomen - thickened appendix.

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DISCLAIMER
Contributors:
// Authors:
Peter Szasz, MD, PhD, FRCSC

General and Minimally Invasive Surgeon
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DISCLOSURES: PS declares that he has no competing interests.
// Acknowledgements:
Dr Peter Szasz would like to gratefully acknowledge Professor Ali Tavakkoli, Professor Dileep N. Lobo and
Dr Nasim Ahmed, previous contributors to this topic. AT is a consultant for Medtronic. DNL is the author of
an article cited in the topic. NA declares that he has no competing interests.
// Peer Reviewers:
John M. Davis, MD
General Surgery
Jersey Shore Medical Center, Neptune, NJ
DISCLOSURES: JMD declares that he has no competing interests.

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Acute appendicitis

Straight to the point of care

Last updated: Jun 11, 2021

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

Definitive treatment is surgical appendectomy. A nonoperative, antibiotic-only approach may be feasible in

Acute appendicitis - intraoperative specimen.

• Retrocecal appendix may cause flank or back pain

Choice of imaging modality

CT abdomen - thickened appendix.

In pregnant women presenting with features of appendicitis, an abdominal sonogram should be

expertize.[10] Low-dose CT is preferred in young people if they have a negative ultrasound.[10]

Tests to exclude other causes

History and exam

right lower quadrant tenderness (common)

Other diagnostic factors

diminished bowel sounds (common)

psoas sign (uncommon)

obturator sign (uncommon)

low dietary fiber

improved personal hygiene

Other tests to consider

Condition Differentiating signs / Differentiating tests

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

Meckel diverticulitis • Usually asymptomatic. • Technetium pertechnetate

Intussusception • Occurs in young children • Barium enema may

Condition Differentiating signs / Differentiating tests

Cholecystitis • Pain and tenderness are • Abdominal ultrasound shows

associated with burning

Pelvic inflammatory • Occurs in females usually • Endocervical swab

Condition Differentiating signs / Differentiating tests

Ruptured Graafian follicle • Midmenstrual cycle, brief • Clinical diagnosis. No

Ectopic pregnancy • Female within childbearing • Human chorionic

Ovarian torsion • Female with right lower • Ultrasonography shows

Adult Appendicitis Score (AAS)[56]

Pain in right lower quadrant = 2 points.

Pain relocation = 2 points.

Right lower quadrant tenderness

• Women, aged 16-49 years = 1 point.

Blood leukocytes (×10⁹/L)

• ≥7.2 and <10.9 = 1 point.

• ≥62 and <75 = 2 points.

CRP (mg/L), symptoms <24 hours

• ≥4 and <11 = 2 points.

• ≥12 and <53 = 2 points.

Sum 11 to 15 = intermediate risk.

Sum 0 to 10 = low risk (further investigation not needed).[10]

Alvarado (MANTRELS) score[27]

M: Migration of pain to right lower quadrant = 1 point.

N: Nausea and vomiting = 1 point.

T: Tenderness in right lower quadrant = 2 points.

R: Rebound tenderness = 1 point.

E: Elevated temperature = 1 point.

S: Shift of WBC count to left = 1 point.

Appendicitis Inflammatory Response (AIR) score[58]

Pain in right inferior fossa = 1 point.

Body temperature ≥38.5 = 1 point.

Polymorphonuclear leukocytes: 70% to 84% = 1 point; ≥85% = 2 points.

WBC count: 10.0 to 14.9 ×10⁹/L = 1 point; ≥15.0 ×10⁹/L = 2 points.