Management

• Perform rapid clinical evaluation using ABCDE approach.

• Screen for peritoneal signs (e.g., due to perforated appendix) or sepsis.

• Keep patients NPO and initiate supportive care: e.g., IV fluids, analgesia, antiemetics

• Determine the likelihood of diagnosis based on a combination of:

  • Patient demographics (e.g., age, sex)

  • Clinical features of appendicitis

  • Initial laboratory studies (see “Diagnostics”)

  • Appendicitis risk scores, e.g., AIR score [10][11]

• Proceed with subsequent management based on the likelihood of diagnosis.

Diagnostic imaging is often performed for most patients. A selective and individualized approach is generally recommended to minimize patient exposure to radiation and expedite care

• Associated scores: AIR score ≤ 4, Alvarado score ≤ 2–4

• Management: Additional testing for appendicitis may not be required. [10]

  • Consider other differential diagnoses of acute abdominal pain.

  • Perform further diagnostic workup of acute abdominal pain as needed

• Associated scores: AIR score ≤ 5–8, Alvarado score ≤ 5–6

• Management: confirmatory imaging required, e.g., ultrasound abdomen, CT abdomen

• Next steps

  • Imaging confirms appendicitis: See “High likelihood of appendicitis”.

  • Imaging is inconclusive or negative for appendicitis

    • Low index of suspicion: See “Low likelihood of appendicitis.”

    • High index of suspicion: Consult surgery.

      • Consider admission, serial abdominal examination, and repeat imaging or diagnostic laparoscopy.

      • Consider empiric antibiotic therapy for acute appendicitis (for at least 3 days)

• Associated scores: AIR score ≥ 9, Alvarado score ≥ 7–9

• Management: Urgent surgical consult for admission and definitive treatment required

  • Begin empiric antibiotic therapy for acute appendicitis.

  • Arrange preoperative CT abdomen as needed (e.g., for patients > 40 years old).

• Next steps

  • Laparoscopic appendectomy within 24 hours for uncomplicated appendicitis (no signs of sepsis or complicated appendicitis)

  • Emergency appendectomy for complicated appendicitis with systemic manifestations (e.g., generalized peritonitis or sepsis)

  • Nonoperative management of appendicitis

    • Recommended for complicated appendicitis with an appendiceal phlegmon or appendiceal abscess

    • Consider in select patients who present with early uncomplicated appendicitis in close consultation with a surgeon.