Management of Acute Appendicitis in Adults

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Management of acute appendicitis in adults
Authors: Douglas Smink, MD, MPH, David I Soybel, MD

Section Editor: Martin Weiser, MD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2018. | This topic last updated: May 07, 2018.
INTRODUCTION — Acute appendicitis is the most common abdominal surgical emergency in the world, with a lifetime
risk of 8.6 percent in males and 6.9 percent in females [1]. For over a century, open appendectomy was the only standard
treatment for appendicitis. Contemporary management of appendicitis is more sophisticated and nuanced: laparoscopic
appendectomy has surpassed open appendectomy in usage, some patients with perforated appendicitis may benefit from
initial antibiotic therapy followed by interval appendectomy, and several European trials have even suggested that it is
feasible to treat uncomplicated appendicitis nonoperatively with antibiotics alone.
The management of appendicitis in adults will be reviewed here. Appendicitis in children and pregnant women is
discussed separately:
● (See "Acute appendicitis in children: Management".)
● (See "Acute appendicitis in pregnancy".)
The clinical manifestations and diagnostic evaluation of appendicitis in adults are also discussed elsewhere.
● (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
● (See "Acute appendicitis in adults: Diagnostic evaluation".)
NONPERFORATED APPENDICITIS — Nonperforated appendicitis, also referred to as simple appendicitis or

uncomplicated appendicitis, refers to acute appendicitis that presents without clinical or radiographic signs of perforation
(eg, inflammatory mass, phlegmon, or abscess).
Most cases of appendicitis are not perforated at presentation. For adult patients with nonperforated appendicitis, we
recommend timely appendectomy, either open or laparoscopically (algorithm 1). Antibiotics can be used to augment rather
than to replace surgery. For the past 120 years, appendectomy has withstood the test of time as a safe, effective, and
definitive therapy for appendicitis. (See 'Appendectomy for nonperforated appendicitis' below.)
Despite evidence that antibiotics alone may be sufficient for managing the initial presentation of appendicitis, we suggest
against its routine use for adult patients presenting with uncomplicated appendicitis. We feel that its routine application in
clinical practice is premature because of many unanswered questions (eg, patient selection, recurrent attacks, and missed
neoplasm). Antibiotics are an option for those who are unfit for or refuse surgery. (See 'Evidence for nonoperative
management' below.)
Our suggestion is in line with treatment guidelines from the American College of Surgeons, Society for Surgery of the
Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, European Association of Endoscopic
Surgery, and World Society of Emergency Surgery [2-4], all of which recommend appendectomy as the treatment of
choice for adult patients with nonperforated appendicitis.
A 2016 collaborative international study confirms that the dominant management strategy for acute uncomplicated
appendicitis remains operative, with either open or laparoscopic appendectomy. In this study, 4282 consecutive patients
from 44 countries were treated for acute appendicitis over the same six-month period in 2016 [5]. Of these, 95.7 percent
underwent surgery (42.2 percent open appendectomy, 51.7 percent laparoscopic appendectomy, 1.8 percent other
procedures). Only 4.3 percent were managed nonoperatively.
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Evidence for nonoperative management — To date, six randomized trials have compared antibiotics with
appendectomy for nonperforated appendicitis in adults [6-11]. Many more systematic reviews and meta-analyses have
been published [12-18]. From these publications, we know that:
● Most patients treated with antibiotics respond clinically with a reduction in white blood cell count [8], avoidance of
peritonitis [6], and general symptom reduction [7,9,10]. Compared with those who underwent immediate
appendectomy, patients treated with antibiotics have lower or similar pain scores [6-8], require fewer doses of
narcotics [8], have a quicker return to work [7,8], and do not have a higher perforation rate.
● Approximately 90 percent of patients treated with antibiotics are able to avoid surgery during the initial admission. The
other 10 percent that fail to respond to antibiotics require a rescue appendectomy. However, there is no reliable way
of predicting who will or will not respond to antibiotics.
● Approximately 70 percent of those successfully treated with antibiotics during the initial admission are able to avoid
surgery during the first year. The other 30 percent eventually require appendectomy for recurrent appendicitis or
symptoms of abdominal pain (mean time to appendectomy 4.2 to 7 months [6,8,9]).
Another randomized trial from Korea went a step further and compared supportive care alone versus antibiotics in 245
adults with computed tomography (CT)-verified uncomplicated appendicitis [19]. Approximately three-quarters of the
patients screened were excluded; exclusion criteria included appendiceal diameter >11 mm, appendicolith, and
complicated appendicitis. Patients treated with supportive care alone did just as well as patients treated with four days of
antibiotics. Approximately 7 percent in each group failed initial treatment, with most requiring appendectomy; an additional
13 to 16 percent in each group had recurrences during the 19-month follow-up, with most requiring appendectomy. The
initial treatment failure rate and recurrence rate with and without antibiotics are strikingly similar to those of earlier
randomized trials, indicating that perhaps supportive care, not antibiotics, was responsible for the success of nonoperative
therapy.
It is conceivable that whether appendicitis can be managed nonoperatively is predetermined by the underlying
pathophysiology, and that patients whose appendicitis is destined to resolve without surgery will improve with or without
antibiotics. However, although such patients represent the majority (70 to 90 percent of those who present with
nonperforated appendicitis), they cannot be reliably identified a priori based on currently available clinical, laboratory, and
radiologic data, and, more importantly, neither can patients who are destined to fail nonoperative management be selected
for early appendectomy.
Despite the mounting evidence for nonoperative management of nonperforated appendicitis, we remain concerned
about the following issues:
● Antibiotic therapy is intended for patients with nonperforated (uncomplicated) appendicitis only. However, preoperative
abdominal CT cannot reliably distinguish uncomplicated appendicitis from complicated disease. In one trial, for
example, among patients in the appendectomy arm, 20 percent had complicated appendicitis identified at the time of
surgery [6]. Patients with fecaliths on imaging have a high rate of complicated appendicitis (up to 40 percent). Thus,
nonoperative management is not recommended for those patients [6,20,21].
● Nonoperative management poses a greater risk for patients who are older, immunocompromised, or have medical
comorbidities. In such patients, the severity of the disease may be underestimated, and the risk of unexpected lesions
in the appendix, such as carcinoid and carcinoma, may be higher [22-26]. Although such high-risk patients could
potentially benefit the most from nonsurgical treatment of appendicitis, they were excluded from all trials. Thus, the
efficacy of the antibiotic-first approach to management of appendicitis in this group of patients remains unknown. (See
'Unexpected intraoperative findings' below.)
For a small minority of patients with either prior history of surgical complications or severe phobia to appendectomy, a
nonoperative approach could be offered as an alternative to immediate surgery (algorithm 1) [27]. Current treatment
strategies derived from trial protocols call for initial intravenous antibiotics for one to three days, followed by oral antibiotics
for up to 10 days; the choices of antibiotics are not standardized [16]. Patients are typically admitted to the hospital during
the first one to three days for close observation in case of clinical deterioration, which requires prompt rescue
appendectomy. It is unclear whether antibiotic treatment increases hospital utilization, and therefore cost, both during the
initial phase of treatment and for recurrences. Patients who choose nonoperative treatment should be warned of a
recurrence rate that is typically 15 to 25 percent but may be up to 38 percent [6,28]. It is also unclear whether the success
in avoiding immediate surgery justifies the fear and burden of potential recurrence or missed appendiceal neoplasm
(especially in older adults).
Appendectomy for nonperforated appendicitis — The current standard treatment for appendicitis is appendectomy,
which can be performed open or laparoscopically [29].
Timing of appendectomy — Patients present with appendicitis at all times of the day. Whether a stable patient with
nonperforated appendicitis requires surgery overnight or the next morning is controversial. However, a meta-analysis of 11
nonrandomized studies showed that a short in-hospital delay of 12 to 24 hours before surgery in that patient population
was not associated with an increased risk of perforation (odds ratio [OR] 0.97, 95% CI 0.78-1.19) [30]. The randomized
trials on treating appendicitis with antibiotics alone also provided additional indirect evidence in support of its safety [15].
However, delaying appendectomy for >48 hours was associated with increased surgical site infections and other
complications [30].
The timing of surgery also depends on the availability of surgeons and operating room resources. Hospitals staffed with an
around-the-clock in-house acute care surgical service and operating room crew may perform an appendectomy whenever
an operating room is available, day or night. For hospital without such resources, appendectomy when the operating room
opens the next morning is appropriate. In either situation, for acute nonperforated appendicitis in a stable patient, we
recommend appendectomy within 12 hours. Patients should be admitted to the hospital and receive intravenous hydration,
pain control, and intravenous antibiotics while awaiting surgery.
Preoperative preparation — Patients with acute appendicitis require adequate hydration with intravenous fluids,
correction of electrolyte abnormalities, and perioperative antibiotics [31]. The patient's vital signs and urine output should
be closely monitored; a Foley catheter may be required in severely dehydrated patients. Once the decision has been
made to perform an operation for acute appendicitis, the patient should proceed to the operating room with as little delay
as possible to minimize the chance of progression to perforation. (See 'Timing of appendectomy' above.)
Antibiotics for nonperforated appendicitis — Prophylactic antibiotics are important for preventing wound infection
and intra-abdominal abscess following appendectomy [31]. The flora of the appendix reflects that of the colon and includes
gram-negative aerobes and anaerobes.
Patients proceeding directly from the emergency room to the operating room for appendectomy without further delay
should receive prophylactic antibiotics within a 60-minute "window" before the initial incision [32,33]. In general, a single
preoperative antibiotic dose for surgical wound prophylaxis is adequate. Guidelines established by the Medical Letter and
the Surgical Care Improvement Project suggest the following options for appendectomy: a single dose of cefoxitin (2 g IV)
or cefotetan (2 g IV), or the combination of cefazolin (2 g if <120 kg or 3 g if ≥120 kg IV) PLUS metronidazole (500 mg IV),
or, in patients allergic to penicillins and cephalosporins, clindamycin PLUS one of the following: ciprofloxacin, levofloxacin,
gentamicin, or aztreonam (table 1) [34,35]. Postoperative antibiotics are unnecessary [36]. (See "Antimicrobial prophylaxis
for prevention of surgical site infection in adults" and "Control measures to prevent surgical site infection following
gastrointestinal procedures in adults", section on 'Gastroduodenal procedures'.)
Patients on aspirin or clopidogrel — Appendectomy is commonly performed urgently or emergently. In a

retrospective case-control study of patients undergoing laparoscopic appendectomy, those who were taking aspirin,
clopidogrel (Plavix), or both did not have more blood loss or transfusion requirement than matched controls; neither was
there any difference in complications, length of hospital stay, readmission, or mortality between the two groups [37]. Thus,
prehospital use of aspirin or clopidogrel should not preclude or delay laparoscopic appendectomy.
Patients who present at night and will not undergo appendectomy until the next morning should be admitted to the hospital
and started on intravenous antibiotics as soon as possible (often in the emergency room), rather than waiting until just
before surgery. In this case, we suggest choosing antibiotics from the list intended for patients with perforated/complicated
appendicitis to provide broad-spectrum coverage (see 'Antibiotics for perforated appendicitis' below). Additional
prophylactic antibiotics may be required if patients did not receive antibiotics within the 60-minute "window" before
incision.
Open versus laparoscopic — Open and laparoscopic appendectomy have been compared in over 70 randomized
trials and analyzed in many systematic reviews and meta-analyses [38-42]. A 2015 systematic review of nine moderate- to
high-quality meta-analyses (each analyzed 8 to 67 randomized trials) concluded that [43]:
The laparoscopic approach was superior for:
● A lower rate of wound infections (all nine meta-analyses; OR 0.3 to 0.52)
● Less pain on postoperative day 1 (two out of three meta-analyses; by 0.7 to 0.8 points on a 10-point visual analog
scale [VAS])
● Shorter duration of hospital stay (seven out of eight meta-analyses; by 0.16 to 1.13 days)
The open approach was superior for:
● A lower rate of intra-abdominal abscesses (three out of six meta-analyses; OR 1.56 to 2.29)
● A shorter operative time (eight meta-analyses; by 7.6 to 18.3 minutes)
A separate systematic review and pooled analysis also found laparoscopic appendectomy to be associated with fewer
short-term (pooled OR 0.43, 95% CI 0.3-0.63) and long-term adhesive bowel obstructions (OR 0.33, 95% CI 0.19-0.56)
[44].
Although laparoscopic appendectomy has gained widespread acceptance, there are both benefits and limitations to the
laparoscopic approach. As a result, the operative approach in patients with suspected appendicitis is best decided by the
surgeon based on personal experience, institutional capabilities, and individual patient factors such as the confidence in
the diagnosis; history of prior surgery; the patient's age, gender, and body habitus; and severity of disease. Evidence
suggests that laparoscopy may be the preferred approach in these following settings:
● An uncertain diagnosis – The laparoscopic approach provides an advantage in patients in whom the diagnosis is
uncertain since it permits inspection of other abdominal organs. This benefit may be greater for women of
childbearing age, who traditionally have had higher negative appendectomy rates, and in whom laparoscopy may
reveal other causes of pelvic pathology [22,45]. In a study of 181 women who underwent laparoscopy for suspected
acute appendicitis, 86 (48 percent) were diagnosed with a gynecologic disorder as the etiology of the symptoms [45].
● Obese patients – Laparoscopic appendectomy is useful in the overweight or obese patient, since exposure of the right
lower quadrant during open appendectomy may require larger, morbidity-prone incisions [46-48]. (See 'Obese
patients' below.)
● Older adult patients – Older adult patients may benefit significantly from a laparoscopic approach, as hospital stay is
shorter and discharge rates to home are higher in this population than with an open appendectomy. (See 'Older
adults' below.)
Laparoscopic techniques — Laparoscopic appendectomy was first described by Semm in 1983 [49]. Although open
appendectomy preceded it by almost 100 years, laparoscopic appendectomy has overtaken its open counterpart in
popularity [38-40,50]. A prospective trend analysis found that rates of complication, conversion, reoperation, and duration
of hospital stay associated with laparoscopic appendectomy have all decreased over a decade of observation [40].
● Anesthesia – Laparoscopic appendectomy is typically performed under general anesthesia.
● Patient preparation – In the laparoscopic approach, an orogastric tube is typically placed to decompress the
stomach. The bladder can be decompressed either with a Foley catheter or by having the patient void immediately
prior to entering the operating room.
● Patient positioning – The patient is positioned supine on the operating room table with the left arm tucked. The
video monitor is placed to the patient's right side because once pneumoperitoneum is established, both the surgeon
and assistant stand on the patient's left.
● Port placement – Various port placements have been advocated for laparoscopic appendectomy. These methods
share the principle of triangulation of instrument ports to ensure adequate visualization and exposure of the appendix.
In one method, pneumoperitoneum is obtained through a 12-mm periumbilical port, through which the laparoscope is
inserted and exploratory laparoscopy performed. The other two ports are placed under direct vision: a 5-mm port in
the left lower quadrant and a 5-mm suprapubic port in the midline (figure 1). If a 5-mm laparoscope is used, it can be
placed through the left lower quadrant trocar, and the umbilical 12-mm trocar can be used for a stapler. Most staplers
require a 12-mm port.
When the appendix is located in the retrocecal position, good triangulation of instruments can also be achieved with a
12-mm port placed in the upper midline. This port allows instruments or the laparoscope to be positioned for access to
the gutter between the right colon and the abdominal wall. If the risk for open conversion is high, all midline incisions
should be oriented vertically so they can easily be incorporated into a lower midline incision.
An alternative abdominal access method to conventional laparoscopy is single-incision laparoscopy, in which all
instruments and the laparoscope are inserted through a multi-channel portal placed at the umbilicus [51,52]. In a
meta-analysis of 11 randomized trials comparing single-incision with conventional laparoscopic appendectomy, single-
incision laparoscopic appendectomy was associated with a shorter length of stay and a quicker return to activities but
a longer operative time and a higher conversion rate [53].
● Mobilization – Once the diseased appendix is identified, any adhesions to surrounding structures can be lysed with a
combination of blunt and sharp dissection. If a retrocecal appendix is encountered, division of the lateral peritoneal
attachments of the cecum to the abdominal wall often improves visualization. Care must be taken to avoid underlying
retroperitoneal structures, specifically the right ureter and iliac vessels.
● Mesoappendix dissection – The appendix or mesoappendix can be gently grasped with a Babcock clamp and
retracted anteriorly. The appendiceal artery, or mesoappendix containing it, can be divided sharply between
hemostatic clips, with a laparoscopic gastrointestinal anastomosis (GIA) stapler, monopolar cautery, or one of the
advanced vessel ligation devices (eg, ultrasonic scalpel or LigaSure). The various technologies differ in operating time
and cost but not in patient-important outcomes such as complication rate and length of stay [54]. Thus, surgeons may
choose a technique based on his/her personal experience, the condition of the appendix, and available resources.
● Appendix transection – The appendix is cleared to its attachment with the cecum, and the appendiceal base is
divided using a laparoscopic GIA stapler, taking care not to leave a significant stump [55]. It is sometimes necessary
to include part of the cecum within the stapler to ensure that the staples are placed in healthy, uninfected tissue.
Alternatively, the appendix can be divided sharply between endoloops. Using endoloops to close the appendiceal
stump takes longer time but costs less than using a laparoscopic GIA stapler; otherwise, the length of stay and
complication rate (including that of intra-abdominal abscess) do not differ [56,57]. Thus, each surgeon may choose
the method of appendiceal stump closure based on his/her personal preference, the condition of the appendix, and
available resources. Other methods of appendiceal stump closure have been described (eg, suture knot, clip,
LigaSure) but are less commonly used due to limited data [58]. The appendiceal stump is typically not inverted after
laparoscopic appendectomy.
● Closure – The appendix is then removed through the umbilical port in a specimen bag to prevent wound infection.
The operative field is inspected for hemostasis and irrigated with saline if needed, and then the fascial defect and skin
incisions are closed.
Open techniques — Open appendectomy was described by McBurney in 1891 [59]. Since then, the technique has
remained largely unchanged.
● Anesthesia – Open appendectomy in adults can be performed under general or regional (spinal) anesthesia.
● Incision – The patient should be reexamined after the induction of general anesthesia, as this allows deep palpation
of the abdomen. If a mass representing the inflamed appendix can be palpated, the incision can be located over the
mass. If no appendiceal mass is detected, the incision should be centered over McBurney's point, one-third of the
distance from the anterior superior iliac spine to the umbilicus. A curvilinear incision in a skin fold allows for an
excellent cosmetic result.
It is important not to make the incision too medial or too lateral. An incision placed too medially opens onto the
anterior rectus sheath, rather than the desired oblique muscles, while an incision placed too laterally may be lateral to
the abdominal cavity. The incision can be oriented transversely or obliquely (perpendicular to the line connecting the
anterior superior iliac spine to the umbilicus) (figure 2). Some surgeons prefer a transverse incision because it can be
more easily extended to increased exposure if needed.
● Mobilization and resection – The dissection begins through the subcutaneous tissue to the external oblique fascia,
which is sharply incised lateral to the rectus sheath. Using a muscle-splitting technique, the external oblique is bluntly
separated in the direction of the muscle fibers; the internal oblique and transversus abdominis muscles are bluntly
separated in a similar fashion. The peritoneum is sharply entered, avoiding injury to the underlying intestine.
The surgeon can often locate the appendix by sweeping a finger laterally to medially in the right paracolic gutter. Thin
adhesions between the appendix and surrounding structures may generally be freed with blunt dissection;
occasionally, sharp dissection is required for more dense adhesions. If the appendix cannot be identified through
palpation, it can be located by following the teniae coli to its origin at the cecal base.
Once identified and freed from adhesions, the appendix is delivered through the incision. The mesoappendix may be
grasped with a Babcock clamp, taking care not to tear the appendiceal wall and cause spillage of enteric contents.
The appendiceal artery, which runs in the mesoappendix, is divided between hemostats and tied with 3-0 absorbable
sutures.
A nonabsorbable purse-string suture is placed in the cecal wall around the appendix. After crushing the appendiceal
base with a Kelly clamp, the appendix is doubly tied with 2-0 absorbable sutures. The appendix is excised with a
scalpel, and the remaining stump is cauterized to prevent a mucocele. The appendiceal stump is typically inverted
into the cecum while the purse-string suture is tightened, although the usefulness of stump inversion is debatable [60-
66]. The surgical bed is then irrigated with saline.
● Closure – The incision is closed in layers with running 2-0 absorbable suture, beginning with the peritoneum, followed
by the transversus abdominis, internal oblique, and external oblique. Irrigation is performed at each layer. To improve
analgesia and limit postoperative narcotic requirements, the external oblique fascia may be injected with local
anesthetic. Scarpa's fascia is closed with interrupted 3-0 absorbable suture, followed by a subcuticular closure or
staples for the skin. In nonperforated appendicitis, the skin may be closed primarily with a low likelihood of wound
infection.
Postoperative management — After either open or laparoscopic appendectomy for nonperforated appendicitis, patients
may be started on a clear liquid diet and advanced as tolerated to a regular diet. Antibiotics are not required
postoperatively. Most patients are discharged within 24 to 48 hours of surgery. Same-day discharge is feasible, most
commonly following a laparoscopic appendectomy [67,68].
PERFORATED APPENDICITIS — Patients with perforated appendicitis may appear acutely ill and have significant
dehydration and electrolyte abnormalities, particularly if fever and vomiting have been present for a long time. The pain
usually localizes to the right lower quadrant if the perforation has been walled off by surrounding intra-abdominal
structures such as the omentum but can be diffuse if generalized peritonitis ensues. On imaging studies, appendicitis can
present with a contained perforation (an inflammatory mass often referred to as a "phlegmon," or an intra-abdominal or
pelvic abscess) or, rarely, a free perforation.
Other unusual presentations of appendiceal perforation can occur, such as retroperitoneal abscess formation due to
perforation of a retrocecal appendix or liver abscess formation due to hematogenous spread of infection through the portal
venous system. An enterocutaneous fistula can result from an intraperitoneal abscess that fistulizes to the skin.
Appendiceal perforation can result in a small bowel obstruction, manifested by bilious vomiting and obstipation. High
fevers and jaundice can be seen with pylephlebitis (septic portal vein thrombosis) and can be confused with cholangitis.
Perforation is found in 13 to 20 percent of patients who present with acute appendicitis [69]. Perforation rate is higher
among men (18 percent men versus 13 percent women) and older adults [22,69]. Although perforation is a major concern
when evaluating a patient with symptoms that have lasted more than 24 hours, the time course of progression of
appendicitis to necrosis and perforation varies among patients, and perforation can develop more rapidly and should
always be considered. Approximately 20 percent of patients with perforated appendicitis present within 24 hours of the
onset of symptoms [70].
The management of perforated appendicitis depends on the condition of the patient (stable versus unstable), the nature of
the perforation (contained versus free perforation), and whether an abscess or phlegmon is present on imaging studies
(algorithm 1):
Unstable patients or patients with free perforation — A free perforation of the appendix can cause intraperitoneal
dissemination of pus and fecal material and generalized peritonitis. These patients are typically quite ill and may be septic
or hemodynamically unstable, thus requiring preoperative resuscitation. The diagnosis is not always appreciated before
exploration.
For patients who are septic or unstable, and for those who have a free perforation of the appendix or generalized
peritonitis, emergency appendectomy is required, as well as drainage and irrigation of the peritoneal cavity. Emergency
appendectomy in this setting can be accomplished open or laparoscopically; the choice is determined by surgeon
preference with consideration of patient condition and local resources. (See 'Appendectomy for perforated appendicitis'
below.)
Stable patients — Stable patients with perforated appendicitis who have symptoms localized to the right lower quadrant
can be treated with immediate appendectomy or initial nonoperative management. Both approaches are safe. A 2017
Cochrane review of two randomized trials concluded that the quality of the evidence was too low to make a
recommendation [71]. Thus, the decision ultimately rests with the treating surgeon. We suggest the following initial
approach based on imaging findings on presentation (algorithm 1):
● Patients with an appendiceal abscess should be treated with intravenous antibiotics and percutaneous, image-guided
drainage of the abscess. Immediate appendectomy is an alternative option for these patients, especially if the
abscess is not amenable to percutaneous drainage. (See 'Appendectomy for perforated appendicitis' below.)
● Patients with a phlegmon of the right lower quadrant should be treated with intravenous antibiotics. Repeat imaging is
often performed to follow the resolution (or progression) of the phlegmon, and to exclude other complications that
could evolve over time (eg, abscess formation). The authors of this topic do not perform immediate appendectomy in
patients with a phlegmon associated with perforated appendicitis.
Patients who fail initial antibiotic therapy clinically or radiographically require rescue appendectomy, whereas those who
respond to initial antibiotic therapy can be discharged with oral antibiotics to complete a 7- to 10-day course (in total) and
return for follow-up in six to eight weeks. (See 'Initial nonoperative management' below.)
Initial nonoperative management — Stable patients with perforated appendicitis who have symptoms localized to the
right lower quadrant (ie, no free perforation or generalized peritonitis) should be treated initially with antibiotics,
intravenous fluids, and bowel rest, rather than immediate surgery [72]. These patients will often have a palpable mass on
physical examination; a computed tomography (CT) scan may reveal a phlegmon or abscess.
Immediate surgery in patients with a long duration of symptoms and phlegmon or abscess formation has been associated
with increased morbidity, due to dense adhesions and inflammation [73]. Under these circumstances, appendectomy often
requires extensive dissection and may lead to injury of adjacent structures. Complications such as a postoperative
abscess or enterocutaneous fistula may ensue, necessitating an ileocolectomy or cecectomy. Nonoperative management
during the initial admission allows the local inflammation to subside; interval appendectomy, if elected, can be carried out
at a lower risk. Fortunately, many of these patients will respond to initial nonoperative management since the appendiceal
process has already been "walled off."
A 2010 meta-analysis of 17 nonrandomized studies showed that, compared with immediate surgery, initial nonoperative
management of perforated appendicitis with abscess or phlegmon is associated with fewer complications and similar
length of stay and duration of antibiotics [74]. Although a small randomized trial published after the meta-analysis showed
immediate laparoscopic appendectomy to be feasible for perforated appendicitis with abscess (median duration of
symptom seven days) and resulted in fewer readmissions and fewer additional interventions than nonoperative
management, substantial portions of patients who underwent immediate surgery required bowel resection (10 percent),
required conversion to open surgery (10 percent), or had incomplete appendectomy (13 percent) [73].
Initial nonoperative management includes intravenous antibiotics and fluids as well as bowel rest; any accessible abscess
should be drained percutaneously under image guidance. Patients should be closely monitored in the hospital during this
time. Treatment failure, as evidenced by bowel obstruction, sepsis, or persistent pain, fever, or leukocytosis, requires
immediate rescue appendectomy. If fever, tenderness, and leukocytosis improve, diet can be slowly advanced, usually
within three to five days. Patients are discharged home when clinical parameters have normalized and return for a follow-
up in six to eight weeks. (See 'Follow-up after initial nonoperative management of perforated appendicitis' below.)
Antibiotics for perforated appendicitis — In patients with perforated appendicitis, the antibiotic regimen should
consist of empiric broad-spectrum therapy with activity against gram-negative rods and anaerobic organisms pending
culture results. The choice of agents is based on patient and disease factors (see "Antimicrobial approach to intra-
abdominal infections in adults", section on 'Regimens'):
● Most perforated appendices or appendiceal abscesses fall into the category of mild-to-moderate community-acquired
intra-abdominal infections without risk factors for antibiotic resistance or treatment failure (table 2). Coverage of
streptococci, non-resistant Enterobacteriaceae, and (in most cases) anaerobes is generally sufficient (table 3).
● In cases of perforated appendicitis that are severe, or in patients at high risk for adverse outcomes or resistance
(table 2), broader empirical coverage is warranted. We generally include an agent with gram-negative activity broad
enough to cover Pseudomonas aeruginosa and Enterobacteriaceae that are resistant to non-pseudomonal
cephalosporins in addition to coverage against enteric streptococci and (in most cases) anaerobes (table 4).
● Although rare for appendicitis, in patients with healthcare-associated infections, the likelihood of drug resistance is
high. Thus, to achieve empiric coverage of likely pathogens, in addition to coverage against streptococci and
anaerobes, regimens should at least include agents with expanded spectra of activity against gram-negative bacilli
(including P. aeruginosa and Enterobacteriaceae that are resistant to non-pseudomonal third-generation
cephalosporins and fluoroquinolones). We also usually use an empiric regimen that has anti-enterococcal activity for
patients with healthcare-associated intra-abdominal infection, particularly those with postoperative infection, those
who have previously received cephalosporins or other antimicrobial agents selecting for Enterococcus species,
immunocompromised patients, and those with valvular heart disease or prosthetic intravascular materials (table 5).
Regardless of the initial empiric regimen, the therapeutic regimen should be revisited once culture and susceptibility
results are available. Recovery of more than one organism should suggest polymicrobial infection including anaerobes,
even if no anaerobes are isolated in culture. In such circumstances, anaerobic coverage should be continued. The
duration of antibiotics is discussed separately. (See "Antimicrobial approach to intra-abdominal infections in adults",
section on 'Duration of therapy'.)
Percutaneous abscess drainage — If imaging studies demonstrate an intra-abdominal or pelvic abscess,

computed tomography- or ultrasound-guided drainage can often be performed percutaneously or transrectally [75].
Studies suggest that percutaneous drainage of appendiceal abscesses results in fewer complications and shorter overall
length of stay than surgical drainage [72,76,77]. It also allows inflammation to subside before appendectomy, thereby
negating the need for a more extended bowel resection (eg, ileocecectomy) in some cases.
Follow-up after initial nonoperative management of perforated appendicitis — Using the initial nonoperative
approach outlined above, more than 80 percent of patients who present with a "walled-off" appendiceal process (ie,
contained perforation) can be spared an appendectomy during the initial admission [78].
After successful nonoperative management of perforated appendicitis, patients should be seen in six to eight weeks, at
which time those over 40 who have not undergone routine colonoscopic screening should be offered a colonoscopy. The
risk of such patients harboring a cecal or appendiceal neoplasm can be high [25]. (See 'Older adults' below.)
Some surgeons also offer routine interval appendectomy, while others do not [79]. The proponents of routine interval
appendectomy argue that:
● It prevents recurrent appendicitis (5 to 38 percent, depending upon studies and duration of follow-up [28,73,80,81]).
● It excludes appendiceal neoplasms. The prevalence of appendiceal neoplasm is significantly higher in interval
appendectomy specimens (5.9 to 12 percent [25,82,83]) than in routine appendectomy specimens (0.9 to 1.4 percent
[22,80,83]), especially in older adults (16 percent of interval appendectomies in patients over 40 [82]). (See
'Appendiceal neoplasms' below and 'Older adults' below.)
The opponents argue that the incidence of recurrent symptoms following successful conservative management of
perforated appendicitis is too low to justify routine surgery in asymptomatic patients [84].
The authors of this topic do not perform interval appendectomy routinely. Instead, we follow patients clinically and offer
appendectomy only to those with residual or recurrent symptoms.
Appendectomy for perforated appendicitis — Appendectomy may be required to treat perforated appendicitis in one
of three clinical scenarios:
● Emergency appendectomy is required for patients with free perforation of the appendicitis, with diffuse peritonitis, or
who are septic or hemodynamically unstable as a result of perforated appendicitis. (See 'Unstable patients or patients
with free perforation' above.)
● The authors of this topic would consider offering immediate appendectomy to patients with perforated appendicitis
with an abscess but not a phlegmon on imaging studies. (See 'Stable patients' above.)
● Rescue appendectomy is required for patients with perforated appendicitis who fail to respond to nonoperative
management with intravenous antibiotics with or without percutaneous drainage, regardless of initial imaging findings.
(See 'Stable patients' above.)
Open versus laparoscopic — In the early days of laparoscopic appendectomy, it was contraindicated in perforated
appendicitis due to the severity of inflammation and complexity of anatomy. In a study of 235,473 patients with suspected
acute appendicitis undergoing a laparoscopic or open appendectomy between 2000 and 2005 from the United States
Nationwide Inpatient Sample, the proportion of patients with uncomplicated appendicitis was significantly higher in the
laparoscopic group (76 versus 69 percent) [38]. For patients with complicated appendicitis, defined as an appendiceal
perforation or abscess, the laparoscopic approach was significantly associated with a shorter mean hospital stay (3.5
versus 4.2 days), higher rates of intraoperative complications (odds ratio [OR] 1.61, 95% CI 1.33-1.94), and higher
hospital costs (9 percent) compared with patients undergoing an open appendectomy.
As surgeons gained more experience with the technique, laparoscopic appendectomy became feasible for patients with
perforated appendicitis undergoing immediate surgery [85]. A 2017 systematic review and meta-analysis of two trials and
14 retrospective studies of perforated appendicitis showed that, compared with open surgery, laparoscopic appendectomy
reduced the risk of surgical site infection, length of hospital stay, and time to oral intake without increasing the rate of intra-
abdominal abscess. The operating time was slightly longer with laparoscopic appendectomy, but only by 14 minutes [86].
We recommend that surgeons choose the technique with which they are more experienced and prepare to convert to
open surgery if unexpected findings occur during laparoscopic exploration.
Techniques — Operative techniques are similar to those used for nonperforated appendicitis described above, with
the following exceptions (see 'Laparoscopic techniques' above and 'Open techniques' above):
● Incision – In an open appendectomy for perforation, a larger incision may be required to provide adequate exposure
for drainage of abscesses, enteric contents, and purulent material. In some instances, a lower midline incision is
preferable to a right lower quadrant incision (eg, free perforation or generalized peritonitis).
● Irrigation – In both open and laparoscopic approaches to perforated appendicitis, the goal is to remove any infected
material and drain all abscess cavities at the time of appendectomy. Copious irrigation was traditionally used to
reduce the likelihood of postoperative abscess formation, although most [87,88], but not all [89], contemporary studies
failed to demonstrate a benefit. For perforated appendicitis with intra-abdominal or pelvic contamination, we suggest
first clearing the purulent collection with suction. Peritoneal irrigation can then be applied judiciously, with frequent,
repeated suctioning of the irrigant. The goal is to dilute and remove infected material without spreading the infection to
the rest of the abdomen.
● Drains – Peritoneal drains are not necessary after an appendectomy for perforated appendicitis [90,91]. A 2018
Cochrane systematic review of six trials found the effect of abdominal drainage on the prevention of intra-peritoneal
abscess or wound infection after open appendectomy uncertain for patients with complicated appendicitis due to low
or very low quality of the evidence [92].
● Closure – Skin closure techniques include primary closure, loose partial closure, and closure with secondary
intention. Because of wound infection rates ranging from 30 to 50 percent with primary closure of grossly
contaminated wounds, many advocate delayed primary or secondary closure [93,94]. However, two meta-analyses
showed that, compared with primary closure, delayed closure increased the length of hospital stay by 1.6 days
without decreasing the wound infection rate [95,96]. A cost-utility analysis of contaminated appendectomy wounds
also showed primary closure to be the most cost-effective method of wound management [97].
For patients with a contaminated wound due to perforated appendicitis, we suggest against delayed wound closure.
Our preferred technique of skin closure after an open appendectomy is interrupted permanent sutures or staples
every 2 cm with loose wound packing in between. Removal of the packing in 48 hours often leaves an excellent
cosmetic result with an acceptable incidence of wound infection. If heavy fecal contamination is present, the skin is
often left open to close secondarily. Wounds are typically closed after a laparoscopic appendectomy for perforated
appendicitis.
Postoperative management — Patients with perforated appendicitis often develop an ileus postoperatively
regardless of the surgical approach (open versus laparoscopic). Thus, diet should only be advanced as the clinical
situation warrants. Patients may be discharged once they tolerate a regular diet, usually in five to seven days. Three to
five days of intravenous antibiotics is recommended for perforated appendicitis after appendectomy [98]. (See
"Antimicrobial approach to intra-abdominal infections in adults", section on 'Duration of therapy'.)
UNEXPECTED INTRAOPERATIVE FINDINGS
Normal appendix — The diagnosis of appendicitis can be uncertain. In some historical studies, more than 15 percent of
patients with suspected appendicitis have a normal appendix at laparotomy, with higher percentages in infants, older
adults, and young women [22,99]. However, the use of imaging studies and laparoscopy have reduced the negative
appendectomy rate [100]. The contemporary negative appendectomy rate varies from 6 percent in the United States
(routine use of preoperative imaging) and Switzerland (routine use of laparoscopy) to 21 percent in the United Kingdom
(selective use of imaging and laparoscopy) [100-102].
If an uninflamed appendix is encountered at appendectomy, it is important to search for other causes of the patient's
symptoms, including terminal ileitis; cecal or sigmoid diverticulitis; a perforating colon carcinoma; Meckel's diverticulitis;
mesenteric adenitis; or uterine, fallopian, or ovarian pathology in a female.
Even if the appendix appears normal, early intramural or serosal inflammatory changes can sometimes be found in
subsequent microscopic evaluation [103,104]. Accordingly, the normal-appearing appendix should be removed. Moreover,
if right lower quadrant pain recurs, appendicitis can be excluded from the differential diagnosis [105].
Chronic appendicitis — Chronic appendicitis refers to the pathologic finding of chronic inflammation or fibrosis of the
appendix in a subset of patients undergoing appendectomy [106,107]. These patients are clinically characterized by
prolonged (>7 days) right lower quadrant pain that may be intermittent and a normal white blood cell count. Most patients
have resolution of pain with appendectomy. Chronic appendicitis may be present in 14 to 30 percent of adults undergoing
appendectomy [106,107] but is much rarer in children.
Appendiceal neoplasms — Neoplasms of the appendix are rare, occurring in less than 1 percent of routine
appendectomies. Patients may present with symptoms of appendicitis, a palpable mass, intussusception, urologic
symptoms, or an incidentally discovered mass on abdominal imaging or at laparotomy for another purpose. It is not
uncommon for patients with an appendiceal neoplasm to have acute appendicitis as well [83,108,109]. Typically, the
diagnosis is not appreciated until surgery or pathologic evaluation of the appendectomy specimen. The most common
appendiceal tumors include carcinoid tumors, adenocarcinoma, and mucinous neoplasms [110].
● Appendiceal neuroendocrine (carcinoid) tumor – Simple appendectomy is sufficient in most cases of appendiceal
carcinoid, while right hemicolectomy is indicated for tumors >2 cm or if the adjacent mesenteric nodes are involved.
Management of carcinoid tumors is discussed elsewhere in detail. (See "Cancer of the appendix and pseudomyxoma
peritonei", section on 'Neuroendocrine tumors'.)
● Appendiceal adenocarcinoma – Standard treatment is right hemicolectomy, and reoperation is recommended if the
diagnosis is made on pathologic evaluation of an appendectomy specimen. This is discussed in detail elsewhere.
(See "Cancer of the appendix and pseudomyxoma peritonei", section on 'Adenocarcinoma'.)
● Appendiceal mucocele – Sometimes referred to as mucoceles, mucinous neoplasms of the appendix include a
spectrum of diseases including simple cyst, mucinous cystadenoma, mucinous cystadenocarcinoma, and
pseudomyxoma peritonei [111]. If there is any preoperative suspicion of an appendiceal tumor, care must be taken to
avoid spillage of mucin-secreting cells throughout the abdomen. These tumors are discussed in detail elsewhere.
(See "Appendiceal mucoceles".)
SPECIAL PATIENT POPULATIONS
Older adults — One in every 2000 adults over age 65 will develop appendicitis annually, making appendicitis an
important cause of abdominal pain in this age group. Older adults tend to have a diminished inflammatory response,
resulting in less remarkable findings on history and physical examination [112]. For these reasons, older patients often
delay seeking medical care, and, as a result, they have a considerably higher rate of perforation at the time of presentation
[113,114]. Older patients may have comorbid cardiac, pulmonary, and renal conditions with resulting morbidity and
mortality from perforation. In one series, the mortality from perforated appendicitis in patients over age 80 was 21 percent
[115]. Older patients can also have a redundant sigmoid colon that can cause right-sided pain from sigmoid diseases.
Accordingly, computed tomography (CT) scanning can improve diagnostic accuracy in this population [116].
Laparoscopic appendectomy can be used successfully in the older adult population and results in shorter hospitalization
for older patients with both perforated and nonperforated appendicitis [117,118]. In a retrospective review based upon
outcome data from the North Carolina Hospital Association Patient Data System on 29,244 appendectomies performed in
adults, 2722 were performed in older patients (defined as age >65 years) [117]. Among the older patients, laparoscopic
appendectomy had the following benefits compared with those undergoing an open appendectomy:
● For uncomplicated appendicitis, laparoscopic appendectomy was associated with a shorter length of hospital stay
(4.6 versus 7.3 days), a higher rate of discharge to home rather than a nursing facility (91 versus 79 percent), fewer
complications (13 versus 22 percent), and lower mortality rate (0.4 versus 2.1 percent).
● For a perforated appendix, laparoscopic appendectomy was also associated with a shorter length of hospital stay
(6.8 versus 9.0 days), a higher rate of discharge to home (87 versus 71 percent), and equivalent mortality rates (0.37
versus 0.15 percent).
Because colonic neoplasms are more common in older patients and can mimic appendicitis, patients over 40 who are
managed nonoperatively for perforated appendicitis should undergo colonic screening with colonoscopy, CT, or both [25],
in additional to undergoing an interval appendectomy. (See 'Follow-up after initial nonoperative management of perforated
appendicitis' above.)
Immunocompromised patients — Immunocompromised patients are increasingly common in surgical practice and
include organ transplant recipients and those receiving immunosuppressive therapy for autoimmune diseases, cancer, and
AIDS. Although certain causes of abdominal pain are specific to the immunocompromised state, appendicitis remains a
concern [119,120]. (See "Surgical issues in HIV infection".)
The immunocompromised are susceptible to infection, and their immune response is blunted due to immunosuppressive
medication or disease. As a result, they may not exhibit the typical signs and symptoms of appendicitis and may have only
mild tenderness on examination. In addition, laboratory and radiological tests may not show the expected level of
inflammation. An expanded differential diagnosis includes but is not limited to opportunistic (mycobacterial) and viral
(cytomegalovirus) infections, fungal infections, secondary malignancies (lymphoma and Kaposi's sarcoma), and typhlitis.
Because of the broad differential diagnoses, there is often a delay in reaching the diagnosis and presentation to surgical
evaluation, which can increase the risk of perforation [119,121].
CT is particularly useful in this patient population as it may not only diagnose appendicitis but may exclude or diagnose
other potential causes for the patient's symptoms. If appendicitis is strongly suspected, operation should not be delayed,
as there is no specific contraindication to operation in immunocompromised patients.
Obese patients — Laparoscopic appendectomy is beneficial in overweight or obese patients, since exposure of the right
lower quadrant during open appendectomy may require larger, morbidity-prone incisions [46-48]. In a meta-analysis of five
studies of patients with a body mass index of >30 kg/m2, laparoscopic appendectomy, as compared with open surgery,
was associated with fewer postoperative complications, including wound infections and intra-abdominal abscesses, short
operative time and hospital stay, and lower hospital charges [122].
Children — Appendicitis in children is discussed in detail separately. (See "Acute appendicitis in children: Diagnostic
imaging" and "Acute appendicitis in children: Clinical manifestations and diagnosis" and "Acute appendicitis in children:
Management".)
Pregnancy — Pregnancy poses unique challenges in the diagnosis of appendicitis. Acute appendicitis in pregnancy is
discussed in detail separately. (See "Acute appendicitis in pregnancy".)
OUTCOMES
Mortality — The mortality associated with appendicitis is low but can vary by geographic locations. In developed
countries, the mortality rate is between 0.09 and 0.24 percent. In developing countries, the mortality rate is higher,
between 1 and 4 percent [98].
In a worldwide observational study of 4282 consecutive patients from 44 countries treated for acute appendicitis in 2016
(95 percent surgically), the overall mortality rate was 0.28 percent [5]. In univariate analyses, predictors of mortality
included age >80 years, immunosuppression, severe cardiovascular disease, Charlson comorbidity score >5, previous
episodes of suspected appendicitis, previous antimicrobial therapy, World Society of Emergency Surgery (WSES)
appendicitis grade 3C to 4, and a pathologic report of perforation. At multivariate analysis, however, only Charlson
comorbidity score >5 (odds ratio [OR] 52.45, p <0.05) and WSES grade 3C (OR 11.77, p <0.05) and 4 (OR 11.32, p <0.05)
were confirmed as independent variables that were predictors of mortality.
Morbidity — Overall complication rates of 8.2 to 31.4 percent, wound infection rates of 3.3 to 10.3 percent, and pelvic
abscess rates of 9.4 percent have been reported following appendectomy [98].
The most common complication following appendectomy is surgical site infection, either a simple wound infection or an
intra-abdominal abscess. Both typically occur in patients with perforated appendicitis and are very rare in those with
simple appendicitis. Thorough irrigation and broad-spectrum antibiotics are used to minimize the incidence of
postoperative infections. Delayed primary closure of the wound has not decreased the rate of wound infection compared
with primary closure. (See 'Techniques' above.)
Compared with open appendectomy, laparoscopic appendectomy has been associated with a lower risk of incisional
infection (OR 0.37, 95% CI 0.32-0.43) but a high risk of organ space (intra-abdominal or pelvic) infection (OR 1.44, 95% CI
1.21-1.73) [123]. (See 'Open versus laparoscopic' above.)
Recurrent or stump appendicitis — Recurrent appendicitis can occur in 5 to 38 percent of patients who are managed
nonoperatively, depending on the study and the length of follow-up. Interval appendectomy eliminates the risk of recurrent
appendicitis. (See 'Follow-up after initial nonoperative management of perforated appendicitis' above.)
Stump appendicitis is a form of recurrent appendicitis that is related to incomplete appendectomy that leaves an
excessively long stump after open or laparoscopic surgery, more commonly for perforated appendicitis. To minimize stump
appendicitis, the appendix should be transected no further than 0.5 cm from its junction with the cecum and removed as a
whole. In case stump appendicitis occurs, stump resection can be performed open or laparoscopically. A perforated
appendiceal stump, however, typically requires a more extensive bowel resection to control [124].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and
regions around the world are provided separately. (See "Society guideline links: Appendicitis in adults".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level
and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)
● Basics topics (see "Patient education: Appendicitis in adults (The Basics)")
SUMMARY AND RECOMMENDATIONS
● For adult patients with nonperforated appendicitis, we suggest appendectomy rather than nonoperative management
with antibiotics (algorithm 1) (Grade 2B). Despite evidence that antibiotics alone can be as effective as surgery for
managing the initial presentation of appendicitis, these studies show modest recurrence rates and missed neoplasms.
Patients who elect for antibiotic-alone therapy must be clearly counseled on the risks and benefits of that option. (See
'Nonperforated appendicitis' above.)
● For acute nonperforated appendicitis, immediate appendectomy should be performed within 12 hours of diagnosis.
(See 'Timing of appendectomy' above.)
• For patients proceeding directly from the emergency room to the operating room for appendectomy without
further delay, a single dose of prophylactic antibiotics should be given within a 60-minute "window" before incision
(table 1). Prophylactic antibiotics are important for preventing wound infection and intra-abdominal abscess
following appendectomy. (See 'Preoperative preparation' above.)
• Patients who present at night and will not undergo appendectomy until the next morning should be admitted to
the hospital and started on intravenous antibiotics as soon as possible (often in the emergency room), rather than
waiting until just before surgery. In this case, we suggest choosing antibiotics from the list intended for patients
with perforated/complicated appendicitis to provide broad-spectrum coverage. Additional prophylactic antibiotics
may be required if patients did not receive antibiotics within the 60-minute "window" before incision. (See
'Preoperative preparation' above and 'Antibiotics for perforated appendicitis' above.)
● Both open and laparoscopic approaches to appendectomy are appropriate for all patients; the choice is by surgeon
preference. In general, patients treated with a laparoscopic appendectomy have fewer wound infections, less pain,
and a shorter duration of hospital stay but more intra-abdominal abscesses and a longer operating time. (See 'Open
versus laparoscopic' above.)
● Patients with perforated appendicitis causing hemodynamic instability, sepsis, free perforation, or generalized
peritonitis require emergency appendectomy, irrigation and drainage of the peritoneal cavity, and sometimes bowel
resection (algorithm 1). Both open and laparoscopic approaches are appropriate, depending on surgeon experience,
patient condition, and local resources. (See 'Unstable patients or patients with free perforation' above.)
● For stable patients with perforated appendicitis and symptoms localized to the right lower quadrant, we suggest initial
nonoperative management rather than immediate appendectomy (Grade 2C). Nonoperative management consists of
intravenous antibiotics and, if an abscess is present, percutaneous drainage (algorithm 1). The choice of antibiotics
depends on whether the disease is mild to moderate (table 3), severe (table 4), or if the patient has been recently
hospitalized (table 5). Patients who fail to respond to antibiotics require rescue appendectomy. Immediate
appendectomy is an alternative option for patients who present with an appendiceal abscess, especially if the
abscess is not amenable to percutaneous drainage. (See 'Stable patients' above.)
● Following initial nonoperative management of perforated appendicitis with an appendiceal abscess or phlegmon,
patients should be seen in six to eight weeks. Patients over 40 who have not undergone routine colonoscopic
screening should be offered a colonoscopy. Whether to perform interval appendectomy routinely or selective is
controversial; the authors only perform interval appendectomy in patients who have persistent or recurrent symptoms.
(See 'Follow-up after initial nonoperative management of perforated appendicitis' above.)
● We suggest removing a grossly normal-appearing appendix at the time of surgical exploration rather than leaving it in
situ (Grade 2C). Subclinical inflammation can be detected by microscopic evaluation. Moreover, if right lower
quadrant pain recurs, appendicitis can be excluded from the differential diagnosis. (See 'Normal appendix' above.)
● Appendiceal neoplasms occur in 1 percent of all appendectomies but in 10 percent of interval appendectomies. The
most common appendiceal tumors include carcinoid tumors, adenocarcinoma, and mucinous neoplasms. Treatments
are discussed separately. (See 'Appendiceal neoplasms' above and "Cancer of the appendix and pseudomyxoma
peritonei".)
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73. Mentula P, Sammalkorpi H, Leppäniemi A. Laparoscopic Surgery or Conservative Treatment for Appendiceal
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75. Gee D, Babineau TJ. The optimal management of adult patients presenting with appendiceal abscess:
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76. Siewert B, Raptopoulos V. CT of the acute abdomen: findings and impact on diagnosis and treatment. AJR Am J
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78. Fagenholz PJ, Peev MP, Thabet A, et al. Abscess due to perforated appendicitis: factors associated with successful
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79. Darwazeh G, Cunningham SC, Kowdley GC. A Systematic Review of Perforated Appendicitis and Phlegmon:
Interval Appendectomy or Wait-and-See? Am Surg 2016; 82:11.
80. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and
meta-analysis. Ann Surg 2007; 246:741.
81. Kaminski A, Liu IL, Applebaum H, et al. Routine interval appendectomy is not justified after initial nonoperative
treatment of acute appendicitis. Arch Surg 2005; 140:897.
82. Wright GP, Mater ME, Carroll JT, et al. Is there truly an oncologic indication for interval appendectomy? Am J Surg
2015; 209:442.
83. Teixeira FJR Jr, Couto Netto SDD, Akaishi EH, et al. Acute appendicitis, inflammatory appendiceal mass and the risk
of a hidden malignant tumor: a systematic review of the literature. World J Emerg Surg 2017; 12:12.
84. Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass--is it necessary?
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85. Lin HF, Lai HS, Lai IR. Laparoscopic treatment of perforated appendicitis. World J Gastroenterol 2014; 20:14338.
86. Yu MC, Feng YJ, Wang W, et al. Is laparoscopic appendectomy feasible for complicated appendicitis ?A systematic
review and meta-analysis. Int J Surg 2017; 40:187.
87. Moore CB, Smith RS, Herbertson R, Toevs C. Does use of intraoperative irrigation with open or laparoscopic
appendectomy reduce post-operative intra-abdominal abscess? Am Surg 2011; 77:78.
88. St Peter SD, Adibe OO, Iqbal CW, et al. Irrigation versus suction alone during laparoscopic appendectomy for
perforated appendicitis: a prospective randomized trial. Ann Surg 2012; 256:581.
89. Sun F, Wang H, Zhang F, et al. Copious Irrigation Versus Suction Alone During Laparoscopic Appendectomy for
Complicated Appendicitis in Adults. J Invest Surg 2018; 31:342.
90. Greenall MJ, Evans M, Pollock AV. Should you drain a perforated appendix? Br J Surg 1978; 65:880.
91. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in
gastrointestinal surgery: a systematic review and meta-analyses. Ann Surg 2004; 240:1074.
92. Li Z, Zhao L, Cheng Y, et al. Abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for
complicated appendicitis. Cochrane Database Syst Rev 2018; 5:CD010168.
93. Lemieur TP, Rodriguez JL, Jacobs DM, et al. Wound management in perforated appendicitis. Am Surg 1999; 65:439.
94. Cohn SM, Giannotti G, Ong AW, et al. Prospective randomized trial of two wound management strategies for dirty
abdominal wounds. Ann Surg 2001; 233:409.
95. Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized clinical trials comparing
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97. Brasel KJ, Borgstrom DC, Weigelt JA. Cost-utility analysis of contaminated appendectomy wounds. J Am Coll Surg
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management. Lancet 2015; 386:1278.
99. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A population-
based analysis. JAMA 2001; 286:1748.
100. SCOAP Collaborative, Cuschieri J, Florence M, et al. Negative appendectomy and imaging accuracy in the
Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 2008; 248:557.
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outcome of emergency appendicectomy. Br J Surg 2013; 100:1240.
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laparoscopic surgery for suspected appendicitis. Br J Surg 2011; 98:589.
103. Phillips AW, Jones AE, Sargen K. Should the macroscopically normal appendix be removed during laparoscopy for
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60:950.
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117. Harrell AG, Lincourt AE, Novitsky YW, et al. Advantages of laparoscopic appendectomy in the elderly. Am Surg
2006; 72:474.
118. Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a
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164:467.
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123. Fleming FJ, Kim MJ, Messing S, et al. Balancing the risk of postoperative surgical infections: a multivariate analysis
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124. Kanona H, Al Samaraee A, Nice C, Bhattacharya V. Stump appendicitis: a review. Int J Surg 2012; 10:425.
Topic 1383 Version 54.0
GRAPHICS
Management of acute appendicitis in adults
* Perforated appendicitis, also referred to as complicated appendicitis, is characterized by a palpable mass in the right lower quadrant on
physical examination or by a phlegmon (inflammatory mass) or abscess on imaging studies. Nonperforated appendicitis, also referred to as
simple or uncomplicated appendicitis, does not have any clinical or radiologic signs of perforation.
¶ The choice of antibiotics varies by clinical situations and is constantly evolving. Refer to related topics in UpToDate for information on
antibiotic selection.
Δ Immediate appendectomy, as opposed to interval appendectomy, should be performed within 12 hours of decision to operate, except in the
case of unstable/septic patient or the presence of free perforation or generalized perforation, where surgery should be performed emergently.
◊ Immediate appendectomy is an alternative option for patients with an appendiceal abscess, especially if the abscess is not amenable to
percutaneous drainage.
Graphic 115333 Version 1.0
Antimicrobial prophylaxis for gastrointestinal surgery in adults
Nature of Common Recommended Usual adult

Redose interval ¶
operation pathogens antimicrobials dose*
Gastroduodenal surgery
Procedures involving Enteric gram-negative Cefazolin Δ <120 kg: 2 g IV Four hours

entry into lumen of bacilli, gram-positive ≥120 kg: 3 g IV
gastrointestinal tract cocci
Procedures not Enteric gram-negative High risk ◊ only: <120 kg: 2 g IV Four hours
involving entry into bacilli, gram-positive cefazolin Δ ≥120 kg: 3 g IV
lumen of cocci
gastrointestinal tract
(selective vagotomy,
antireflux)
Biliary tract surgery (including pancreatic procedures)
Open procedure or Enteric gram-negative Cefazolin Δ ¥ <120 kg: 2 g IV Four hours

laparoscopic bacilli, enterococci, ≥120 kg: 3 g IV
procedure (high clostridia
risk) § OR cefotetan 2 g IV Six hours
OR cefoxitin 2 g IV Two hours
OR ampicillin- 3 g IV Two hours

sulbactam
Laparoscopic N/A None None None

procedure (low risk)
Appendectomy ‡
Enteric gram-negative Cefoxitin Δ 2 g IV Two hours

bacilli, anaerobes,
OR cefotetan Δ 2 g IV Six hours
enterococci
OR cefazolin Δ <120 kg: 2 g IV Four hours
≥120 kg: 3 g IV
PLUS metronidazole 500 mg IV N/A
Small intestine surgery
Nonobstructed Enteric gram-negative Cefazolin Δ <120 kg: 2 g IV Four hours

bacilli, gram-positive ≥120 kg: 3 g IV
cocci
Obstructed Enteric gram-negative Cefoxitin Δ 2 g IV Two hours

bacilli, anaerobes,
enterococci
≥120 kg: 3 g IV
Hernia repair
Aerobic gram-positive Cefazolin Δ <120 kg: 2 g IV Four hours

organisms ≥120 kg: 3 g IV
Colorectal surgery †
Enteric gram-negative Parenteral:

bacilli, anaerobes,
Cefoxitin Δ 2 g IV Two hours
enterococci

≥120 kg: 3 g IV
OR ampicillin- 3 g IV (based on Two hours

sulbactam Δ,** combination)
Oral (used in conjunction with mechanical bowel preparation):
Neomycin PLUS ¶¶ ¶¶
erythromycin base or
metronidazole
IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If vancomycin or
a fluoroquinolone is used, the infusion should be started within 60 to 120 minutes before the initial incision to have adequate tissue
levels at the time of incision and to minimize the possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns, additional intraoperative doses
should be given at intervals one to two times the half-life of the drug.
Δ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15 mg/kg IV; not to exceed 2 g) with
either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg IV), or aztreonam (2 g IV) is a reasonable alternative.
Metronidazole (500 mg IV) plus an aminoglycoside or fluoroquinolone are also acceptable alternative regimens, although metronidazole
plus aztreonam should not be used, since this regimen does not have aerobic gram-positive activity.
◊ Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy or perforation, or
immunosuppression.
§ Factors that indicate high risk may include age >70 years, pregnancy, acute cholecystitis, nonfunctioning gall bladder, obstructive
jaundice, common bile duct stones, immunosuppression.
¥ Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.
‡ For a ruptured viscus, therapy is often continued for approximately five days.
† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.
** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local sensitivity profiles should be
reviewed prior to use.
¶¶ In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered: neomycin (1 g) plus erythromycin
base (1 g) OR neomycin (1 g) plus metronidazole (1 g). The oral regimen should be given as three doses over approximately 10 hours
the afternoon and evening before the operation. Issues related to mechanical bowel preparation are discussed further separately; refer to
the UpToDate topic on overview of colon resection.
Data from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infec
(Larchmt) 2013; 14:73.
Laparoscopic appendectomy
Illustration by Jenny Wang.
Open appendectomy
Risk factors that warrant broad empiric antimicrobial coverage for intra-abdominal
infections
Factors associated with mortality

Age >70 years
Medical comorbidity (eg, renal or liver disease, presence of malignancy, chronic malnutrition)
Immunocompromising condition (eg, poorly controlled diabetes mellitus, chronic high-dose corticosteroid use, use of other
immunosuppressive agents, neutropenia, advanced HIV infection, B or T leukocyte deficiency)
High severity of illness (ie, sepsis)
Extensive peritoneal involvement or diffuse peritonitis
Delay in initial intervention (source control) >24 hours
Inability to achieve adequate debridement or drainage control
Factors associated with infection with antibiotic-resistant bacteria

Healthcare-acquired infection
Travel to areas with higher rates of antibiotic-resistant organisms* within the few weeks prior to infection onset or if antibiotics
were received during travel
Known colonization with antibiotic-resistant organisms
* High rates of antibiotic resistance have been reported from southeast Asia, east Asia, the Middle East, and Africa.
References:
1. Solomkin JS, Mazuski JE, Bradley 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. Clin Infect Dis 2010; 50:133.
2. Woerther PL, Burdet C, Chachaty E, Andremont A. Trends in human fecal carriage of extended-spectrum β-lactamases in the
community: toward the globalization of CTX-M. Clin Microbiol Rev 2013; 26:744.
Empiric antibiotic regimens for low-risk community-acquired intra-abdominal infections in

adults
Dose
Single-agent regimen
Ertapenem 1 g IV once daily
Piperacillin-tazobactam 3.375 g IV every 6 hours
Ticarcillin-clavulanate 3.1 g IV every 4 hours
Combination regimen with metronidazole
ONE of the following:
Cefazolin 1 to 2 g IV every 8 hours
OR
Cefuroxime 1.5 g IV every 8 hours
OR
Ceftriaxone 2 g IV once daily
OR
Cefotaxime 2 g IV every 8 hours
OR
Ciprofloxacin 400 mg IV every 12 hours or

500 mg PO every 12 hours
OR
Levofloxacin 750 mg IV or PO once daily
PLUS:
Metronidazole 500 mg IV or PO every 8 hours
Low-risk community-acquired intra-abdominal infections are those that are of mild-to-moderate severity (including perforated
appendix or appendiceal abscess) in the absence of risk factors for antibiotic resistance or treatment failure. Such risk factors
include recent travel to areas of the world with high rates of antibiotics-resistant organisms, known colonization with such
organisms, advanced age, immunocompromising conditions, or other major medical comorbidities. Refer to other UpToDate
content on the antimicrobial treatment of intra-abdominal infections for further discussion of these risk factors.
For empiric therapy of low-risk community-acquired intra-abdominal infections, we cover streptococci, Enterobacteriaceae, and
anaerobes.
The antibiotic doses listed are for adult patients with normal renal function.
IV: intravenously; PO: orally.
Empiric antibiotic regimens for high-risk community-acquired intra-abdominal infections in

adults
Dose
Imipenem-cilastatin 500 mg IV every six hours
Meropenem 1 g IV every eight hours
Doripenem 500 mg IV every eight hours
Piperacillin-tazobactam 4.5 g IV every six hours
Combination regimen with metronidazole
Cefepime 2 g IV every eight hours
OR
Ceftazidime 2 g IV every eight hours
PLUS:
Metronidazole 500 mg IV or PO every eight hours
High-risk community-acquired intra-abdominal infections are those that are severe or in patients at high risk for adverse
outcomes or antimicrobial resistance. These include patients with recent travel to areas of the world with high rates of
antibiotics-resistant organisms, known colonization with such organisms, advanced age, immunocompromising conditions, or
other major medical comorbidities. Refer to the topic on the antimicrobial treatment of intra-abdominal infections for further
discussion of these risk factors.
For empiric therapy of high-risk community-acquired intra-abdominal infections, we cover streptococci, Enterobacteriaceae
resistant to third-generation cephalosporins, Pseudomonas aeruginosa, and anaerobes. Empiric antifungal therapy is usually not
warranted, but is reasonable for critically ill patients with an upper gastrointestinal source.
Local rates of resistance should inform antibiotic selection (ie, agents for which there is >10 percent resistance among
Enterobacteriaceae should be avoided). If the patient is at risk for infection with an extended-spectrum beta-lactamase (ESBL)-
producing organism (eg, known colonization or prior infection with an ESBL-producing organism), a carbapenem should be
chosen. When beta-lactams or carbapenems are chosen for patients who are critically ill or are at high risk of infection with
drug-resistant pathogens, we favor a prolonged infusion dosing strategy. Refer to other UpToDate content on prolonged infusions
of beta-lactam antibiotics.
The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot use beta-lactams or
carbapenems (eg, because of severe reactions).
IV: intravenous; PO: orally.
Empiric antibiotic regimens for health care-associated intra-abdominal infections in adults
Dose
Imipenem-cilastatin 500 mg IV every six hours
Meropenem 1 g IV every eight hours
Doripenem 500 mg IV every eight hours
Piperacillin-tazobactam 4.5 g IV every six hours
Combination regimen
Cefepime 2 g IV every eight hours
OR
Ceftazidime 2 g IV every eight hours
PLUS:
Metronidazole 500 mg IV or PO every eight hours
PLUS ONE of the following (in some cases*):
Ampicillin 2 g IV every four hours
OR
Vancomycin 15 to 20 mg/kg IV every eight to twelve hours
For empiric therapy of health care-associated intra-abdominal infections, we cover streptococci, enterococci, Enterobacteriaceae
that are resistant to third-generation cephalosporins and fluoroquinolones, Pseudomonas aeruginosa, and anaerobes. We include
coverage against methicillin-resistant Staphylococcus aureus (MRSA) with vancomycin in those who are known to be colonized,
those with prior treatment failure, and those with significant prior antibiotic exposure. Empiric antifungal coverage is appropriate
for patients at risk for infection with Candida spp, including those with upper gastrointestinal perforations, recurrent bowel
perforations, surgically treated pancreatitis, heavy colonization with Candida spp, and/or yeast identified on Gram stain of
samples from infected peritoneal fluid or tissue. Refer to other UpToDate content on treatment of invasive candidiasis.
If the patient is at risk for infection with an extended-spectrum beta-lactamase (ESBL)-producing organism (eg, known
colonization or prior infection with an ESBL-producing organism), a carbapenem should be chosen. For patients who are known
to be colonized with highly resistant gram-negative bacteria, the addition of an aminoglycoside, polymyxin, or novel beta-lactam
combination (ceftolozane-tazobactam or ceftazidime-avibactam) to an empiric regimen may be warranted. In such cases,
consultation with an expert in infectious diseases is advised.
When beta-lactams or carbapenems are chosen for patients who are critically ill or are at high risk of infection with drug-
resistant pathogens, we favor a prolonged infusion dosing strategy. Refer to other UpToDate content on prolonged infusions of
beta-lactam antibiotics.
The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot use beta-lactams or
carbapenems (eg, because of severe reactions).
IV: intravenous; PO: orally.

* We add ampicillin or vancomycin to a cephalosporin-based regimen to provide enterococcal coverage, particularly in those with
postoperative infection, prior use of antibiotics that select for Enterococcus, immunocompromising condition, valvular heart disease, or
prosthetic intravascular materials. Coverage against vancomycin-resistant enterococci (VRE) is generally not recommended, although it is
reasonable in patients who have a history of VRE colonization or in liver transplant recipients who have an infection of hepatobiliary
source.
Contributor Disclosures
Douglas Smink, MD, MPH Nothing to disclose David I Soybel, MD Nothing to disclose Martin Weiser, MD Nothing to
disclose Wenliang Chen, MD, PhD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

Management of Acute Appendicitis in Adults - UpToDate

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8/15/2018 Management of acute appendicitis in adults - UpToDate

Official reprint from UpToDate®

Authors: Douglas Smink, MD, MPH, David I Soybel, MD

● (See "Acute appendicitis in children: Management".)

● (See "Acute appendicitis in pregnancy".)

● (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

● (See "Acute appendicitis in adults: Diagnostic evaluation".)

NONPERFORATED APPENDICITIS — Nonperforated appendicitis, also referred to as simple appendicitis or

Patients on aspirin or clopidogrel — Appendectomy is commonly performed urgently or emergently. In a

The laparoscopic approach was superior for:

● A lower rate of wound infections (all nine meta-analyses; OR 0.3 to 0.52)

The open approach was superior for:

● A shorter operative time (eight meta-analyses; by 7.6 to 18.3 minutes)

● Anesthesia – Laparoscopic appendectomy is typically performed under general anesthesia.

Percutaneous abscess drainage — If imaging studies demonstrate an intra-abdominal or pelvic abscess,

UNEXPECTED INTRAOPERATIVE FINDINGS

SPECIAL PATIENT POPULATIONS

● Basics topics (see "Patient education: Appendicitis in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 1383 Version 54.0

Management of acute appendicitis in adults

Graphic 115333 Version 1.0

Antimicrobial prophylaxis for gastrointestinal surgery in adults

Nature of Common Recommended Usual adult

Procedures involving Enteric gram-negative Cefazolin Δ <120 kg: 2 g IV Four hours

Biliary tract surgery (including pancreatic procedures)

Open procedure or Enteric gram-negative Cefazolin Δ ¥ <120 kg: 2 g IV Four hours

OR cefoxitin 2 g IV Two hours

OR ampicillin- 3 g IV Two hours

Laparoscopic N/A None None None

Enteric gram-negative Cefoxitin Δ 2 g IV Two hours

PLUS metronidazole 500 mg IV N/A

Small intestine surgery

Nonobstructed Enteric gram-negative Cefazolin Δ <120 kg: 2 g IV Four hours

Obstructed Enteric gram-negative Cefoxitin Δ 2 g IV Two hours

PLUS metronidazole 500 mg IV N/A

Aerobic gram-positive Cefazolin Δ <120 kg: 2 g IV Four hours

Enteric gram-negative Parenteral:

OR cefazolin Δ <120 kg: 2 g IV Four hours

PLUS metronidazole 500 mg IV N/A

OR ampicillin- 3 g IV (based on Two hours

Oral (used in conjunction with mechanical bowel preparation):

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Illustration by Jenny Wang.

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Factors associated with mortality

High severity of illness (ie, sepsis)

Extensive peritoneal involvement or diffuse peritonitis

Delay in initial intervention (source control) >24 hours

Inability to achieve adequate debridement or drainage control

Factors associated with infection with antibiotic-resistant bacteria

Known colonization with antibiotic-resistant organisms

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Empiric antibiotic regimens for low-risk community-acquired intra-abdominal infections in

Ertapenem 1 g IV once daily

Piperacillin-tazobactam 3.375 g IV every 6 hours

Ticarcillin-clavulanate 3.1 g IV every 4 hours

Combination regimen with metronidazole

ONE of the following:

Cefazolin 1 to 2 g IV every 8 hours

Cefuroxime 1.5 g IV every 8 hours