JTACS EGS ALGORITHMS – ALGORITHM

Evidence-based, cost-effective management of acute appendicitis:

An algorithm of the Journal of Trauma and Acute Care Surgery
emergency general surgery algorithms work group

Jose J. Diaz, MD, CPE, CNS, FACS, FCCM, Lena Napolitano, MD, David H. Livingston, MD,
Todd Costantini, MD, Kenji Inaba, MD, Walter L. Biffl, MD, Robert Winchell, MD, Ali Salim, MD,
and Raul Coimbra, MD, PhD, Tampa, Florida

KEY WORDS: Acute appendicitis; interval appendectomy; pregnancy and appendicitis. (J Trauma Acute Care Surg. 2025;98: 368–373. Copyright © 2025
The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

THE EVALUATION OF THE PATIENT WITH ACUTE further imaging or operative management. It is important to note
ABDOMINAL PAIN: HISTORY AND PHYSICAL that white blood count may not be elevated in early acute appen-
AND INITIAL LABORATORIES dicitis.2 A urine analysis would assist in ruling out other diagno-
ses, such as urinary tract infection, pyelonephritis, or renal stones.
Evaluation of the patient with abdominal pain begins with a thor- A pregnancy test is mandatory for women of childbearing age.
ough history and physical examination (Fig. 1). Patients typically
present with 12 to 24 hours of mid-abdominal pain, which may
migrate to the right lower quadrant. In the early course of appen- CALCULATION OF SCORING SYSTEMS
dicitis, the physical examination may reveal nonlocalizing, mid- FOR APPENDICITIS
abdominal pain without peritoneal irritation. Additional symp-
Utilizing a scoring system such as the Appendicitis Scor-
toms may include loss of appetite, abdominal distention, nausea,
ing score (Fig. 2) may contribute to the accuracy of clinical
vomiting, malaise, obstipation, fever, and chills. Patients may also
decision-making and support shared decision-making by identi-
have certain physical signs associated with appendicitis. The
fying patients at low risk of appendicitis.3
psoas sign is an irritation of the iliopsoas muscle in the abdomen,
The Alvarado score (Table 1) is the most commonly used
a classic finding of acute appendicitis, which can be elicited by
scoring system for predicting the likelihood of acute appendici-
performing passive extension of the right hip with the patient lay-
tis. If a patient scores 1 to 4, the risk of appendicitis drops to
ing on their left side. The Rovsing's sign can also be seen in acute
33%. If a patient scores >5, the risk of acute appendicitis is
appendicitis and is observed when deep palpation of the left lower
66% or greater. The Alvarado score can be used to select which
quadrant elicits pain in the right lower quadrant. Patients present-
ing later in the course of the disease process may develop perito- patients will proceed for confirmational imaging.4,5 In many
current practice settings, abdominal imaging will have been ob-
neal inflammation with localized guarding and rebound tender-
tained prior to surgical consultation.6,7
ness adjacent to the appendix in the right lower quadrant.1
Standard laboratory tests should include a complete blood Appendicitis inflammatory response score (Fig. 3) has
been shown to perform best in terms of sensitivity, specificity
count, urine analysis, and routine chemistry if the patient requires
area under the curve values, and usability but has been validated
Submitted: December 12, 2024, Revised: January 22, 2025, Accepted: December 13,
in only a small number of studies. The original Alvarado score
2024, Published online: February 3, 2025. outperformed the modified Alvarado score across all three
From the Division of Acute Care Surgery, Department of Surgery (J.J.D.), University criteria (sensitivity, specificity, and area under the curve values).
of South Florida Morsani School of Medicine; University of Michigan Health
(L.N.); Rutgers New Jersey Medical School (D.H.L.); University of Minnesota
(T.C.); Keck School of Medicine of USC (K.I.); Scripps Health (W.L.B.); Weill
Cornell Medicine (R.W.); Brigham and Women's Hospital, Harvard (A.S.); and IMAGING OF THE PATIENT SUSPECTED
Riverside University Health (R.C.). OF APPENDICITIS
Address for correspondence: Jose J. Diaz, MD, CPE, CNS, FACS, FCCM, Division of
Acute Care Surgery, Department of Surgery, University of South Florida Morsani Ultrasound Versus Computed Tomography Scan
School of Medicine, 1 Tampa General Circle, G-417, Tampa, FL 33606; email:
[email protected].
Ultrasound (US) has been used to evaluate patients
This is an open-access article distributed under the terms of the Creative Commons suspected of acute appendicitis and has an 85% to 90% positive
Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is predictive value with an appendiceal diameter greater than 9 to
permissible to download and share the work provided it is properly cited. The work can- 10 mm.8 It does not use radiation energy, is repeatable, and is safe
not be changed in any way or used commercially without permission from the journal.
for pregnant women. It can also demonstrate other pelvic pathology
DOI: 10.1097/TA.0000000000004569 in women.9,10 Ultrasound is frequently used in pediatric patients
J Trauma Acute Care Surg
368 Volume 98, Issue 3
J Trauma Acute Care Surg
Volume 98, Issue 3 Diaz et al.

Figure 1. Acute appendicitis management.

and is favored as an initial study in small children. The utility of US used with increasing frequency if US findings are not diagnostic.
is less well documented in the adult population. A CT scan should be considered if a patient is acutely ill, and the
Computed tomography scan with contrast has been the diagnosis is still in question.11,14–19 Alternatively, if CT scan does
standard for imaging the abdomen when searching for acute pa- not clearly demonstrate acute appendicitis in the pregnant patient,
thology and is used with increasing frequency in the general di- magnetic resonance imaging has been shown to have a high sen-
agnosis of abdominal pain, especially by nonsurgeons. It provides sitivity and negative predictive value of 100% in some studies.20
a high degree of sensitivity and specificity for the diagnosis of
acute appendicitis but has the potential to identify radiographic MANAGEMENT OF PATIENTS WITH ACUTE
abnormalities of the appendix that are not clinically relevant. Com- APPENDICITIS (AMERICAN ASSOCIATION FOR
puted tomography imaging should always be interpreted in the con-
text of clinical history and physical examination. Computed tomog-
THE SURGERY OF TRAUMA ACUTE APPENDICITIS
raphy can also demonstrate an appendiceal fecalith, periappendiceal SEVERITY OF ILLNESS)
fluid collection, or an abscess, findings that may be of importance (Additional classification of appendicitis commonly used
in clinical decision-making. The sensitivity, specificity, positive, are as follows: uncomplicated appendicitis [nonperforated, no
and negative predictive values of computed tomography (CT) scans abscess, or phlegmon] or complicated appendicitis [perforated
based on pathology results were 87.9%, 81.8%, 94.7%, and 79.3%, appendicitis, periappendicular abscess or peritonitis, defined as
respectively, in patients with low clinical suspicion.11 acute inflammation of the peritoneum secondary to infection
In many circumstances, the position of the appendix within of the appendix].) (Fig. 4)21
the abdomen and its relation to the cecum will be demonstrated.12
Women a. American Association for the Surgery of Trauma Grade I
(mild) represents mild appendicitis without significant in-
Childbearing Age flammation (uncomplicated appendicitis). The current litera-
Pelvic pathology must be ruled out when suspecting acute ture demonstrates that nonoperative management with antibi-
appendicitis in women of childbearing age. A urine analysis may otics and pain control is noninferior to surgical treatment.22,23
demonstrate urinary tract infection or potential kidney stones. Although early appendectomy is likely the most expeditious
An US or CT scan may show an adnexal tubo-ovarian abscess treatment, patient-centered concerns such as a desire to avoid
or ectopic pregnancy.13 surgery or timing of surgery should be discussed and consid-
ered as part of shared decision-making. A publicly available
Pregnant Women decision support tool called AppyOrNot (AppyOrNot.org)
Ultrasound is the primary imaging modality to assess ab- provides an educational video to assist patient decision-mak-
dominal pain and make the diagnosis of acute appendicitis in ing. The presence of a fecalith does not preclude nonoperative
pregnant patients, although magnetic resonance imaging is being management, although the likelihood of requiring additional

© 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma. 369
 J Trauma Acute Care Surg
Diaz et al. Volume 98, Issue 3

Figure 2. Adult appendicitis score. Adapted from Bhangu,3 published under Creative Commons CC-BY-NC-ND license.

procedures is higher. The report of long-term outcomes from Some patients presenting with sepsis will require preopera-
the Comparison of outcomes of antibiotic drugs and appen- tive fluid resuscitation in addition to early antibiotics. Mini-
dectomy trial confirmed that the hazard ratio for appendec- mally invasive approaches to appendectomy have become
tomy among patients with an appendicolith compared with the procedure of choice. If not available, an open appendec-
those without an appendicolith was 2.9 within 48 hours but tomy is indicated.29–33
was not difference thereafter from 48 hours to 30 days
(Hazard ratio, 1.4; 95% confidence interval, 0.8–2.4) and i. Patients presenting with perforated appendicitis and a large
from 31 days to 2 years (Hazard ratio, 1.1; 95% confidence inflammatory tumor (phlegmon) with abscess are best man-
interval, 0.8–1.6).24–28 aged with early broad-spectrum antibiotics and percutane-
b. American Association for the Surgery of Trauma Grades II ous drainage (80% successful) for source control. A surgical
to IV (moderate to severe) (complicated appendicitis) rep- approach to abscess drainage, either by minimally invasive
resents increasing degrees of inflammation, development or open technique, may be indicated if drainage and antibi-
of periappendiceal fluid collections, abscess formation, otics fail to resolve the infection.34
progression of gangrenous appendicitis, and peritonitis.
The decision between initial appendectomy versus initial c. American Association for the Surgery of Trauma Grade V
nonoperative management is complex, as patients with (most severe) represents the most severe presentation of free
larger phlegmon and more advanced inflammatory changes perforation due to acute appendicitis in the abdominal cav-
involving surrounding organs may benefit from initial non- ity. Patients are commonly present in septic shock and
operative management. Decision-making should be individ- Sepsis 3 guidelines for resuscitation should be followed.35
ualized based on patient factors and surgeon experience. These are surgical emergencies. Treatment consists of

370 © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.
J Trauma Acute Care Surg
Volume 98, Issue 3 Diaz et al.

ment strategy for complicated appendicitis among pregnant

TABLE 1. Alvarado Score (Adapted From Ohle et al.4)
women.37
Alvarado Score
Variable Clinical Findings Score TIMING OF APPENDECTOMY AND RISK OF
Symptoms Migratory RIF pain 1 APPENDICEAL PERFORATION
Anorexia 1
Nausea and vomiting 1
With early initiation of early empiric intravenous systemic
Signs Tenderness RIF 2
antibiotic therapy for acute uncomplicated appendicitis, appendiceal
Rebound tenderness 1
perforation prior to surgical intervention for uncomplicated ap-
Elevated temperature 1
pendicitis is now rare. The PERFECT open-label multicenter
Laboratory Leukocytosis 2
randomized trial compared appendectomies scheduled within
Left shift (bandemia) 1
8 or 24 hours in adult patients (n = 1,803) with predicted uncom-
plicated acute appendicitis. The appendiceal perforation rate was
Total score similar (8% vs. 9%), and no significant differences in complica-
RIF, right iliac fossa.
tion rates (7% vs. 6%) were found, with no mortality differences
noted. A meta-analysis comparison (15 studies, n = 33,596) of
resuscitation, administration of broad-spectrum antibi- daytime versus nighttime appendectomy reported no differences
otics, pharmacological cardiovascular support, and emer- in postoperative mortality or complication rates, but the conver-
gent operative management.36 sion to laparotomy was almost twofold higher among patients
who underwent appendectomy during nighttime. These data
support postponing night-time appendectomy to daytime if
MANAGEMENT OF COMPLICATED APPENDICITIS possible.38,39
DURING PREGNANCY
ANTIBIOTIC MANAGEMENT
In this retrospective cohort study of 8,087 pregnant
women with complicated appendicitis using National Inpatient In the setting of operative management of American As-
Sample data (January 2003 to September 2015), immediate sociation for the Surgery of Trauma (AAST) Grade I or II, a sin-
appendectomy was associated with lower odds of infectious gle perioperative dose of antibiotics should be sufficient. In
complications, including amniotic infection and sepsis, com- AAST Grade III or higher, perioperative antibiotic management
pared with successful and unsuccessful nonoperative manage- should be dictated by source control. Once source control is ob-
ment. When nonoperative management failed and required de- tained, a perioperative dose plus four additional days should be
layed operation, it was associated with significantly higher odds sufficient to align with the STOP-IT trial. In the setting of a
of preterm labor, preterm delivery, or abortion. These findings periappendiceal abscess managed by percutaneous drainage or
suggest that immediate operation may be the preferred manage- phlegmon, an initial course of 7 to 10 days of antibiotics is

Figure 3. Appendicitis inflammatory response. Reproduced without changes from Andersson et al.,6 published under Creative
Commons Attribution 4.0 International License.

© 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma. 371
 J Trauma Acute Care Surg
Diaz et al. Volume 98, Issue 3

Figure 4. American Association for the Surgery of Trauma — Appendicitis Grades.21 Reused with permission from the American Asso-
ciation for the Surgery of Trauma.

generally chosen, although there is little evidence to support the 20% of cases.44–47 American Association for the Surgery of
practice. In the absence of clinical improvement, additional im- Trauma Grades II to IV may require interval appendectomy,
aging is warranted.40–42 but AAST Grade I may not absolutely require interval appen-
dectomy unless symptoms recurred.
INTERVAL APPENDECTOMY AFTER
AUTHORSHIP
NONOPERATIVE MANAGEMENT WITH
ANTIBIOTICS J.J.D. and R.C. contributed in the conception and study design. All authors
contributed in the literature review. All authors contributed in the drafting
In patients treated with antibiotics for uncomplicated appen- of the manuscript. All authors contributed in the critical revisions.
dicitis, interval appendectomy is commonly considered for patients
with recurrent symptoms or recurrent disease. Appendiceal neo- DISCLOSURE
plasm is rare in patients with uncomplicated appendicitis treated Conflict of Interest: Author Disclosure forms have been supplied and are
with antibiotics. In a review of 4,962 patients with appendicitis provided as Supplemental Digital Content (http://links.lww.com/TA/E245).
(38% complicated, 62% uncomplicated) enrolled in 4 compara-
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