What are the guideline sources, guidelines and references for Acute appendicitis ?
Guideline sources The following summarized guidelines for the evaluation and management of acute appendicitis are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2022), the Pathway (Pathway 2020), the World Society of Emergency Surgery (WSES 2020), the Eastern Association for the Surgery of Trauma (EAST 2019), the American Association of Family Physicians (AAFP 2018), the European Association for Endoscopic Surgery (EAES 2016), and the American College of Surgeons (ACS 2013). 1 2 3 4 5 6 7 8 9 10 11 11 12 Definition Acute appendicitis is a disease resulting from acute inflammation of the vermiform appendix. 8 Epidemiology Acute appendicitis is initiated by a process that causes obstruction of the appendiceal lumen, such as fecaliths, lymphoid hyperplasia, parasites, Crohn's disease, foreign bodies, or neoplasms. 10 Pathophysiology https://web.pathway.md/diseases/recFwDBzssIJqaRqC 1/10 6/23/23, 1:36 AM Acute appendicitis Pathway The incidence of acute appendicitis is estimated at 110 per 100,000 person-years in the United States, with a male predominance. 9 Disease course Progressive luminal obstruction is associated with inflammation and distension of the appendix, leading to suppurative transmural inflammation, ischemia, infarction, and perforation. Perforated appendicitis progresses to generalized peritonitis and intra-abdominal abscess formation. 11 Prognosis and risk of recurrence The mortality rate associated with non-perforated appendicitis is 0.8 per 1,000 individuals, whereas, for perforated appendicitis, it increases to 5.1 per 1000 individuals. The risk of recurrent appendicitis post interval appendicectomy is about 20% within a year. Recurrent appendicitis may also occur in the setting of previous appendicectomy in patients with a long appendiceal stump. 11 12 Calculator Calculator Calculator Acetaminophen dosing calculator Adult Appendicitis score AAS Alvarado s Guidelines 1. Classification and risk stratification Risk stratification: As per WSES 2020 guidelines, adopt a tailored individualized diagnostic approach for stratifying the risk and disease probability and planning an appropriate stepwise diagnostic pathway in patients with suspected acute appendicitis, depending on age, sex, and clinical signs and symptoms of the patient. B Show 4 more As per AAFP 2018 guidelines, consider using the Alvarado score with point-of-care or formal ultrasound and laboratory testing to assist in diagnosing acute appendicitis and reduce the use of CT. C As per EAES 2016 guidelines, use the Alvarado score to determine the likelihood of appendicitis. A 2. Diagnostic investigations Abdominal ultrasound: https://web.pathway.md/diseases/recFwDBzssIJqaRqC 2/10 6/23/23, 1:36 AM Acute appendicitis Pathway As per WSES 2020 guidelines, obtain diagnostic imaging in patients with suspected appendicitis after an initial assessment and risk stratification using clinical scores. B Show 3 more As per AAFP 2018 guidelines, obtain an abdominal ultrasound as first-line imaging in patients with suspected acute appendicitis when skilled sonographers are available, especially in children and pregnant women. B As per EAES 2016 guidelines, obtain an abdominal ultrasound in patients with suspected appendicitis. A Computed tomography and magnetic resonance imaging: As per ACR 2022 guidelines, obtain CT of the abdomen and pelvis with IV contrast for the initial imaging of RLQ pain, including in the presence of fever, leukocytosis, and suspected appendicitis. B As per WSES 2020 guidelines, obtain cross-sectional imaging before surgery in patients with normal investigations but non-resolving right iliac fossa pain. A Show 2 more As per EAES 2016 guidelines, consider second-line imaging studies (either CT or MRI; MRI preferred in children or pregnant patients) in patients in whom the diagnosis of appendicitis remains in question after ultrasound. C As per ACS 2013 guidelines, avoid obtaining CT for evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. D 3. Diagnostic procedures Explorative laparoscopy: Perform explorative laparoscopy in patients with negative imaging but progressive or persistent pain to establish/exclude the diagnosis of acute appendicitis or alternative diagnoses. A Avoid obtaining cross-sectional imaging (CT) in < 40 years old high-risk patients with AIR score 9-12, Alvarado score 9-10 and AAS 16 before proceeding to diagnostic and/or therapeutic laparoscopy. D Histopathology: As per WSES 2020 guidelines, perform routine histopathology after appendectomy. B As per EAES 2016 guidelines, obtain histopathological analysis of all resected appendices. B 4. Medical management Non-operative management: As per WSES 2020 guidelines, consider offering nonoperative management with antibiotics as a safe alternative to surgery in selected patients with uncomplicated acute appendicitis and https://web.pathway.md/diseases/recFwDBzssIJqaRqC 3/10 6/23/23, 1:36 AM Acute appendicitis Pathway absence of appendicolith, recognizing the possibility of failure and misdiagnosing complicated appendicitis. B Show 6 more Landmark trials: CODA In adult patients with appendicitis, antibiotics were noninferior to appendectomy with respect to mean improvement in health status at day 30 as measured by the european quality of life- 5 dimension questionnaire score. CODA Collaborative et al. N Engl J Med. 2020 Nov 12. As per EAST 2019 guidelines: Insufficient evidence to recommend for or against antibiotics-first therapy versus surgery in patients with acute uncomplicated appendicitis. Avoid performing routine interval appendectomy following initial nonoperative management in patients with appendiceal abscess or phlegmon. D As per AAFP 2018 guidelines, consider nonoperative management with intravenous antibiotics as first-line therapy for children and adults with acute appendicitis. B Landmark trials: APPAC In patients with uncomplicated appendicitis confirmed by a CT scan, antibiotic treatment was not noninferior to surgical appendectomy with respect to treatment success. Salminen P et al. JAMA. 2015 Jun 16. As per EAES 2016 guidelines, consider nonoperative treatment for patients with a contained phlegmon or abscess in the absence of diffuse peritonitis. C Show 2 more Landmark trials: APPAC In patients with uncomplicated appendicitis confirmed by a CT scan, antibiotic treatment was not noninferior to surgical appendectomy with respect to treatment success. Salminen P et al. JAMA. 2015 Jun 16. Analgesic therapy: administer analgesic therapy (acetaminophen, NSAIDs, or opioids) for pain control in patients with suspected acute appendicitis. A https://web.pathway.md/diseases/recFwDBzssIJqaRqC 4/10 6/23/23, 1:36 AM Acute appendicitis Pathway 5. Perioperative care Preoperative antibiotics: As per WSES 2020 guidelines, administer a single preoperative dose of broad spectrum antibiotics in patients with acute appendicitis undergoing appendectomy. A As per EAES 2016 guidelines, administer preoperative prophylactic antibiotics in adults undergoing appendectomy. A Intraoperative grading systems: Consider adopting an intraoperative grading system for acute appendicitis based on clinical, imaging and operative findings, such as WSES 2015 grading score (provided below) or AAST EGS grading score: Situation Guidance Normal looking appendix (endoappendicitis/periappendicitis) Grade 0 Inflamed appendix (hyperemia, edema +/- fibrin without or little pericolic fluid) Grade 1 A - segmental necrosis (without or little pericolic fluid) Grade 2 B - base necrosis (without or little pericolic fluid) A - flegmon Grade 3 B - abscess < 5 cm without peritoneal free air C - abscess > 5 cm without peritoneal free air Perforated, diffuse peritonitis with or without peritoneal free air. C Grade 4 Postoperative antibiotics: As per WSES 2020 guidelines: Do not administer postoperative antibiotics in patients with uncomplicated appendicitis. D Do not prolong antibiotics longer than 3-5 days postoperatively in patients with complicated appendicitis with adequate source-control. D Updated evidence: APPIC In patients, aged 8 years, with complex appendicitis, short 2-day course was noninferior to standard 5-day course with respect to the rate of infectious complications and death within 90 days. Elisabeth M L de Wijkerslooth et al. Lancet. 2023 Jan 17. https://web.pathway.md/diseases/recFwDBzssIJqaRqC 5/10 6/23/23, 1:36 AM Acute appendicitis Pathway As per EAES 2016 guidelines, administer postoperative antibiotics in patients with complicated appendicitis. B Postoperative nasogastric tube: avoid routine postoperative nasogastric tube placement. D Postoperative diet: consider avoiding postoperative dietary restrictions after an uncomplicated appendectomy. D 6. Surgical interventions Timing of surgery: As per WSES 2020 guidelines: Plan laparoscopic appendectomy for the next available operating list within 24 hours in patients with uncomplicated acute appendicitis, minimizing the delay wherever possible. B Do not delay appendectomy in patients with acute appendicitis requiring surgery beyond 24 hours from the admission. D As per EAES 2016 guidelines, perform surgery as soon as feasible after the diagnosis of acute appendicitis is established. B Laparoscopic appendectomy: As per WSES 2020 guidelines, prefer laparoscopic appendectomy over open appendectomy in patients with either uncomplicated or complicated acute appendicitis, if laparoscopic equipment and expertise are available. A Show 4 more As per EAES 2016 guidelines, perform laparoscopic appendectomy in adults with uncomplicated appendicitis. B Show 3 more Technical considerations for surgery: As per WSES 2020 guidelines, consider performing appendix removal if the appendix appears "normal" during surgery and no other disease is found in symptomatic patients. C Show 7 more As per EAES 2016 guidelines, perform meticulous suction of intraperitoneal fluid or collections. B Show 6 more 7. Specific circumstances Pediatric patients, diagnosis: As per WSES 2020 guidelines, avoid diagnosing acute appendicitis in pediatric patients solely based on clinical scores. D Show 5 more https://web.pathway.md/diseases/recFwDBzssIJqaRqC 6/10 6/23/23, 1:36 AM Acute appendicitis Pathway As per EAES 2016 guidelines, obtain an abdominal MRI study (rather than an abdominal CT scan) as second-line imaging in children, in order to avoid radiation. B Pediatric patients, management: As per WSES 2020 guidelines, consider offering nonoperative management with antibiotics as a safe and effective alternative to surgery in pediatric patients with uncomplicated acute appendicitis in the absence of an appendicolith, recognizing the possibility of failure and misdiagnosing complicated appendicitis. C Show 8 more As per EAES 2016 guidelines, consider performing laparoscopic appendectomy, if appendectomy is indicated, as the procedure of choice in pediatric patients with acute appendicitis. C Elderly patients: As per WSES 2020 guidelines, consider performing laparoscopic appendectomy in older patients with acute appendicitis. C As per EAES 2016 guidelines, perform laparoscopic appendectomy as the procedure of choice in patients over 65 years of age. B Pregnant patients, diagnosis: As per ACR 2022 guidelines, obtain abdominal ultrasound or MRI of the abdomen and pelvis without IV contrast for the initial imaging in pregnant patients with RLQ pain with fever, leukocytosis, and suspected appendicitis. B As per WSES 2020 guidelines, do not diagnose acute appendicitis in pregnant patients solely based on symptoms and signs, rather always obtain laboratory tests and inflammatory serum parameters (such as CRP). D Show 2 more As per EAES 2016 guidelines, obtain abdominal MRI (rather than CT) as second-line imaging (in case of diagnostic doubt) in pregnant patients, in order to avoid radiation. B Pregnant patients, management: As per WSES 2020 guidelines: Avoid offering nonoperative management in pregnant patients with acute appendicitis. D Consider preferring laparoscopic appendectomy over open appendectomy in pregnant patients, if surgery is indicated, recognizing that it is technically safe and feasible during pregnancy if expertise of laparoscopy is available. C As per EAES 2016 guidelines, consider performing laparoscopic appendectomy as the procedure of choice in pregnant patients (even in the third trimester) with acute appendicitis. C Obese patients: As per WSES 2020 guidelines, consider performing laparoscopic appendectomy in obese patients with acute appendicitis. C As per EAES 2016 guidelines, select laparoscopic appendectomy as the procedure of choice in obese patients with acute appendicitis. B https://web.pathway.md/diseases/recFwDBzssIJqaRqC 7/10 6/23/23, 1:36 AM Acute appendicitis Pathway Immunosuppressed patients: consider treating immunosuppressed patients with appendicitis following the same approach as outlined for immunocompetent patients. C Likelihood Ratios Pertinent positives The following findings increase the probability of acute appendicitis in adults. 1 1 Finding LR+ Value Increased Alvarado score ( 7) 3.1 (1.9-5.0) Presence of rebound tenderness 3.0 (2.3-3.9) Presence of rectal tenderness 2.3 (1.3-4.1) Increased WBC count (> 10,000 cells/ L) 2.0 (1.3-2.9) Show 5 more Pertinent negatives The following findings decrease the probability of acute appendicitis in adults. 1 1 Finding LR- Value WBC count not increased ( 10,000 cells/ L) 0.22 (0.17-0.30) Alvarado score not increased (< 7) 0.26 (0.19-0.35) Absence of rebound tenderness 0.28 (0.14-0.55) Absence of RLQ tenderness 0.45 (0.35-0.59) Show 6 more References 1. L Mullie. Investigation Algorithms. Pathway Editors. Open 2. Salomone Di Saverio, Mauro Podda, Belinda De Simone et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020 Apr 15;15 1 27. Open 3. Gorter RR, Eker HH, Gorter-Stam MA et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016 Nov;30 11 4668 4690. Open 4. Expert Panel on Gastrointestinal Imaging, Avinash R Kambadakone, Cynthia S Santillan et al. ACR Appropriateness Criteria Right Lower Quadrant Pain: 2022 Update. J Am Coll Radiol. 2022 Nov;19 11S S445 S461. Open 5. Amy Rushing, Nikolay Bugaev, Christian Jones et al. Management of acute appendicitis in adults: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019 Jul;87 1 214 224. Open https://web.pathway.md/diseases/recFwDBzssIJqaRqC 8/10 6/23/23, 1:36 AM Acute appendicitis Pathway 6. Snyder MJ, Guthrie M, Cagle S. Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician. 2018 Jul 1;98 1 25 33. Open 7. American College of Surgeons. Choosing Wisely: Recommendations of the American College of Surgeons. Choosing Wisely. 2013 Sept. Open 8. Morgan AC. Unveiling appendicitis. 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Aneel Bhangu, Kjetil S reide, Salomone Di Saverio et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015 Sep 26;386 10000 1278 1287. Open 18. Matthew J Snyder, Marjorie Guthrie, Stephen Cagle. Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician. 2018 Jul 1;98 1 25 33. Open 19. Michel Wagner, Dustin John Tubre, Juan A Asensio. Evolution and Current Trends in the Management of Acute Appendicitis. Surg Clin North Am. 2018 Oct;98 5 1005 1023. Open 20. Manne Andersson, Roland E Andersson. The Appendicitis Inflammatory Response Score: A Tool for the Diagnosis of Acute Appendicitis that Outperforms the Alvarado Score. World J Surg 2008 Aug;32 8 1843 9. Open 21. Anand Singla, Satpaul Singla, Mohinder Singh et al. A comparison between modified Alvarado score and RIPASA score in the diagnosis of acute appendicitis. Updates Surg. 2016 Dec;68 4 351 355. Open 22. James M. Wagner, MD, W. Paul McKinney et al. Does This Patient Have Appendicitis?. JAMA. 1996;276 19 1589 1594. Open 23. C F Chong, M I W Adi, A Thien et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J. 2010 Mar;51 3 220 5. Open 24. Sohail R Shah, Kelly A Sinclair, Stephanie B Theut et al. Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm. Ann Surg. 2016 Sep;264 3 474 81. Open 25. Henna E Sammalkorpi, Panu Mentula, Ari Lepp niemi. A new adult appendicitis score improves diagnostic accuracy of acute appendicitis a prospective study. BMC Gastroenterol. 2014 Jun 26;14 114. https://web.pathway.md/diseases/recFwDBzssIJqaRqC 9/10 6/23/23, 1:36 AM Acute appendicitis Pathway Open 26. CODA Collaborative, David R Flum, Giana H Davidson et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Nov 12;383 20 1907 1919. Open 27. Elisabeth M L de Wijkerslooth, Evert-Jan G Boerma, Charles C van Rossem et al. 2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial. Lancet. 2023 Jan 17;S0140 6736 22 02588 0. Open https://web.pathway.md/diseases/recFwDBzssIJqaRqC 10/10