Last reviewed: 19 Aug 2021
Last updated: 11 Jun 2021
11 Jun 2021

Updated international guidance on the diagnosis and management of acute appendicitis.

The World Society of Emergency Surgery has released an update (2020) of its Jerusalem guidelines on the diagnosis and treatment of acute appendicitis. New or revised recommendations include the following:

In uncomplicated appendicitis:

  • Postoperative antibiotics should no longer be prescribed since there is no evidence they decrease the rate of surgical infection. This resolves previous controversy over the risk-benefit ratio of their use.

  • An antibiotic-only approach should not be used if an appendicolith is present since nonoperative management carries a significant failure rate.

In complicated appendicitis:

  • Screening for colonic malignancy should be completed in any patient ages ≥40 years who is managed conservatively without interval appendectomy, since the incidence of appendicular neoplasms is high in this group.

  • Conservative treatment should be considered in selected patients with a periappendicular phlegmon or abscess. Although optimal management remains subject to date, intravenous antibiotics and percutaneous image-guided drainage in patients is a reasonable alternative to surgery if the patient is stable, and laparoscopic appendicectomy is unavailable.

In pregnancy:

  • A negative or inconclusive MRI does not exclude appendicitis and surgery should be still considered if clinical suspicion is high.

  • Laparoscopic appendectomy should be preferred to open appendectomy when surgery is indicated and where expertise of laparoscopy is available. Laparoscopy during pregnancy is safe in terms of risk of fetal loss and preterm delivery and is associated with shorter hospital stays and lower incidence of surgical site infection compared to open surgery. This recommendation resolves previous controversy around fetal risks associated with the surgical approach.

See Diagnosis: approach

See Management: approach

Original source of updateexternal link opens in a new window



History and exam

Key diagnostic factors

  • abdominal pain
  • anorexia
  • right lower quadrant tenderness

Other diagnostic factors

  • age of occurrence
  • nausea
  • fever
  • diminished bowel sounds
  • tachycardia
  • vomiting
  • Rovsing sign
  • psoas sign
  • obturator sign

Risk factors

  • <6 months of breastfeeding
  • low dietary fiber
  • improved personal hygiene
  • smoking

Diagnostic investigations

1st investigations to order

  • CBC
  • CRP
  • abdominal and pelvic CT scan
  • urinary pregnancy test

Investigations to consider

  • abdominal ultrasound
  • urinalysis
  • abdominal and pelvic MRI in pregnancy

Treatment algorithm



Peter Szasz, MD, PhD, FRCSC

General and Minimally Invasive Surgeon





PS declares that he has no competing interests.


Dr Peter Szasz would like to gratefully acknowledge Professor Ali Tavakkoli, Professor Dileep N. Lobo and Dr Nasim Ahmed, previous contributors to this topic. AT is a consultant for Medtronic. DNL is the author of an article cited in the topic. NA declares that he has no competing interests.

Peer reviewers

John M. Davis, MD

General Surgery

Jersey Shore Medical Center




JMD declares that he has no competing interests.

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