Acute Appendicitis · Conservative vs Surgery + Approach

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Classification + preference/fecalith
   Classification (uncomplicated/complicated) + fecalith/high-risk/preference? (Trauma ABCs first. Complicated = abscess/phlegmon/perforation/peritonitis; uncomplicated = none of these. A fecalith predicts higher antibiotic failure.)
   • Perforation/diffuse peritonitis/sepsis → Perforation/peritonitis → emergency surgery
   • Localized abscess or phlegmon → Localized abscess → non-operative first
   • Uncomplicated (CT-confirmed, no fecalith) → Uncomplicated · antibiotics vs surgery (shared decision)
   • Uncomplicated but with fecalith/high-risk/unsuitable for conservative → Surgery · choose approach
2. [End] Perforation/peritonitis → emergency surgery
   Perforation/diffuse peritonitis/sepsis → emergency appendectomy (laparoscopic preferred, open if heavily contaminated) + broad-spectrum antibiotics + fluid resuscitation; peritoneal lavage and drainage.
3. [End] Localized abscess → non-operative first
   Localized abscess/phlegmon → non-operative first (IV antibiotics ± percutaneous/ultrasound-guided drainage); interval appendectomy is debated (optional); for those >40, follow with colonoscopy/imaging to exclude malignancy.
4. [Decision] Uncomplicated · antibiotics vs surgery (shared decision)
   Uncomplicated: antibiotics-first or surgery? (For CT-confirmed uncomplicated appendicitis without a fecalith, both are reasonable — use shared decision-making.)
   • Antibiotics-first (NOM) → Antibiotics-first (NOM)
   • Surgery (definitive) → Surgery · choose approach
5. [End] Antibiotics-first (NOM)
   Antibiotics-first (NOM): IV for 48 h then oral, total 7–10 days; ~73% 1-year success, recurrence 25–40%; better suited to those without a fecalith; failure/progression (fecalith, worsening) → surgery.
6. [Decision] Surgery · choose approach
   Appendectomy approach? (Laparoscopy is the contemporary gold standard (less SSI, faster recovery), can be day-case.)
   • Laparoscopic appendectomy (preferred) → Laparoscopic appendectomy
   • Open appendectomy (heavy contamination/laparoscopy contraindicated/unavailable) → Open appendectomy
7. [End] Laparoscopic appendectomy
   Laparoscopic appendectomy = gold standard: less wound infection, faster recovery, day-case possible; suits most uncomplicated and selected complicated cases.
8. [End] Open appendectomy
   Open appendectomy — for heavy contamination/extensive adhesions/laparoscopy contraindicated or unavailable; McBurney incision; watch for wound infection postoperatively.

Source guidelines & references

• WSES Jerusalem guidelines for acute appendicitis, 2020 update (World J Emerg Surg)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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