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Acute appendicitis

Definition
Acute appendicitis is a disease resulting from acute inflammation of the vermiform appendix.
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Pathophysiology
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.
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Epidemiology
The incidence of acute appendicitis is estimated at 110 per 100,000 person-years in the US, with a male predominance.
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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.
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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 1,000 individuals. The risk of recurrent appendicitis after 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.
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Key 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 World Society of Emergency Surgery (WSES 2020), the Pathway (Pathway 2020), the Eastern Association for the Surgery of Trauma (EAST 2019), the American Academy of Family Physicians (AAFP 2018), the European Association for Endoscopic Surgery (EAES 2016), and the American College of Surgeons (ACS 2013).
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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
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2.Diagnostic investigations

Abdominal ultrasound: as per WSES 2020 guidelines, obtain diagnostic imaging in patients with suspected appendicitis after an initial assessment and risk stratification using clinical scores.
B
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  • CT and MRI

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.
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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

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  • Histopathology

4.Medical management

Nonoperative 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 absence of appendicolith, recognizing the possibility of failure and misdiagnosing complicated appendicitis.
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  • Analgesic therapy

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

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  • Intraoperative grading systems

  • Postoperative antibiotics

  • Postoperative nasogastric tube

  • Postoperative diet

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.
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Do not delay appendectomy in patients with acute appendicitis requiring surgery beyond 24 hours from the admission.
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  • Laparoscopic appendectomy

  • Technical considerations for surgery

7.Specific circumstances

Pediatric patients, diagnosis, WSES: avoid diagnosing acute appendicitis in pediatric patients solely based on clinical scores.
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  • Pediatric patients (management)

  • Elderly patients

  • Pregnant patients (diagnosis)

  • Pregnant patients (management)

  • Obese patients

  • Immunosuppressed patients