START: Suspected Acute Appendicitis
RLQ pain, anorexia, nausea/vomiting, fever
All Pathways
Emergency MedicineEmergency
Acute Appendicitis Management (WSES 2020)
Acute Appendicitis Management (WSES 2020): START: Suspected Acute Appendicitis → Clinical Assessment → Risk Stratification → Imaging Needed? → Low Risk.
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Clinical Assessment
History and physical exam
- Classic presentation: Periumbilical pain → RLQ
- Anorexia, nausea, low-grade fever
- McBurney point tenderness
- Rovsing, psoas, obturator signs
- Labs: WBC, CRP (elevated supports diagnosis)
03Action Risk Stratification
Use clinical scoring
- Alvarado Score or AIR Score
- LOW RISK (Alvarado ≤4): Unlikely appendicitis
- INTERMEDIATE (5-6): Imaging recommended
- HIGH RISK (≥7): High probability, consider surgery
04Decision Imaging Needed?
Based on clinical probability
05Action Low Risk
Unlikely appendicitis
- Consider alternative diagnoses
- Observation with re-evaluation
- Discharge with return precautions
06Outcome Discharge
Post-operative or post-treatment
- Tolerating diet
- Pain controlled
- Afebrile
- Follow-up in 1-2 weeks
- Return if fever, worsening pain, wound issues
07Action Imaging
Confirm diagnosis
- CT abdomen/pelvis (gold standard in adults)
- Ultrasound (first-line in children, pregnancy)
- MRI if pregnant and US inconclusive
- Findings: Dilated appendix >6mm, periappendiceal fat stranding, appendicolith
08Decision Appendicitis Confirmed?
Imaging or clinical diagnosis
- Path rejoins step 05Shared downstream outcome
09Decision Classify Appendicitis
Complicated vs uncomplicated
- UNCOMPLICATED: No perforation, abscess, or diffuse peritonitis
- COMPLICATED: Perforation, abscess, phlegmon, diffuse peritonitis
10Action Uncomplicated Appendicitis
Treatment options
- SURGERY (standard): Laparoscopic appendectomy
- ANTIBIOTICS ONLY: Select patients, shared decision-making
- - Antibiotics: Ertapenem or Ceftriaxone + Metronidazole
- - 15-30% recurrence rate at 5 years
- Surgery preferred if appendicolith present
11Action Appendectomy
Surgical treatment
- Laparoscopic preferred over open
- Single-dose preoperative antibiotics
- Typical recovery 1-2 days
- Pathology to rule out neoplasm
- Path rejoins step 06Shared downstream outcome
12Warning Complicated Appendicitis
More complex management
- PERFORATION with PERITONITIS: Urgent surgery
- ABSCESS/PHLEGMON: IV antibiotics ± percutaneous drainage
- - Consider interval appendectomy 6-8 weeks later
- Broad-spectrum antibiotics covering GNR and anaerobes
- Path rejoins step 11Shared downstream outcome
13Action High Clinical Probability
May proceed without imaging
- Alvarado ≥7 with classic presentation
- Young male with classic symptoms
- Surgical consult, consider direct to OR
- Path rejoins step 08Shared downstream outcome
Guideline Source
WSES Jerusalem Guidelines for Diagnosis and Treatment of Acute Appendicitis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Antibiotics-only approach still evolving
- Pediatric and pregnant patients need special consideration
- Scoring systems aid but don't replace clinical judgment
- Local surgical practice may vary
Applicable Regions
USEUGlobal
Global: WSES 2020 widely adopted
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Acute Appendicitis Management (WSES 2020)?
The Acute Appendicitis Management (WSES 2020) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on WSES Jerusalem Guidelines for Diagnosis and Treatment of Acute Appendicitis.
What guideline is the Acute Appendicitis Management (WSES 2020) based on?
This algorithm is based on WSES Jerusalem Guidelines for Diagnosis and Treatment of Acute Appendicitis (DOI: 10.1186/s13017-020-00306-3).
What are the limitations of the Acute Appendicitis Management (WSES 2020)?
Known limitations include: Antibiotics-only approach still evolving; Pediatric and pregnant patients need special consideration; Scoring systems aid but don't replace clinical judgment; Local surgical practice may vary. Individual patient factors may require deviation from these recommendations.
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