APPENDICITIS

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APPENDICITIS

Overview & Epidemiology

Appendicitis is the most common intra-abdominal surgical emergency, affecting ~1 per 1,000 adults annually worldwide. Lifetime risk is 7–10% (8.7% men, 6.9% women). In the United States, ~400,000 cases are diagnosed per year, with 16–40% presenting with perforation. Peak incidence is ages 9–12 years; it is uncommon under age 5 but carries the highest perforation rate in that group (>50% ruptured at surgery).

Current Surgical Therapy 14e | Goldman-Cecil Medicine | Rosen's Emergency Medicine

Anatomy

The appendix is an ~9 cm long, 0.6 cm wide vermiform ("worm-shaped") hollow structure arising from the terminal cecum, at the convergence of the three taenia coli. While the base is consistently cecal, the tip position varies widely:

Retrocecal (most common, ~65%)
Pelvic / subcecal
Pre-ileal / post-ileal

This positional variability explains the diversity of clinical presentations. Blood supply: appendiceal artery, a branch of the ileocolic artery (branch of superior mesenteric artery).

Variations in position of the vermiform appendix

Variations in positions of the vermiform appendix — Current Surgical Therapy 14e

Pathophysiology

The central mechanism is luminal obstruction → bacterial overgrowth → progressive ischemia → perforation.

Causes of obstruction:

Cause	Notes
Fecalith / appendicolith	Most common
Lymphoid hyperplasia	Common in children (viral infections)
Neoplasm	Carcinoid, mucocele
Parasites	Enterobius, Ascaris
Foreign body	Less common

Sequence of events:

Obstruction → increased intraluminal pressure
Mucus accumulation, bacterial overgrowth (E. coli, B. fragilis, Klebsiella, Streptococcus, Enterococcus, Pseudomonas)
Venous congestion → distension → visceral pain (periumbilical)
Arterial ischemia → necrosis → gangrene
Perforation → local abscess or diffuse peritonitis

Children have thinner appendiceal walls and underdeveloped omentum → perforation occurs earlier and diffuse peritonitis develops more readily.

Current Surgical Therapy 14e

Clinical Features

Classic Presentation

Anorexia (often earliest symptom)
Nausea and vomiting
Periumbilical pain initially (visceral, colicky) → migrates to RLQ (McBurney's point) within hours as parietal peritoneum becomes involved
Low-grade fever (develops later; high fever suggests perforation/abscess)
Progressive worsening over 24–72 hours

McBurney's point: two-thirds of the distance from the umbilicus to the right anterosuperior iliac spine.

Physical Examination Signs

Sign	How to Elicit	Significance
McBurney's tenderness	Direct palpation at McBurney's point	Most reliable
Rovsing's sign	Palpation of LLQ causes RLQ pain	Peritoneal irritation
Psoas sign	Pain with extension of right hip (patient prone) or flexion against resistance	Retrocecal appendix
Obturator sign	Pain with internal rotation of flexed right hip	Pelvic appendix
Dunphy's sign	Increased RLQ pain with coughing	Peritonitis
Heel-tap sign	RLQ pain when patient drops from tiptoes	Peritoneal irritation
Rebound tenderness	Sudden release of pressure causes pain	Peritoneal irritation
Guarding / rigidity	Involuntary muscle spasm	Peritonitis

Important caveats: Rovsing, psoas, and obturator signs have poor sensitivity/specificity, especially in young children. Classic signs may be absent in retrocecal appendicitis, elderly patients, immunosuppressed patients, and pregnant women.

Rosen's Emergency Medicine | Textbook of Family Medicine 9e

Differential Diagnosis

Surgical causes: Intestinal obstruction, intussusception, acute cholecystitis, Meckel's diverticulitis, mesenteric adenitis, ovarian torsion, ectopic pregnancy

Gynecological: Pelvic inflammatory disease, ovarian cyst (ruptured/torsion), endometriosis, mittelschmerz

Medical/other: Urinary tract infection, right ureteral stone, psoas abscess, right-sided pneumonia, Crohn's disease, gastroenteritis, constipation

Goldman-Cecil Medicine, Table 128-1

Diagnostic Workup

Laboratory Tests

No single test is diagnostic. Typical findings:

WBC >10,000/μL (in 87–92% of cases) but <18,000/μL unless perforation has occurred; left shift
CRP elevated (>0.6 mg/dL sensitive; highly elevated suggests perforation/abscess)
Procalcitonin: elevated with complicated appendicitis
Urinalysis: mild sterile pyuria (<5–10 WBC/hpf) possible due to ureteral inflammation; does not exclude appendicitis
β-hCG: mandatory in women of reproductive age to exclude ectopic pregnancy

Clinical Scoring Systems

Alvarado Score (MANTRELS):

Feature	Points
Migration of pain to RLQ	1
Anorexia	1
Nausea/vomiting	1
RLQ tenderness	2
Rebound tenderness	1
Elevated temperature (>37.3°C)	1
Leukocytosis (WBC >10,000)	2
Left shift	1
Total	10

Interpretation: ≤4 = unlikely; 5–6 = possible; 7–8 = probable; 9–10 = very likely.

Other validated systems: Pediatric Appendicitis Score (PAS), Adult Appendicitis Score, Appendicitis Inflammatory Response (AIR) score.

Imaging

Modality	Sensitivity	Specificity	Notes
CT (multidetector, low-dose)	≥94%	≥94%	Preferred in adults and obese patients; can detect perforation and complications
Ultrasound	~83%	~93%	First-line in children and pregnant women; non-compressible appendix >6 mm is diagnostic; operator-dependent
MRI	Comparable to CT	Comparable to CT	Preferred in pregnancy (avoids radiation); good alternative
Plain X-ray	Low	Low	Not diagnostic; may show appendicolith, ileus, RLQ soft tissue density

CT findings in appendicitis:

Dilated appendix >6 mm diameter
Appendiceal wall thickening and enhancement
Periappendiceal fat stranding
Appendicolith (seen in ~30%)
Periappendiceal abscess (with perforation)

CT scan showing dilated appendix with fat stranding

Contrast-enhanced CT: distended, fluid-filled appendix with fat stranding in the right iliac fossa

Coronal CT showing thickened appendix with fat stranding

Coronal CT: thickened, dilated appendix (~1 cm) with periappendiceal fat stranding (arrows)

RLQ ultrasound in a 10-year-old: dilated fluid-filled tubular structure with echogenic appendicolith — consistent with acute appendicitis

Goldman-Cecil Medicine | Current Surgical Therapy 14e | Rosen's Emergency Medicine

Classification

Type	Features
Simple (uncomplicated)	Inflamed but intact; no necrosis, perforation, or abscess
Gangrenous	Necrosis of appendiceal wall; almost always associated with luminal obstruction
Perforated	Full-thickness rupture; risk of peritonitis or abscess
Phlegmon / Abscess	Walled-off perforation; mass palpable in RLQ

Management

Preoperative

IV fluids and electrolyte correction
NPO
Preoperative antibiotics (reduce infectious complications in uncomplicated disease):
- Cefotetan 2 g IV, or Cefoxitin 2 g IV (3 postoperative doses for uncomplicated disease)
- Piperacillin-tazobactam or ticarcillin-clavulanic acid for complicated/perforated
- Target: E. coli, Bacteroides (gram-negative aerobes + anaerobes)

Operative Management

Laparoscopic appendectomy is now the standard of care for most cases:

Lower rate of postoperative complications vs. open
Faster return to normal activity and diet
Appropriate for: uncomplicated and most complicated appendicitis

Open appendectomy (McBurney's / Gridiron incision):

Preferred when perforation is evident preoperatively
McBurney's incision: oblique through McBurney's point; muscle-splitting (gridiron)
Remains essential skill for surgeons

Interval appendectomy: For patients who present with phlegmon/abscess after >5 days of symptoms → nonoperative management first (IV antibiotics ± percutaneous drainage by interventional radiology), followed by interval appendectomy at 6–8 weeks.

Nonoperative (Antibiotic-Only) Management

Growing evidence supports antibiotics alone for uncomplicated appendicitis:

~80–90% symptom resolution within 24–48 hours
2025 WSES Jerusalem Guidelines and 2024 SAGES Guidelines acknowledge this as a viable alternative
Recurrence rate ~25–40% at 5 years (higher in children)
Contraindicated if: fecalith/appendicolith present, perforation, immunocompromised, unable to comply with follow-up
Most surgeons still prefer operative management as definitive treatment
Current Surgical Therapy 14e | Goldman-Cecil Medicine | SAGES 2024 [PMID: 38740595] | WSES 2025 [PMID: 41604201]

Complications

Complication	Features
Perforation	Increases mortality 0.0002% → 3%; morbidity 3% → 47%
Peritonitis	Diffuse or localized; requires broad-spectrum antibiotics + surgery
Periappendiceal abscess	Walled-off perforation; drain percutaneously if accessible
Wound infection	More common after open or contaminated surgery
Ileus / adhesions	Post-surgical bowel obstruction
Pylephlebitis	Septic portal vein thrombosis (rare but serious)
Stump appendicitis	Inflammation of residual appendiceal stump after appendectomy

Special Populations

Children

Perforation rate inversely correlates with age; >50% perforation rate in children <5 years
US and MRI preferred (avoid radiation)
Nonoperative management acceptable in select cases; recurrence up to 40%
Same-day discharge possible after laparoscopic appendectomy in early disease

Pregnancy

Most common surgical emergency in pregnancy (same incidence as non-pregnant)
Diagnosis challenging: displaced appendix (tip moves to RUQ by third trimester in <25% of cases), physiologic leukocytosis and elevated ESR
MRI preferred imaging (avoids fetal radiation)
Perforation → increased risk of sepsis, fetal mortality, preterm labor
Laparoscopic appendectomy safe throughout all trimesters

Elderly

Atypical presentation common; diagnosis often delayed
Higher perforation rate at presentation (~70%)
Higher mortality and morbidity

Prognosis

Uncomplicated appendicitis: mortality ~0.0002%; full recovery expected
Perforated appendicitis: mortality ~3%; morbidity ~47%
Laparoscopic vs. open: laparoscopic carries lower wound infection rate, shorter hospital stay

Recent Guidelines (2024–2025)

Guideline	Key Recommendation
SAGES 2024 [PMID: 38740595]	Laparoscopic appendectomy preferred; antibiotics-first is a valid option for uncomplicated disease in selected patients
WSES Jerusalem Guidelines 2025 [PMID: 41604201]	Updated diagnostic and management algorithms; CT preferred for adults; nonoperative management supported for uncomplicated, fecalith-free appendicitis

Definition Etiology Pathophysiology ( chart form) Clinical features Types Diagnosis/ investigation Management ( table form) Medical management Surgical management Algorithm to approach appendicitis (chart form) with arrow Of appendicitis

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APPENDICITIS — Structured Clinical Reference

1. DEFINITION

Appendicitis is an acute inflammation of the vermiform appendix — a blind-ended tubular structure arising from the cecum — resulting from luminal obstruction, bacterial overgrowth, and progressive ischemic injury to the appendiceal wall.

It is the most common intra-abdominal surgical emergency worldwide, responsible for ~300,000–400,000 hospitalizations annually in the United States, with a lifetime risk of 6–10% in the general population.

Sabiston Textbook of Surgery | Goldman-Cecil Medicine

2. ETIOLOGY

Primary Cause: Luminal Obstruction

Cause	Details
Fecalith / Appendicolith	Most common; hardened stool or calcified concretion; ~1/3 of cases
Lymphoid hyperplasia	Common in children/adolescents following viral infections (adenovirus, EBV)
Neoplasms	Carcinoid tumor, mucinous adenocarcinoma, carcinoma
Parasites	Enterobius vermicularis (pinworm), Ascaris lumbricoides
Foreign body	Ingested material, vegetable seeds, barium
Fecal stasis	Low-fiber, high-fat (Western) diet implicated epidemiologically
Stricture / adhesion	Post-inflammatory scarring

Bacteriology (polymicrobial)

Escherichia coli
Bacteroides fragilis
Klebsiella pneumoniae
Enterococcus spp.
Pseudomonas aeruginosa
Streptococcus spp.

Sabiston Textbook of Surgery | Current Surgical Therapy 14e

3. PATHOPHYSIOLOGY (Flow Chart)

LUMINAL OBSTRUCTION
(fecalith, lymphoid hyperplasia, neoplasm, parasite)
            │
            ▼
INCREASED INTRALUMINAL PRESSURE
(mucus secretion + bacterial gas production continue)
            │
            ▼
VENOUS CONGESTION & LYMPHATIC OBSTRUCTION
(visceral afferent nerve fibers stretched)
            │
            ▼
VAGUE PERIUMBILICAL / EPIGASTRIC PAIN
(T10 dermatome, colicky, visceral)
            │
            ▼
BACTERIAL OVERGROWTH & MUCOSAL ISCHEMIA
(E. coli, B. fragilis, Klebsiella, Pseudomonas)
            │
            ▼
TRANSMURAL INFLAMMATION
(appendiceal wall becomes full-thickness inflamed)
            │
            ▼
PARIETAL PERITONEUM INVOLVED
            │
            ▼
LOCALIZED SOMATIC PAIN → RLQ (McBurney's point)
+ Fever, guarding, rigidity
            │
            ▼
    ┌───────┴────────┐
    ▼                ▼
UNCOMPLICATED     ARTERIAL ISCHEMIA
APPENDICITIS      → FULL-THICKNESS NECROSIS
(inflamed but         (Gangrenous appendicitis)
 intact)                    │
                            ▼
                      PERFORATION
                   ┌──────┴──────┐
                   ▼             ▼
           LOCALIZED          FREE PERFORATION
           ABSCESS /          (Diffuse peritonitis,
           PHLEGMON           sepsis, death)

Sabiston Textbook of Surgery | Current Surgical Therapy 14e

4. CLINICAL FEATURES

Symptoms

Symptom	Description
Anorexia	Earliest and most consistent symptom
Periumbilical pain	Initial visceral pain — vague, colicky
Migration of pain to RLQ	Hallmark; occurs over 12–24 h as parietal peritoneum becomes involved
Nausea & vomiting	Usually follows pain onset
Low-grade fever	37.5–38.5°C; high fever (>39°C) suggests perforation
Constipation / diarrhea	Variable; tenesmus possible with pelvic appendix

Signs

Sign	Method	Significance
McBurney's tenderness	Direct palpation 2/3 from umbilicus to ASIS	Most reliable RLQ finding
Guarding / rigidity	Involuntary abdominal wall spasm	Peritoneal irritation
Rebound tenderness (Blumberg's)	Sudden release of deep pressure → pain	Peritonitis
Rovsing's sign	LLQ palpation → RLQ pain	Refers peritoneal irritation
Psoas sign	Pain on right hip extension (patient prone) or active flexion against resistance	Retrocecal appendix
Obturator sign	Pain with internal rotation of flexed right hip	Pelvic appendix
Dunphy's (cough) sign	RLQ pain increased by coughing	Peritonitis
Heel-drop test	Patient drops from tiptoes → RLQ pain	Peritoneal irritation
Rigidity / Board-like abdomen	Involuntary muscle guarding	Perforated / diffuse peritonitis

Rosen's Emergency Medicine | Textbook of Family Medicine 9e | Sabiston Textbook of Surgery

5. TYPES / CLASSIFICATION

By Acuity

Type	Features
Acute appendicitis	Evolves over hours to days; most common presentation
Chronic / Recurrent appendicitis	Symptoms spanning weeks to months; low-grade, intermittent pain

By Severity (most clinically important)

Type	Pathology	Key Features
Simple (Uncomplicated)	Inflamed appendix, wall intact, no necrosis	RLQ pain, fever, leukocytosis; no perforation
Gangrenous	Full-thickness wall necrosis	More severe pain; almost always associated with fecalith; pre-perforation state
Perforated	Transmural rupture	High fever, peritonism, sepsis; two subtypes below
Appendiceal Phlegmon	Contained inflammatory mass	Palpable RLQ mass; present after ≥5 days of symptoms
Periappendiceal Abscess	Walled-off pus collection	Mass, swinging fever; amenable to percutaneous drainage
Diffuse Peritonitis	Free perforation, peritoneal soilage	Generalized rigidity, sepsis, high mortality

Sabiston Textbook of Surgery | Current Surgical Therapy 14e

6. DIAGNOSIS / INVESTIGATIONS

Clinical Scoring: Alvarado Score (MANTRELS)

Feature	Score
Migration of pain to RLQ	1
Anorexia	1
Nausea / vomiting	1
Tenderness in RLQ	2
Rebound tenderness	1
Elevated temperature (>37.3°C)	1
Leukocytosis (WBC >10,000)	2
Shift to left (neutrophilia)	1
Total	10

Interpretation: ≤4 = Appendicitis unlikely | 5–6 = Possible | 7–8 = Probable | 9–10 = Highly likely

Other scores: Pediatric Appendicitis Score (PAS), Appendicitis Inflammatory Response (AIR) Score, Adult Appendicitis Score

Laboratory Investigations

Test	Expected Finding	Notes
WBC count	>10,000/μL; usually <18,000	Elevated in 87–92%; left shift (neutrophilia)
CRP	Elevated (>0.6 mg/dL)	Highly elevated → perforation/abscess
Procalcitonin	Elevated	Indicates complicated/perforated disease
Urinalysis	Mild sterile pyuria possible	≤5–10 WBC/hpf; bacteria absent; from ureteral irritation
β-hCG (serum/urine)	Negative	Mandatory in all women of reproductive age
Blood cultures	Positive in sepsis	Needed if systemic infection suspected
Electrolytes / BMP	Disturbances with vomiting	Baseline for surgical planning
LFTs / Lipase	Normal (helps exclude biliary/pancreatic)	Part of differential workup

Imaging Investigations

Modality	Sensitivity	Specificity	When to Use
CT Abdomen/Pelvis (MDCT)	≥94%	≥94%	Gold standard in adults; low-dose (2 mSv); detects perforation, abscess, alternative diagnoses
Ultrasound (RLQ)	~83%	~93%	First-line in children and pregnant women; non-compressible appendix >6 mm diagnostic; operator-dependent
MRI Abdomen	~95%	~95%	Preferred in pregnancy (no radiation); safe, accurate
Plain X-ray (AXR)	Low	Low	Not routinely used; may show appendicolith, air-fluid levels, RLQ soft tissue density

CT Diagnostic Criteria:

Appendix diameter >6 mm
Appendiceal wall thickening + enhancement
Periappendiceal fat stranding
Appendicolith (30% of cases)
Periappendiceal fluid / abscess (with perforation)
"Target sign": thickened, fluid-filled appendix (sagittal view)

CT of acute appendicitis — target sign and fat stranding

CT abdomen: (A) Sagittal — thickened, fluid-filled appendix (target sign); (B) Coronal — elongated appendix with fat stranding — Sabiston Textbook of Surgery

Ultrasound appendicitis with appendicolith

RLQ ultrasound: dilated fluid-filled tubular structure + echogenic appendicolith — Current Surgical Therapy 14e

Goldman-Cecil Medicine | Sabiston Textbook of Surgery | Current Surgical Therapy 14e

7. MANAGEMENT (Table Form)

Overview by Type

Type of Appendicitis	Management Strategy
Uncomplicated (simple)	Laparoscopic appendectomy OR antibiotics-first (shared decision making)
Gangrenous	Laparoscopic appendectomy (urgent)
Perforated with diffuse peritonitis	Emergency open or laparoscopic appendectomy + peritoneal lavage
Perforated with abscess (<5 days)	Laparoscopic appendectomy + drainage
Phlegmon / Abscess (>5 days symptoms)	Nonoperative: IV antibiotics ± percutaneous drain → Interval appendectomy 6–8 weeks
Chronic/recurrent	Elective laparoscopic appendectomy

A. MEDICAL MANAGEMENT

Component	Details
IV Fluid Resuscitation	Normal saline or Lactated Ringer's to correct dehydration and electrolyte imbalances
NPO	Nothing by mouth in anticipation of surgery or while monitoring
Analgesia	IV opioids (morphine, fentanyl) — does NOT mask diagnosis; provide adequate pain relief
Antiemetics	Ondansetron, metoclopramide for nausea/vomiting
Antipyretics	Paracetamol / NSAIDs for fever management
Preoperative antibiotics	Single dose within 60 min of incision (reduces surgical site infections)

Antibiotic Regimens

Setting	First-Line	Alternatives
Uncomplicated (prophylaxis)	Cefotetan 2 g IV OR Cefoxitin 2 g IV	Cefazolin + metronidazole
Complicated / Perforated	Piperacillin-tazobactam 3.375 g IV q6h	Ticarcillin-clavulanate; Meropenem (severe)
Antibiotics-only (nonoperative)	Ertapenem 1 g IV daily OR Ceftriaxone + metronidazole	Amoxicillin-clavulanate (oral step-down)
Penicillin allergy	Ciprofloxacin + metronidazole	Aztreonam + metronidazole

Duration:

Uncomplicated: single preoperative dose (3 doses post-op max)
Complicated/perforated: 3–5 days IV then consider oral step-down based on clinical response
Nonoperative (antibiotics-only): 7–10 days (IV 24–48 h → oral)

Nonoperative (Antibiotics-Only) — Indications & Criteria

Factor	Suitable for Nonoperative	NOT Suitable
Appendicolith	No	Yes (higher failure/complication rate)
Imaging	Uncomplicated, no abscess	Perforation, free air, abscess
Age	Adults, select pediatric	Very young children
Recurrence risk	Counseled (~25–40% at 5 years)	Refused by patient
Comorbidities	Low surgical risk prefers nonop	High surgical risk

Sabiston Textbook of Surgery (CODA trial, APPAC trial) | Current Surgical Therapy 14e

B. SURGICAL MANAGEMENT

Laparoscopic Appendectomy (Standard of Care)

Step	Details
Position	Supine; left arm tucked; possible reverse Trendelenburg + right side up
Access	Veress needle (closed) or Hasson technique (open) through umbilicus
Insufflation	CO₂ to 12–15 mmHg
Port placement	Umbilical camera port (10–12 mm) + 2 working ports (5 mm) in LLQ / suprapubic
Procedure	Identify cecum → follow taenia coli to appendix base → divide mesoappendix (stapler/LigaSure) → staple/ligate appendix base → place in retrieval bag → remove
Irrigation	Pelvic irrigation if contamination present; consider cultures
Advantages	Lower wound infection rate, faster recovery, shorter hospital stay, diagnostic capability

Open Appendectomy

Step	Details
Incision	McBurney's (gridiron): oblique muscle-splitting incision at McBurney's point
Alternative	Lanz (transverse) incision for better cosmesis
Preferred when	Perforation with peritonitis; technical failure of laparoscopy; laparoscopy unavailable
Technique	Identify cecum → mesoappendix ligated and divided → appendix base doubly ligated → appendix excised → stump inverted (optional)

Interval Appendectomy

Indication	Timing	Route
Phlegmon or abscess (>5 days) managed nonoperatively	6–8 weeks after resolution	Elective laparoscopic

Percutaneous Drainage (IR-guided)

For periappendiceal abscess amenable to drainage
Performed by interventional radiology
Followed by interval appendectomy at 6–8 weeks
Not appropriate if no safe window, peritonitis, or free perforation

Sabiston Textbook of Surgery | Current Surgical Therapy 14e | Goldman-Cecil Medicine

8. ALGORITHM TO APPROACH APPENDICITIS

PATIENT PRESENTS WITH ACUTE ABDOMINAL PAIN
                    │
                    ▼
        HISTORY & PHYSICAL EXAMINATION
   (Pain migration, anorexia, RLQ tenderness,
    fever, guarding, Rovsing/Psoas/Obturator signs)
                    │
                    ▼
           CALCULATE ALVARADO SCORE
          ┌──────────┼──────────┐
          ▼          ▼          ▼
       SCORE ≤4   SCORE 5–6  SCORE ≥7
    (Unlikely)  (Equivocal) (Probable)
          │          │          │
          ▼          │          ▼
   Consider        IMAGING    LABS + IMAGING
   Alternatives       │       (CBC, CRP, PCT)
   Discharge if  ┌────┴─────┐       │
   well          │          │       │
              ULTRASOUND    CT    CT ABDOMEN
              (children,  (adults,    /PELVIS
              pregnant)    obese)
                    │
            ┌───────┴────────┐
            ▼                ▼
     CT NEGATIVE         CT POSITIVE
   (Appendix normal)   (Appendicitis confirmed)
            │                    │
            ▼                    ▼
     Observe / Admit     DETERMINE TYPE
     Re-evaluate                 │
     Consider alt Dx    ┌────────┴─────────┐
                        ▼                  ▼
               UNCOMPLICATED         COMPLICATED
               (No perforation,    (Perforation / Abscess /
                no gangrene)         Phlegmon / Peritonitis)
                        │                  │
              ┌─────────┴──────┐    ┌──────┴──────┐
              ▼                ▼    ▼              ▼
       APPENDECTOMY    ANTIBIOTICS  DURATION     FREE
       (Laparoscopic,  -ONLY        OF Sx <5d   PERFORATION
       Gold standard)  (selected,   Appendectomy  /PERITONITIS
              │        no fecalith)  ± Drainage       │
              ▼                │         │             ▼
          PREOP ABX       Ertapenem  DURATION Sx ≥5d  EMERGENCY
       + Resuscitation   IV 24–48h   ┌────────────┐   OPEN / LAP
              │         → Oral 7–10d │ IV ABX +   │  APPENDECTOMY
              ▼               │      │Percutaneous│  + LAVAGE
        SURGERY             MONITOR  │  Drainage  │
              │            (Failure? │            │
              ▼             → Surgery)└────────────┘
       POST-OP CARE               │
     (Uncomplicated:              ▼
      same-day/next-day     INTERVAL APPENDECTOMY
      discharge;            at 6–8 WEEKS
      Complicated:
      IV ABX 3–5 days)

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