INTRODUCTION — Acute appendicitis is the most common abdominal surgical emergency

in the world, with a lifetime risk of 8.6 percent in males and 6.9 percent in females [1]. For
over a century, open appendectomy was the only standard treatment for appendicitis.
Contemporary management of appendicitis is more sophisticated and nuanced:
laparoscopic appendectomy has surpassed open appendectomy in usage, some patients
with perforated appendicitis may benefit from initial antibiotic therapy followed by interval
appendectomy, and several European trials have even suggested that it is feasible to treat
uncomplicated appendicitis nonoperatively with antibiotics alone.

The management of appendicitis in adults will be reviewed here. Appendicitis in children

and pregnant women is discussed separately:

●(See "Acute appendicitis in children: Management".)

●(See "Acute appendicitis in pregnancy".)

The clinical manifestations and diagnostic evaluation of appendicitis in adults are also
discussed elsewhere.

●(See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

●(See "Acute appendicitis in adults: Diagnostic evaluation".)

NONPERFORATED APPENDICITIS — Nonperforated appendicitis, also referred to as

simple appendicitis or uncomplicated appendicitis, refers to acute appendicitis that presents
without clinical or radiographic signs of perforation (eg, inflammatory mass, phlegmon, or
abscess).

Most cases of appendicitis are not perforated at presentation. For adult patients with
nonperforated appendicitis, we recommend timely appendectomy, either open or
laparoscopically (algorithm 1). Antibiotics can be used to augment rather than to replace
surgery. For the past 120 years, appendectomy has withstood the test of time as a safe,
effective, and definitive therapy for appendicitis. (See 'Appendectomy for nonperforated
appendicitis' below.)

Despite evidence that antibiotics alone may be sufficient for managing the initial
presentation of appendicitis, we suggest against its routine use for adult patients
presenting with uncomplicated appendicitis. We feel that its routine application in clinical
practice is premature because of many unanswered questions (eg, patient selection,
recurrent attacks, and missed neoplasm). Antibiotics are an option for those who are unfit
for or refuse surgery. (See 'Evidence for nonoperative management' below.)
Our suggestion is in line with treatment guidelines from the American College of
Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal
and Endoscopic Surgeons, European Association of Endoscopic Surgery, and World
Society of Emergency Surgery [2-4], all of which recommend appendectomy as the
treatment of choice for adult patients with nonperforated appendicitis.

Evidence for nonoperative management — To date, six randomized trials have

compared antibiotics with appendectomy for nonperforated appendicitis in adults [5-10].
Many more systematic reviews and meta-analyses have been published [11-17]. From
these publications, we know that:

●Most patients treated with antibiotics respond clinically with a reduction in white blood
cell count [7], avoidance of peritonitis [5], and general symptom reduction [6,8,9].
Compared with those who underwent immediate appendectomy, patients treated with
antibiotics have lower or similar pain scores [5-7], require fewer doses of narcotics [7],
have a quicker return to work [6,7], and do not have a higher perforation rate.
●Approximately 90 percent of patients treated with antibiotics are able to avoid surgery
during the initial admission. The other 10 percent that fail to respond to antibiotics
require a rescue appendectomy. However, there is no reliable way of predicting who
will or will not respond to antibiotics.
●Approximately 70 percent of those successfully treated with antibiotics during the
initial admission are able to avoid surgery during the first year. The other 30 percent
eventually require appendectomy for recurrent appendicitis or symptoms of abdominal
pain (mean time to appendectomy 4.2 to 7 months [5,7,8]).

Another randomized trial from Korea went a step further and compared supportive care
alone versus antibiotics in 245 adults with computed tomography (CT)-verified
uncomplicated appendicitis [18]. Approximately three-quarters of the patients screened
were excluded; exclusion criteria included appendiceal diameter >11 mm, appendicolith,
and complicated appendicitis. Patients treated with supportive care alone did just as well as
patients treated with four days of antibiotics. Approximately 7 percent in each group failed
initial treatment, with most requiring appendectomy; an additional 13 to 16 percent in each
group had recurrences during the 19-month follow-up, with most requiring appendectomy.
The initial treatment failure rate and recurrence rate with and without antibiotics are
strikingly similar to those of earlier randomized trials, indicating that perhaps supportive
care, not antibiotics, was responsible for the success of nonoperative therapy.

It is conceivable that whether appendicitis can be managed nonoperatively is predetermined

by the underlying pathophysiology, and that patients whose appendicitis is destined to
resolve without surgery will improve with or without antibiotics. However, although such
patients represent the majority (70 to 90 percent of those who present with nonperforated
appendicitis), they cannot be reliably identified a priori based on currently available clinical,
laboratory, and radiologic data, and, more importantly, neither can patients who are
destined to fail nonoperative management be selected for early appendectomy.

Despite the mounting evidence for nonoperative management of nonperforated

appendicitis, we remain concerned about the following issues:
●Antibiotic therapy is intended for patients with nonperforated (uncomplicated)
appendicitis only. However, preoperative abdominal CT cannot reliably distinguish
uncomplicated appendicitis from complicated disease. In one trial, for example, among
patients in the appendectomy arm, 20 percent had complicated appendicitis identified
at the time of surgery [5]. Patients with fecaliths on imaging have a high rate of
complicated appendicitis (up to 40 percent). Thus, nonoperative management is not
recommended for those patients [5,19,20].
●Nonoperative management poses a greater risk for patients who are older,
immunocompromised, or have medical comorbidities. In such patients, the severity of
the disease may be underestimated, and the risk of unexpected lesions in the
appendix, such as carcinoid and carcinoma, may be higher [21-25]. Although such
high-risk patients could potentially benefit the most from nonsurgical treatment of
appendicitis, they were excluded from all trials. Thus, the efficacy of the antibiotic-first
approach to management of appendicitis in this group of patients remains unknown.
(See 'Unexpected intraoperative findings' below.)

For a small minority of patients with either prior history of surgical complications or severe
phobia to appendectomy, a nonoperative approach could be offered as an alternative to
immediate surgery (algorithm 1) [26]. Current treatment strategies derived from trial
protocols call for initial intravenous antibiotics for one to three days, followed by oral
antibiotics for up to 10 days; the choices of antibiotics are not standardized [15]. Patients
are typically admitted to the hospital during the first one to three days for close observation
in case of clinical deterioration, which requires prompt rescue appendectomy. It is unclear
whether antibiotic treatment increases hospital utilization, and therefore cost, both during
the initial phase of treatment and for recurrences. Patients who choose nonoperative
treatment should be warned of a recurrence rate that is typically 15 to 25 percent but may
be up to 38 percent [5,27]. It is also unclear whether the success in avoiding immediate
surgery justifies the fear and burden of potential recurrence or missed appendiceal
neoplasm (especially in older adults).

Appendectomy for nonperforated appendicitis — The current standard treatment for

appendicitis is appendectomy, which can be performed open or laparoscopically [28].
Timing of appendectomy — Patients present with appendicitis at all times of the day.
Whether a stable patient with nonperforated appendicitis requires surgery overnight or the
next morning is controversial. However, a meta-analysis of 11 nonrandomized studies
showed that a short in-hospital delay of 12 to 24 hours before surgery in that patient
population was not associated with an increased risk of perforation (odds ratio [OR] 0.97,
95% CI 0.78-1.19) [29]. The randomized trials on treating appendicitis with antibiotics alone
also provided additional indirect evidence in support of its safety [14]. However, delaying
appendectomy for >48 hours was associated with increased surgical site infections and
other complications [29].

The timing of surgery also depends on the availability of surgeons and operating room
resources. Hospitals staffed with an around-the-clock in-house acute care surgical service
and operating room crew may perform an appendectomy whenever an operating room is
available, day or night. For hospital without such resources, appendectomy when the
operating room opens the next morning is appropriate. In either situation, for acute
nonperforated appendicitis in a stable patient, we recommend appendectomy within 12
hours. Patients should be admitted to the hospital and receive intravenous hydration, pain
control, and intravenous antibiotics while awaiting surgery.

Preoperative preparation — Patients with acute appendicitis require adequate hydration

with intravenous fluids, correction of electrolyte abnormalities, and perioperative antibiotics
[30]. The patient's vital signs and urine output should be closely monitored; a Foley catheter
may be required in severely dehydrated patients. Once the decision has been made to
perform an operation for acute appendicitis, the patient should proceed to the operating
room with as little delay as possible to minimize the chance of progression to perforation.
(See 'Timing of appendectomy' above.)

Antibiotics for nonperforated appendicitis — Prophylactic antibiotics are important for

preventing wound infection and intra-abdominal abscess following appendectomy [30]. The
flora of the appendix reflects that of the colon and includes gram-negative aerobes and
anaerobes.

Patients proceeding directly from the emergency room to the operating room for
appendectomy without further delay should receive prophylactic antibiotics within a 60-
minute "window" before the initial incision [31,32]. In general, a single preoperative antibiotic
dose for surgical wound prophylaxis is adequate. Guidelines established by the Medical
Letter and the Surgical Care Improvement Project suggest the following options for
appendectomy: a single dose of cefoxitin (2 g IV) or cefotetan (2 g IV), or the combination
of cefazolin (2 g if <120 kg or 3 g if ≥120 kg IV) PLUS metronidazole (500 mg IV), or, in
patients allergic to penicillins and cephalosporins, clindamycin PLUS one of the
following: ciprofloxacin, levofloxacin, gentamicin, or aztreonam (table 1) [33,34].
Postoperative antibiotics are unnecessary [35]. (See "Antimicrobial prophylaxis for
prevention of surgical site infection in adults" and "Control measures to prevent surgical site
infection following gastrointestinal procedures in adults", section on 'Gastroduodenal
procedures'.)

Patients on aspirin or clopidogrel — Appendectomy is commonly performed urgently or

emergently. In a retrospective case-control study of patients undergoing laparoscopic
appendectomy, those who were taking aspirin, clopidogrel (Plavix), or both did not have
more blood loss or transfusion requirement than matched controls; neither was there any
difference in complications, length of hospital stay, readmission, or mortality between the
two groups [36]. Thus, prehospital use of aspirin or clopidogrel should not preclude or delay
laparoscopic appendectomy.

Patients who present at night and will not undergo appendectomy until the next morning
should be admitted to the hospital and started on intravenous antibiotics as soon as
possible (often in the emergency room), rather than waiting until just before surgery. In this
case, we suggest choosing antibiotics from the list intended for patients
with perforated/complicated appendicitis to provide broad-spectrum coverage
(see 'Antibiotics for perforated appendicitis' below). Additional prophylactic antibiotics may
be required if patients did not receive antibiotics within the 60-minute "window" before
incision.

Open versus laparoscopic — Open and laparoscopic appendectomy have been

compared in over 70 randomized trials and analyzed in many systematic reviews and meta-
analyses [37-41]. A 2015 systematic review of nine moderate- to high-quality meta-analyses
(each analyzed 8 to 67 randomized trials) concluded that [42]:

The laparoscopic approach was superior for:

●A lower rate of wound infections (all nine meta-analyses; OR 0.3 to 0.52)

●Less pain on postoperative day 1 (two out of three meta-analyses; by 0.7 to 0.8 points
on a 10-point visual analog scale [VAS])
●Shorter duration of hospital stay (seven out of eight meta-analyses; by 0.16 to 1.13
days)

The open approach was superior for:

●A lower rate of intra-abdominal abscesses (three out of six meta-analyses; OR 1.56 to

2.29)
 ●A shorter operative time (eight meta-analyses; by 7.6 to 18.3 minutes)

A separate systematic review and pooled analysis also found laparoscopic appendectomy
to be associated with fewer short-term (pooled OR 0.43, 95% CI 0.3-0.63) and long-term
adhesive bowel obstructions (OR 0.33, 95% CI 0.19-0.56) [43].

Although laparoscopic appendectomy has gained widespread acceptance, there are both
benefits and limitations to the laparoscopic approach. As a result, the operative approach in
patients with suspected appendicitis is best decided by the surgeon based on personal
experience, institutional capabilities, and individual patient factors such as the confidence in
the diagnosis; history of prior surgery; the patient's age, gender, and body habitus; and
severity of disease. Evidence suggests that laparoscopy may be the preferred approach in
these following settings:

●An uncertain diagnosis – The laparoscopic approach provides an advantage in

patients in whom the diagnosis is uncertain since it permits inspection of other
abdominal organs. This benefit may be greater for women of childbearing age, who
traditionally have had higher negative appendectomy rates, and in whom laparoscopy
may reveal other causes of pelvic pathology [21,44]. In a study of 181 women who
underwent laparoscopy for suspected acute appendicitis, 86 (48 percent) were
diagnosed with a gynecologic disorder as the etiology of the symptoms [44].
●Obese patients – Laparoscopic appendectomy is useful in the overweight or obese
patient, since exposure of the right lower quadrant during open appendectomy may
require larger, morbidity-prone incisions [45-47]. (See 'Obese patients' below.)
●Older adult patients – Older adult patients may benefit significantly from a
laparoscopic approach, as hospital stay is shorter and discharge rates to home are
higher in this population than with an open appendectomy. (See 'Older adults' below.)

Laparoscopic techniques — Laparoscopic appendectomy was first described by Semm in

1983 [48]. Although open appendectomy preceded it by almost 100 years, laparoscopic
appendectomy has overtaken its open counterpart in popularity [37-39,49]. A prospective
trend analysis found that rates of complication, conversion, reoperation, and duration of
hospital stay associated with laparoscopic appendectomy have all decreased over a decade
of observation [39].

●Anesthesia – Laparoscopic appendectomy is typically performed under general

anesthesia.
●Patient preparation – In the laparoscopic approach, an orogastric tube is typically
placed to decompress the stomach. The bladder can be decompressed either with a
Foley catheter or by having the patient void immediately prior to entering the operating
room.
●Patient positioning – The patient is positioned supine on the operating room table
with the left arm tucked. The video monitor is placed to the patient's right side because
once pneumoperitoneum is established, both the surgeon and assistant stand on the
patient's left.
●Port placement – Various port placements have been advocated for laparoscopic
appendectomy. These methods share the principle of triangulation of instrument ports
to ensure adequate visualization and exposure of the appendix. In one method,
pneumoperitoneum is obtained through a 12-mm periumbilical port, through which the
laparoscope is inserted and exploratory laparoscopy performed. The other two ports
are placed under direct vision: a 5-mm port in the left lower quadrant and a 5-mm
suprapubic port in the midline (figure 1). If a 5-mm laparoscope is used, it can be
placed through the left lower quadrant trocar, and the umbilical 12-mm trocar can be
used for a stapler. Most staplers require a 12-mm port.
When the appendix is located in the retrocecal position, good triangulation of
instruments can also be achieved with a 12-mm port placed in the upper midline. This
port allows instruments or the laparoscope to be positioned for access to the gutter
between the right colon and the abdominal wall. If the risk for open conversion is high,
all midline incisions should be oriented vertically so they can easily be incorporated into
a lower midline incision.
An alternative abdominal access method to conventional laparoscopy is single-incision
laparoscopy, in which all instruments and the laparoscope are inserted through a multi-
channel portal placed at the umbilicus [50,51]. In a meta-analysis of 11 randomized
trials comparing single-incision with conventional laparoscopic appendectomy, single-
incision laparoscopic appendectomy was associated with a shorter length of stay and a
quicker return to activities but a longer operative time and a higher conversion rate
[52].
●Mobilization – Once the diseased appendix is identified, any adhesions to
surrounding structures can be lysed with a combination of blunt and sharp dissection. If
a retrocecal appendix is encountered, division of the lateral peritoneal attachments of
the cecum to the abdominal wall often improves visualization. Care must be taken to
avoid underlying retroperitoneal structures, specifically the right ureter and iliac
vessels.
●Mesoappendix dissection – The appendix or mesoappendix can be gently grasped
with a Babcock clamp and retracted anteriorly. The appendiceal artery, or
mesoappendix containing it, can be divided sharply between hemostatic clips, with a
laparoscopic gastrointestinal anastomosis (GIA) stapler, monopolar cautery, or one of
the advanced vessel ligation devices (eg, ultrasonic scalpel or LigaSure). The various
 technologies differ in operating time and cost but not in patient-important outcomes
such as complication rate and length of stay [53]. Thus, surgeons may choose a
technique based on his/her personal experience, the condition of the appendix, and
available resources.
●Appendix transection – The appendix is cleared to its attachment with the cecum,
and the appendiceal base is divided using a laparoscopic GIA stapler, taking care not
to leave a significant stump [54]. It is sometimes necessary to include part of the
cecum within the stapler to ensure that the staples are placed in healthy, uninfected
tissue. Alternatively, the appendix can be divided sharply between endoloops. Using
endoloops to close the appendiceal stump takes longer time but costs less than using
a laparoscopic GIA stapler; otherwise, the length of stay and complication rate
(including that of intra-abdominal abscess) do not differ [55,56]. Thus, each surgeon
may choose the method of appendiceal stump closure based on his/her personal
preference, the condition of the appendix, and available resources. Other methods of
appendiceal stump closure have been described (eg, suture knot, clip, LigaSure) but
are less commonly used due to limited data [57]. The appendiceal stump is typically
not inverted after laparoscopic appendectomy.
●Closure – The appendix is then removed through the umbilical port in a specimen
bag to prevent wound infection. The operative field is inspected for hemostasis and
irrigated with saline if needed, and then the fascial defect and skin incisions are
closed.

Open techniques — Open appendectomy was described by McBurney in 1891 [58]. Since
then, the technique has remained largely unchanged.

●Anesthesia – Open appendectomy in adults can be performed under general or

regional (spinal) anesthesia.
●Incision – The patient should be reexamined after the induction of general
anesthesia, as this allows deep palpation of the abdomen. If a mass representing the
inflamed appendix can be palpated, the incision can be located over the mass. If no
appendiceal mass is detected, the incision should be centered over McBurney's point,
one-third of the distance from the anterior superior iliac spine to the umbilicus. A
curvilinear incision in a skin fold allows for an excellent cosmetic result.
It is important not to make the incision too medial or too lateral. An incision placed too
medially opens onto the anterior rectus sheath, rather than the desired oblique
muscles, while an incision placed too laterally may be lateral to the abdominal cavity.
The incision can be oriented transversely or obliquely (perpendicular to the line
connecting the anterior superior iliac spine to the umbilicus) (figure 2). Some surgeons
prefer a transverse incision because it can be more easily extended to increased
exposure if needed.
 ●Mobilization and resection – The dissection begins through the subcutaneous
tissue to the external oblique fascia, which is sharply incised lateral to the rectus
sheath. Using a muscle-splitting technique, the external oblique is bluntly separated in
the direction of the muscle fibers; the internal oblique and transversus abdominis
muscles are bluntly separated in a similar fashion. The peritoneum is sharply entered,
avoiding injury to the underlying intestine.
The surgeon can often locate the appendix by sweeping a finger laterally to medially in
the right paracolic gutter. Thin adhesions between the appendix and surrounding
structures may generally be freed with blunt dissection; occasionally, sharp dissection
is required for more dense adhesions. If the appendix cannot be identified through
palpation, it can be located by following the teniae coli to its origin at the cecal base.
Once identified and freed from adhesions, the appendix is delivered through the
incision. The mesoappendix may be grasped with a Babcock clamp, taking care not to
tear the appendiceal wall and cause spillage of enteric contents. The appendiceal
artery, which runs in the mesoappendix, is divided between hemostats and tied with 3-
0 absorbable sutures.
A nonabsorbable purse-string suture is placed in the cecal wall around the appendix.
After crushing the appendiceal base with a Kelly clamp, the appendix is doubly tied
with 2-0 absorbable sutures. The appendix is excised with a scalpel, and the remaining
stump is cauterized to prevent a mucocele. The appendiceal stump is typically inverted
into the cecum while the purse-string suture is tightened, although the usefulness of
stump inversion is debatable [59-65]. The surgical bed is then irrigated with saline.
●Closure – The incision is closed in layers with running 2-0 absorbable suture,
beginning with the peritoneum, followed by the transversus abdominis, internal oblique,
and external oblique. Irrigation is performed at each layer. To improve analgesia and
limit postoperative narcotic requirements, the external oblique fascia may be injected
with local anesthetic. Scarpa's fascia is closed with interrupted 3-0 absorbable suture,
followed by a subcuticular closure or staples for the skin. In nonperforated appendicitis,
the skin may be closed primarily with a low likelihood of wound infection.

Postoperative management — After either open or laparoscopic appendectomy for

nonperforated appendicitis, patients may be started on a clear liquid diet and advanced as
tolerated to a regular diet. Antibiotics are not required postoperatively. Most patients are
discharged within 24 to 48 hours of surgery. Same-day discharge is feasible, most
commonly following a laparoscopic appendectomy [66,67].

PERFORATED APPENDICITIS — Patients with perforated appendicitis may appear

acutely ill and have significant dehydration and electrolyte abnormalities, particularly if fever
and vomiting have been present for a long time. The pain usually localizes to the right lower
quadrant if the perforation has been walled off by surrounding intra-abdominal structures
such as the omentum but can be diffuse if generalized peritonitis ensues. On imaging
studies, appendicitis can present with a contained perforation (an inflammatory mass often
referred to as a "phlegmon," or an intra-abdominal or pelvic abscess) or, rarely, a free
perforation.

Other unusual presentations of appendiceal perforation can occur, such as retroperitoneal

abscess formation due to perforation of a retrocecal appendix or liver abscess formation
due to hematogenous spread of infection through the portal venous system. An
enterocutaneous fistula can result from an intraperitoneal abscess that fistulizes to the skin.
Appendiceal perforation can result in a small bowel obstruction, manifested by bilious
vomiting and obstipation. High fevers and jaundice can be seen with pylephlebitis (septic
portal vein thrombosis) and can be confused with cholangitis.

Perforation is found in 13 to 20 percent of patients who present with acute appendicitis [68].
Perforation rate is higher among men (18 percent men versus 13 percent women) and older
adults [21,68]. Although perforation is a major concern when evaluating a patient with
symptoms that have lasted more than 24 hours, the time course of progression of
appendicitis to necrosis and perforation varies among patients, and perforation can develop
more rapidly and should always be considered. Approximately 20 percent of patients with
perforated appendicitis present within 24 hours of the onset of symptoms [69].

The management of perforated appendicitis depends on the condition of the patient (stable
versus unstable), the nature of the perforation (contained versus free perforation), and
whether an abscess or phlegmon is present on imaging studies (algorithm 1):

Unstable patients or patients with free perforation — A free perforation of the appendix
can cause intraperitoneal dissemination of pus and fecal material and generalized
peritonitis. These patients are typically quite ill and may be septic or hemodynamically
unstable, thus requiring preoperative resuscitation. The diagnosis is not always appreciated
before exploration.

For patients who are septic or unstable, and for those who have a free perforation of the
appendix or generalized peritonitis, emergency appendectomy is required, as well as
drainage and irrigation of the peritoneal cavity. Emergency appendectomy in this setting can
be accomplished open or laparoscopically; the choice is determined by surgeon preference
with consideration of patient condition and local resources. (See 'Appendectomy for
perforated appendicitis' below.)

Stable patients — Stable patients with perforated appendicitis who have symptoms
localized to the right lower quadrant can be treated with immediate appendectomy or initial
nonoperative management. Both approaches are safe. A 2017 Cochrane review of two
randomized trials concluded that the quality of the evidence was too low to make a
recommendation [70]. Thus, the decision ultimately rests with the treating surgeon. We
suggest the following initial approach based on imaging findings on presentation (algorithm
1):

●Patients with an appendiceal abscess should be treated with intravenous antibiotics

and percutaneous, image-guided drainage of the abscess. Immediate appendectomy is
an alternative option for these patients, especially if the abscess is not amenable to
percutaneous drainage. (See 'Appendectomy for perforated appendicitis' below.)
●Patients with a phlegmon of the right lower quadrant should be treated with
intravenous antibiotics. Repeat imaging is often performed to follow the resolution (or
progression) of the phlegmon, and to exclude other complications that could evolve
over time (eg, abscess formation). The authors of this topic do not perform immediate
appendectomy in patients with a phlegmon associated with perforated appendicitis.

Patients who fail initial antibiotic therapy clinically or radiographically require rescue
appendectomy, whereas those who respond to initial antibiotic therapy can be discharged
with oral antibiotics to complete a 7- to 10-day course (in total) and return for follow-up in six
to eight weeks. (See 'Initial nonoperative management'below.)

Initial nonoperative management — Stable patients with perforated appendicitis who

have symptoms localized to the right lower quadrant (ie, no free perforation or generalized
peritonitis) should be treated initially with antibiotics, intravenous fluids, and bowel rest,
rather than immediate surgery [71]. These patients will often have a palpable mass on
physical examination; a computed tomography (CT) scan may reveal a phlegmon or
abscess.

Immediate surgery in patients with a long duration of symptoms and phlegmon or abscess
formation has been associated with increased morbidity, due to dense adhesions and
inflammation [72]. Under these circumstances, appendectomy often requires extensive
dissection and may lead to injury of adjacent structures. Complications such as a
postoperative abscess or enterocutaneous fistula may ensue, necessitating an
ileocolectomy or cecectomy. Nonoperative management during the initial admission allows
the local inflammation to subside; interval appendectomy, if elected, can be carried out at a
lower risk. Fortunately, many of these patients will respond to initial nonoperative
management since the appendiceal process has already been "walled off."

A 2010 meta-analysis of 17 nonrandomized studies showed that, compared with immediate

surgery, initial nonoperative management of perforated appendicitis with abscess or
phlegmon is associated with fewer complications and similar length of stay and duration of
antibiotics [73]. Although a small randomized trial published after the meta-analysis showed
immediate laparoscopic appendectomy to be feasible for perforated appendicitis with
abscess (median duration of symptom seven days) and resulted in fewer readmissions and
fewer additional interventions than nonoperative management, substantial portions of
patients who underwent immediate surgery required bowel resection (10 percent), required
conversion to open surgery (10 percent), or had incomplete appendectomy (13 percent)
[72].

Initial nonoperative management includes intravenous antibiotics and fluids as well as

bowel rest; any accessible abscess should be drained percutaneously under image
guidance. Patients should be closely monitored in the hospital during this time. Treatment
failure, as evidenced by bowel obstruction, sepsis, or persistent pain, fever, or leukocytosis,
requires immediate rescue appendectomy. If fever, tenderness, and leukocytosis improve,
diet can be slowly advanced, usually within three to five days. Patients are discharged
home when clinical parameters have normalized and return for a follow-up in six to eight
weeks. (See 'Follow-up after initial nonoperative management of perforated
appendicitis' below.)

Antibiotics for perforated appendicitis — In patients with perforated appendicitis, the

antibiotic regimen should consist of empiric broad-spectrum therapy with activity against
gram-negative rods and anaerobic organisms pending culture results. The choice of agents
is based on patient and disease factors (see "Antimicrobial approach to intra-abdominal
infections in adults", section on 'Regimens'):

●Most perforated appendices or appendiceal abscesses fall into the category of mild-
to-moderate community-acquired intra-abdominal infections without risk factors for
antibiotic resistance or treatment failure (table 2). Coverage of streptococci, non-
resistant Enterobacteriaceae, and (in most cases) anaerobes is generally sufficient
(table 3).
●In cases of perforated appendicitis that are severe, or in patients at high risk for
adverse outcomes or resistance (table 2), broader empirical coverage is warranted. We
generally include an agent with gram-negative activity broad enough to
cover Pseudomonas aeruginosa and Enterobacteriaceae that are resistant to non-
pseudomonal cephalosporins in addition to coverage against enteric streptococci and
(in most cases) anaerobes (table 4).
●Although rare for appendicitis, in patients with healthcare-associated infections, the
likelihood of drug resistance is high. Thus, to achieve empiric coverage of likely
pathogens, in addition to coverage against streptococci and anaerobes, regimens
should at least include agents with expanded spectra of activity against gram-negative
bacilli (including P. aeruginosa and Enterobacteriaceae that are resistant to non-
 pseudomonal third-generation cephalosporins and fluoroquinolones). We also usually
use an empiric regimen that has anti-enterococcal activity for patients with healthcare-
associated intra-abdominal infection, particularly those with postoperative infection,
those who have previously received cephalosporins or other antimicrobial agents
selecting for Enterococcus species, immunocompromised patients, and those with
valvular heart disease or prosthetic intravascular materials (table 5).

Regardless of the initial empiric regimen, the therapeutic regimen should be revisited once
culture and susceptibility results are available. Recovery of more than one organism should
suggest polymicrobial infection including anaerobes, even if no anaerobes are isolated in
culture. In such circumstances, anaerobic coverage should be continued. The duration of
antibiotics is discussed separately. (See "Antimicrobial approach to intra-abdominal
infections in adults", section on 'Duration of therapy'.)

Percutaneous abscess drainage — If imaging studies demonstrate an intra-abdominal or

pelvic abscess, computed tomography- or ultrasound-guided drainage can often be
performed percutaneously or transrectally [74]. Studies suggest that percutaneous drainage
of appendiceal abscesses results in fewer complications and shorter overall length of stay
than surgical drainage [71,75,76]. It also allows inflammation to subside before
appendectomy, thereby negating the need for a more extended bowel resection (eg,
ileocecectomy) in some cases.

Follow-up after initial nonoperative management of perforated appendicitis — Using

the initial nonoperative approach outlined above, more than 80 percent of patients who
present with a "walled-off" appendiceal process (ie, contained perforation) can be spared an
appendectomy during the initial admission [77].

After successful nonoperative management of perforated appendicitis, patients should be

seen in six to eight weeks, at which time those over 40 who have not undergone routine
colonoscopic screening should be offered a colonoscopy. The risk of such patients
harboring a cecal or appendiceal neoplasm can be high [24]. (See 'Older adults' below.)

Some surgeons also offer routine interval appendectomy, while others do not [78]. The
proponents of routine interval appendectomy argue that:

●It prevents recurrent appendicitis (5 to 38 percent, depending upon studies and

duration of follow-up [27,72,79,80]).
●It excludes appendiceal neoplasms. The prevalence of appendiceal neoplasm is
significantly higher in interval appendectomy specimens (5.9 to 12 percent [24,81,82])
than in routine appendectomy specimens (0.9 to 1.4 percent [21,79,82]), especially in
 older adults (16 percent of interval appendectomies in patients over 40 [81]).
(See 'Appendiceal neoplasms' below and 'Older adults' below.)

The opponents argue that the incidence of recurrent symptoms following successful
conservative management of perforated appendicitis is too low to justify routine surgery in
asymptomatic patients [83].

The authors of this topic do not perform interval appendectomy routinely. Instead, we follow
patients clinically and offer appendectomy only to those with residual or recurrent
symptoms.

Appendectomy for perforated appendicitis — Appendectomy may be required to treat

perforated appendicitis in one of three clinical scenarios:

●Emergency appendectomy is required for patients with free perforation of the

appendicitis, with diffuse peritonitis, or who are septic or hemodynamically unstable as
a result of perforated appendicitis. (See 'Unstable patients or patients with free
perforation' above.)
●The authors of this topic would consider offering immediate appendectomy to patients
with perforated appendicitis with an abscess but not a phlegmon on imaging studies.
(See 'Stable patients' above.)
●Rescue appendectomy is required for patients with perforated appendicitis who fail to
respond to nonoperative management with intravenous antibiotics with or without
percutaneous drainage, regardless of initial imaging findings. (See 'Stable
patients' above.)

Open versus laparoscopic — In the early days of laparoscopic appendectomy, it was

contraindicated in perforated appendicitis due to the severity of inflammation and complexity
of anatomy. In a study of 235,473 patients with suspected acute appendicitis undergoing a
laparoscopic or open appendectomy between 2000 and 2005 from the United States
Nationwide Inpatient Sample, the proportion of patients with uncomplicated appendicitis
was significantly higher in the laparoscopic group (76 versus 69 percent) [37]. For patients
with complicated appendicitis, defined as an appendiceal perforation or abscess, the
laparoscopic approach was significantly associated with a shorter mean hospital stay (3.5
versus 4.2 days), higher rates of intraoperative complications (odds ratio [OR] 1.61, 95% CI
1.33-1.94), and higher hospital costs (9 percent) compared with patients undergoing an
open appendectomy.

As surgeons gained more experience with the technique, laparoscopic appendectomy

became feasible for patients with perforated appendicitis undergoing immediate surgery
[84]. A 2017 systematic review and meta-analysis of two trials and 14 retrospective studies
of perforated appendicitis showed that, compared with open surgery, laparoscopic
appendectomy reduced the risk of surgical site infection, length of hospital stay, and time to
oral intake without increasing the rate of intra-abdominal abscess. The operating time was
slightly longer with laparoscopic appendectomy, but only by 14 minutes [85].

We recommend that surgeons choose the technique with which they are more experienced
and prepare to convert to open surgery if unexpected findings occur during laparoscopic
exploration.

Techniques — Operative techniques are similar to those used for nonperforated

appendicitis described above, with the following exceptions (see 'Laparoscopic
techniques' above and 'Open techniques' above):

●Incision – In an open appendectomy for perforation, a larger incision may be

required to provide adequate exposure for drainage of abscesses, enteric contents,
and purulent material. In some instances, a lower midline incision is preferable to a
right lower quadrant incision (eg, free perforation or generalized peritonitis).
●Irrigation – In both open and laparoscopic approaches to perforated appendicitis, the
goal is to remove any infected material and drain all abscess cavities at the time of
appendectomy. Copious irrigation was traditionally used to reduce the likelihood of
postoperative abscess formation, although most [86,87], but not all [88], contemporary
studies failed to demonstrate a benefit. For perforated appendicitis with intra-abdominal
or pelvic contamination, we suggest first clearing the purulent collection with suction.
Peritoneal irrigation can then be applied judiciously, with frequent, repeated suctioning
of the irrigant. The goal is to dilute and remove infected material without spreading the
infection to the rest of the abdomen.
●Drains – Peritoneal drains are not necessary after an appendectomy for perforated
appendicitis [89,90]. In a 2015 Cochrane systematic review of five trials, drains
increased the length of hospital stay by two days without reducing the incidence of
wound infection or abscess [91].
●Closure – Skin closure techniques include primary closure, loose partial closure, and
closure with secondary intention. Because of wound infection rates ranging from 30 to
50 percent with primary closure of grossly contaminated wounds, many advocate
delayed primary or secondary closure [92,93]. However, two meta-analyses showed
that, compared with primary closure, delayed closure increased the length of hospital
stay by 1.6 days without decreasing the wound infection rate [94,95]. A cost-utility
analysis of contaminated appendectomy wounds also showed primary closure to be
the most cost-effective method of wound management [96].
 For patients with a contaminated wound due to perforated appendicitis, we suggest
against delayed wound closure. Our preferred technique of skin closure after an open
appendectomy is interrupted permanent sutures or staples every 2 cm with loose
wound packing in between. Removal of the packing in 48 hours often leaves an
excellent cosmetic result with an acceptable incidence of wound infection. If heavy
fecal contamination is present, the skin is often left open to close secondarily. Wounds
are typically closed after a laparoscopic appendectomy for perforated appendicitis.

Postoperative management — Patients with perforated appendicitis often develop an ileus

postoperatively regardless of the surgical approach (open versus laparoscopic). Thus, diet
should only be advanced as the clinical situation warrants. Patients may be discharged
once they tolerate a regular diet, usually in five to seven days. Three to five days of
intravenous antibiotics is recommended for perforated appendicitis after appendectomy
[97]. (See "Antimicrobial approach to intra-abdominal infections in adults", section on
'Duration of therapy'.)

UNEXPECTED INTRAOPERATIVE FINDINGS

Normal appendix — The diagnosis of appendicitis can be uncertain. In some historical

studies, more than 15 percent of patients with suspected appendicitis have a normal
appendix at laparotomy, with higher percentages in infants, older adults, and young women
[21,98]. However, the use of imaging studies and laparoscopy have reduced the negative
appendectomy rate [99]. The contemporary negative appendectomy rate varies from 6
percent in the United States (routine use of preoperative imaging) and Switzerland (routine
use of laparoscopy) to 21 percent in the United Kingdom (selective use of imaging and
laparoscopy) [99-101].

If an uninflamed appendix is encountered at appendectomy, it is important to search for

other causes of the patient's symptoms, including terminal ileitis; cecal or sigmoid
diverticulitis; a perforating colon carcinoma; Meckel's diverticulitis; mesenteric adenitis; or
uterine, fallopian, or ovarian pathology in a female.

Even if the appendix appears normal, early intramural or serosal inflammatory changes can
sometimes be found in subsequent microscopic evaluation [102,103]. Accordingly, the
normal-appearing appendix should be removed. Moreover, if right lower quadrant pain
recurs, appendicitis can be excluded from the differential diagnosis [104].

Chronic appendicitis — Chronic appendicitis refers to the pathologic finding of chronic

inflammation or fibrosis of the appendix in a subset of patients undergoing appendectomy
[105,106]. These patients are clinically characterized by prolonged (>7 days) right lower
quadrant pain that may be intermittent and a normal white blood cell count. Most patients
have resolution of pain with appendectomy. Chronic appendicitis may be present in 14 to 30
percent of adults undergoing appendectomy [105,106] but is much rarer in children.

Appendiceal neoplasms — Neoplasms of the appendix are rare, occurring in less than 1
percent of routine appendectomies. Patients may present with symptoms of appendicitis, a
palpable mass, intussusception, urologic symptoms, or an incidentally discovered mass on
abdominal imaging or at laparotomy for another purpose. It is not uncommon for patients
with an appendiceal neoplasm to have acute appendicitis as well [82,107,108]. Typically,
the diagnosis is not appreciated until surgery or pathologic evaluation of the appendectomy
specimen. The most common appendiceal tumors include carcinoid tumors,
adenocarcinoma, and mucinous neoplasms [109].

●Appendiceal neuroendocrine (carcinoid) tumor – Simple appendectomy is

sufficient in most cases of appendiceal carcinoid, while right hemicolectomy is
indicated for tumors >2 cm or if the adjacent mesenteric nodes are involved.
Management of carcinoid tumors is discussed elsewhere in detail. (See "Cancer of the
appendix and pseudomyxoma peritonei", section on 'Neuroendocrine tumors'.)
●Appendiceal adenocarcinoma – Standard treatment is right hemicolectomy, and
reoperation is recommended if the diagnosis is made on pathologic evaluation of an
appendectomy specimen. This is discussed in detail elsewhere. (See "Cancer of the
appendix and pseudomyxoma peritonei", section on 'Adenocarcinoma'.)
●Appendiceal mucocele – Sometimes referred to as mucoceles, mucinous
neoplasms of the appendix include a spectrum of diseases including simple cyst,
mucinous cystadenoma, mucinous cystadenocarcinoma, and pseudomyxoma peritonei
[110]. If there is any preoperative suspicion of an appendiceal tumor, care must be
taken to avoid spillage of mucin-secreting cells throughout the abdomen. These tumors
are discussed in detail elsewhere. (See "Appendiceal mucoceles".)

SPECIAL PATIENT POPULATIONS

Older adults — One in every 2000 adults over age 65 will develop appendicitis annually,
making appendicitis an important cause of abdominal pain in this age group. Older adults
tend to have a diminished inflammatory response, resulting in less remarkable findings on
history and physical examination [111]. For these reasons, older patients often delay
seeking medical care, and, as a result, they have a considerably higher rate of perforation
at the time of presentation [112,113]. Older patients may have comorbid cardiac,
pulmonary, and renal conditions with resulting morbidity and mortality from perforation. In
one series, the mortality from perforated appendicitis in patients over age 80 was 21
percent [114]. Older patients can also have a redundant sigmoid colon that can cause right-
sided pain from sigmoid diseases. Accordingly, computed tomography (CT) scanning can
improve diagnostic accuracy in this population [115].

Laparoscopic appendectomy can be used successfully in the older adult population and
results in shorter hospitalization for older patients with both perforated and nonperforated
appendicitis [116,117]. In a retrospective review based upon outcome data from the North
Carolina Hospital Association Patient Data System on 29,244 appendectomies performed in
adults, 2722 were performed in older patients (defined as age >65 years) [116]. Among the
older patients, laparoscopic appendectomy had the following benefits compared with those
undergoing an open appendectomy:

●For uncomplicated appendicitis, laparoscopic appendectomy was associated with a

shorter length of hospital stay (4.6 versus 7.3 days), a higher rate of discharge to home
rather than a nursing facility (91 versus 79 percent), fewer complications (13 versus 22
percent), and lower mortality rate (0.4 versus 2.1 percent).
●For a perforated appendix, laparoscopic appendectomy was also associated with a
shorter length of hospital stay (6.8 versus 9.0 days), a higher rate of discharge to home
(87 versus 71 percent), and equivalent mortality rates (0.37 versus 0.15 percent).

Because colonic neoplasms are more common in older patients and can mimic appendicitis,
patients over 40 who are managed nonoperatively for perforated appendicitis should
undergo colonic screening with colonoscopy, CT, or both [24], in additional to undergoing
an interval appendectomy. (See 'Follow-up after initial nonoperative management of
perforated appendicitis' above.)

Immunocompromised patients — Immunocompromised patients are increasingly

common in surgical practice and include organ transplant recipients and those receiving
immunosuppressive therapy for autoimmune diseases, cancer, and AIDS. Although certain
causes of abdominal pain are specific to the immunocompromised state, appendicitis
remains a concern [118,119]. (See "Surgical issues in HIV infection".)

The immunocompromised are susceptible to infection, and their immune response is

blunted due to immunosuppressive medication or disease. As a result, they may not exhibit
the typical signs and symptoms of appendicitis and may have only mild tenderness on
examination. In addition, laboratory and radiological tests may not show the expected level
of inflammation. An expanded differential diagnosis includes but is not limited to
opportunistic (mycobacterial) and viral (cytomegalovirus) infections, fungal infections,
secondary malignancies (lymphoma and Kaposi's sarcoma), and typhlitis. Because of the
broad differential diagnoses, there is often a delay in reaching the diagnosis and
presentation to surgical evaluation, which can increase the risk of perforation [118,120].
CT is particularly useful in this patient population as it may not only diagnose appendicitis
but may exclude or diagnose other potential causes for the patient's symptoms. If
appendicitis is strongly suspected, operation should not be delayed, as there is no specific
contraindication to operation in immunocompromised patients.

Obese patients — Laparoscopic appendectomy is beneficial in overweight or obese

patients, since exposure of the right lower quadrant during open appendectomy may require
larger, morbidity-prone incisions [45-47]. In a meta-analysis of five studies of patients with a
body mass index of >30 kg/m2, laparoscopic appendectomy, as compared with open
surgery, was associated with fewer postoperative complications, including wound infections
and intra-abdominal abscesses, short operative time and hospital stay, and lower hospital
charges [121].

Children — Appendicitis in children is discussed in detail separately. (See "Acute

appendicitis in children: Diagnostic imaging" and "Acute appendicitis in children: Clinical
manifestations and diagnosis" and "Acute appendicitis in children: Management".)

Pregnancy — Pregnancy poses unique challenges in the diagnosis of appendicitis. Acute

appendicitis in pregnancy is discussed in detail separately. (See "Acute appendicitis in
pregnancy".)

OUTCOMES

Mortality — The mortality associated with appendicitis is low but can vary by geographic
locations. In developed countries, the mortality rate is between 0.09 and 0.24 percent. In
developing countries, the mortality rate is higher, between 1 and 4 percent [97].

Morbidity — Overall complication rates of 8.2 to 31.4 percent, wound infection rates of 3.3
to 10.3 percent, and pelvic abscess rates of 9.4 percent have been reported following
appendectomy [97].

The most common complication following appendectomy is surgical site infection, either a
simple wound infection or an intra-abdominal abscess. Both typically occur in patients with
perforated appendicitis and are very rare in those with simple appendicitis. Thorough
irrigation and broad-spectrum antibiotics are used to minimize the incidence of
postoperative infections. Delayed primary closure of the wound has not decreased the rate
of wound infection compared with primary closure. (See 'Techniques' above.)

Compared with open appendectomy, laparoscopic appendectomy has been associated with
a lower risk of incisional infection (odds ratio 0.37, 95% CI 0.32-0.43) but a high risk of
organ space (intra-abdominal or pelvic) infection (odds ratio 1.44, 95% CI 1.21-1.73) [122].
(See 'Open versus laparoscopic' above.)

Recurrent or stump appendicitis — Recurrent appendicitis can occur in 5 to 38 percent of

patients who are managed nonoperatively, depending on the study and the length of follow-
up. Interval appendectomy eliminates the risk of recurrent appendicitis. (See 'Follow-up
after initial nonoperative management of perforated appendicitis' above.)

Stump appendicitis is a form of recurrent appendicitis that is related to incomplete

appendectomy that leaves an excessively long stump after open or laparoscopic surgery,
more commonly for perforated appendicitis. To minimize stump appendicitis, the appendix
should be transected no further than 0.5 cm from its junction with the cecum and removed
as a whole. In case stump appendicitis occurs, stump resection can be performed open or
laparoscopically. A perforated appendiceal stump, however, typically requires a more
extensive bowel resection to control [123].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines

from selected countries and regions around the world are provided separately.
(See "Society guideline links: Appendicitis in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Appendicitis in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

●For adult patients with nonperforated appendicitis, we suggest appendectomy rather

than nonoperative management with antibiotics (algorithm 1) (Grade 2B). Despite
evidence that antibiotics alone can be as effective as surgery for managing the initial
presentation of appendicitis, these studies show modest recurrence rates and missed
neoplasms. Patients who elect for antibiotic-alone therapy must be clearly counseled
on the risks and benefits of that option. (See 'Nonperforated appendicitis' above.)
●For acute nonperforated appendicitis, immediate appendectomy should be performed
within 12 hours of diagnosis. (See 'Timing of appendectomy' above.)
•For patients proceeding directly from the emergency room to the operating room
for appendectomy without further delay, a single dose of prophylactic antibiotics
should be given within a 60-minute "window" before incision (table 1). Prophylactic
antibiotics are important for preventing wound infection and intra-abdominal
abscess following appendectomy. (See 'Preoperative preparation' above.)
•Patients who present at night and will not undergo appendectomy until the next
morning should be admitted to the hospital and started on intravenous antibiotics
as soon as possible (often in the emergency room), rather than waiting until just
before surgery. In this case, we suggest choosing antibiotics from the list intended
for patients with perforated/complicated appendicitis to provide broad-spectrum
coverage. Additional prophylactic antibiotics may be required if patients did not
receive antibiotics within the 60-minute "window" before incision.
(See 'Preoperative preparation' above and 'Antibiotics for perforated
appendicitis'above.)
●Both open and laparoscopic approaches to appendectomy are appropriate for all
patients; the choice is by surgeon preference. In general, patients treated with a
laparoscopic appendectomy have fewer wound infections, less pain, and a shorter
duration of hospital stay but more intra-abdominal abscesses and a longer operating
time. (See 'Open versus laparoscopic' above.)
●Patients with perforated appendicitis causing hemodynamic instability, sepsis, free
perforation, or generalized peritonitis require emergency appendectomy, irrigation and
drainage of the peritoneal cavity, and sometimes bowel resection (algorithm 1). Both
open and laparoscopic approaches are appropriate, depending on surgeon experience,
patient condition, and local resources. (See 'Unstable patients or patients with free
perforation' above.)
●For stable patients with perforated appendicitis and symptoms localized to the right
lower quadrant, we suggest initial nonoperative management rather than immediate
appendectomy (Grade 2C). Nonoperative management consists of intravenous
antibiotics and, if an abscess is present, percutaneous drainage (algorithm 1). The
choice of antibiotics depends on whether the disease is mild to moderate (table 3),
severe (table 4), or if the patient has been recently hospitalized (table 5). Patients who
fail to respond to antibiotics require rescue appendectomy. Immediate appendectomy
is an alternative option for patients who present with an appendiceal abscess,
especially if the abscess is not amenable to percutaneous drainage. (See 'Stable
patients' above.)
 ●Following initial nonoperative management of perforated appendicitis with an
appendiceal abscess or phlegmon, patients should be seen in six to eight weeks.
Patients over 40 who have not undergone routine colonoscopic screening should be
offered a colonoscopy. Whether to perform interval appendectomy routinely or
selective is controversial; the authors only perform interval appendectomy in patients
who have persistent or recurrent symptoms. (See 'Follow-up after initial nonoperative
management of perforated appendicitis' above.)
●We suggest removing a grossly normal-appearing appendix at the time of surgical
exploration rather than leaving it in situ (Grade 2C). Subclinical inflammation can be
detected by microscopic evaluation. Moreover, if right lower quadrant pain recurs,
appendicitis can be excluded from the differential diagnosis. (See 'Normal
appendix' above.)
●Appendiceal neoplasms occur in 1 percent of all appendectomies but in 10 percent of
interval appendectomies. The most common appendiceal tumors include carcinoid
tumors, adenocarcinoma, and mucinous neoplasms. Treatments are discussed
separately. (See 'Appendiceal neoplasms' above and "Cancer of the appendix and
pseudomyxoma peritonei".)

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