Updated evidence-based guidelines intended to reduce variation in care and promote more consistent clinical decision-making for acute appendicitis across diverse patient populations have been issued by the World Society of Emergency Surgery (WSES).
Acute appendicitis is the most common abdominal surgical emergency worldwide, with an estimated annual incidence of approximately 100 cases per 100,000 population. Despite its prevalence, there is significant variation in diagnostic and management approaches.
To address this variability, updated WSES Jerusalem guidelines were developed by an international panel of 41 experts in surgery, emergency medicine and related disciplines, supported by a dedicated evidence-review team.
The primary objective was to standardise care, minimise unwarranted variability and support safe, effective and patient-centred management of acute appendicitis in adults, children, pregnant women, older adults, individuals with obesity and immunocompromised populations.
The recommendations were developed using the Grading of Recommendations Assessment, Development and Evaluation methodology, informed by a systematic review of literature from five major databases, including studies published up to May 2025.
Evidence from randomised trials, observational studies, systematic reviews and meta-analyses was evaluated for 19 key clinical questions across key domains including diagnosis, non-operative management, surgical timing, operative techniques and antibiotic therapy.
Customised approaches to appendicitis care
The guidelines recommend structured diagnostic pathways and validated clinical risk scores, such as the Appendicitis Inflammatory Response score, Adult Appendicitis Score and Paediatric Appendicitis Score, to guide initial assessment and reduce unnecessary imaging and negative appendectomy rates.
Tailored imaging strategies are endorsed, including ultrasound for children, magnetic resonance imaging in pregnancy when ultrasound is inconclusive, and low-dose computed tomography as the preferred modality for adults, where available.
The guidelines also support non-operative management with antibiotics as a safe and effective option for selected patients with uncomplicated appendicitis, provided appropriate monitoring and shared decision-making are implemented. However, appendectomy remains the preferred approach for specific populations, including pregnant women and many older adults.
When surgery is indicated, laparoscopic appendectomy within 24 hours of admission is strongly recommended. Evidence indicates that short in-hospital delays do not increase risk, the authors said.
For complicated appendicitis, short courses of postoperative antibiotics, typically two to three days after adequate source control, are advocated, replacing historically longer regimens. However, routine use of abdominal drains and prolonged antibiotic therapy is discouraged due to a lack of benefit and potential harm.
The guidelines emphasise the importance of follow-up after non-operative management of complicated appendicitis with abscess, particularly in adults aged 35 years or older, to detect underlying neoplasms, which may be present in up to 14.3% of cases.
Future research directions
Several additional research priorities were identified, including validation of diagnostic scores in special populations, optimisation of imaging strategies, and assessment of long-term outcomes following non-operative management.
The WSES panel concluded that widespread adoption of the recommendations could enhance consistency, safety and quality of care for patients with acute appendicitis globally but emphasised that implementation should be adapted to local resources and healthcare systems.
Reference
Podda M et al. Diagnosis and Treatment of Acute Appendicitis 2025 Edition of the World Society of Emergency Surgery Jerusalem Guidelines. JAMA Surg 2026;Jan 28:doi:10.1001/jamasurg.2025.6218.
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