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The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

SIFIPAC/WSES/SICG/SIMEU · 2020 · international

Source and licence

Authors
Paola Fugazzola, Marco Ceresoli, Vanni Agnoletti et al.
Title
The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)
Journal
World Journal of Emergency Surgery : WJES, 2020
DOI
10.1186/s13017-020-00298-0
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC7063712

Licence statement of the original publication

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Diagnosis

  • Statement 1.1We suggest the use of scoring systems for excluding acute appendicitis in elderly patients with a low-probability scoreConditional recommendation, low quality evidence
  • Statement 1.2We suggest against basing the diagnosis of acute appendicitis in elderly patients only on scoring systemsConditional recommendation, low quality evidence
  • Statement 2In elderly population, we recommend against basing the diagnosis of acute appendicitis only on patient's clinical signs and symptomsStrong recommendation, low quality evidence
  • Statement 3We recommend against basing the diagnosis of acute appendicitis in elderly patients only on elevated leukocytes count and CRP value. It should prompt adequate diagnostic courseStrong recommendation, low quality evidence
  • Statement 4.1We recommend the use of CT scan in all elderly patients with an Alvarado score ≥ 5 to confirm or exclude the diagnosis of acute appendicitis and to distinguish perforated from non-perforated appendicitisStrong recommendation, low quality evidence
  • Statement 4.2We suggest that elderly patients with an Alvarado score < 5 should be clinically observed and, in case of failure to improve, they could receive abdominal CT with IV contrastConditional recommendation, very low-quality evidence
  • Statement 4.3We suggest the use of US in elderly patients with an Alvarado score ≥ 5 who cannot undergo CT scan with IV contrast (i.e. acute or chronic kidney disease) to confirm the diagnosis of acute appendicitis, but not for excluding itConditional recommendation, low quality evidence
  • Statement 4.4We suggest against the use of US for distinguishing perforated from non-perforated appendicitis in elderly patientsConditional recommendation, very low-quality evidence
  • Statement 4.5We suggest the use of MRI to confirm or exclude the diagnosis of acute appendicitis and to distinguish perforated from non-perforated appendicitis in elderly patients with an Alvarado score ≥ 5 who cannot undergo CT scan with IV contrast (i.e. acute or chronic kidney disease), if this resource is available. If it is not available, non-contrast CT scan is suggestedConditional recommendation, very low-quality evidence

Non-operative management

  • Statement 5We suggest the application of NOM in selected elderly patients, with evidence of uncomplicated appendicitis at CT scan and without clinical signs suspected for complicated appendicitis, who wish to avoid surgery and accept the risk of recurrenceConditional recommendation, low-quality evidence
  • Statement 6.1We suggest the use of NOM with percutaneous drainage (if accessible) in elderly patients with complicated appendicitis with appendicular abscessConditional recommendation, low quality evidence
  • Statement 6.2We recommend against the use of NOM in elderly patients with complicated appendicitis with diffuse peritonitis or with a suspected free-perforated appendicitis at CT scanStrong recommendation, low quality evidence
  • Statement 7We recommend elective colonic screening in all elderly patients with appendicitis (treated both non-operatively and operatively, specially if laparoscopically)Strong recommendation, very low-quality evidence

Surgical treatment

  • Statement 8In elderly patients with acute appendicitis, we suggest laparoscopic appendectomy due to a reduced LOS, morbidity and costsConditional recommendation, moderate quality evidences
  • Statement 9In elderly patients operated for acute appendicitis, there are no clinical evidences about advantages in the use of linear stapler against other methods (endoloops, clips) for stump closure; we suggest the use of the preferred technique based on local expertise and availability (Conditional recommendation, moderate quality evidences.
  • Statement 10In elderly patient, we suggest the positioning of an abdominal drainage in case of complicated (with perforation/abscess/peritonitis) appendicitisConditional recommendation, very low quality evidences
  • Statement 11In elderly patient with acute appendicitis, once operation is indicated, we suggest to perform appendectomy as soon as possibleConditional recommendation based on very low quality evidences
  • Statement 12There is no consensus about the removal of a normal appendix with very low quality and indirect evidences; therefore, no recommendation could be made.

Antibiotic therapy

  • Statement 13We recommend pre-operative broad-spectrum antibiotics in elderly patients undergoing appendectomy for acute appendicitisStrong recommendation, moderate quality evidences
  • Statement 14.1In elderly patients operated on for uncomplicated acute appendicitis, we suggest to not administrate post-operative antibioticsConditional recommendation based on low quality evidences
  • Statement 14.2In elderly patients operated for complicated acute appendicitis, we suggest post-operative broad-spectrum antibioticsConditional recommendation based on low quality evidences
  • Statement 15In elderly patients operated for acute appendicitis, when post-operative antibiotic therapy is indicated, we suggest a period of 3-5 days although discontinuation of antimicrobial treatment should be based on clinical and laboratory criteria such as fever and leucocytosisConditional recommendation, low quality evidences

Discussion

  • Statement 9In elderly patients operated for acute appendicitis, there are no clinical evidences about advantages in the use of linear stapler against other methods (endoloops, clips) for stump closure; we suggest the use of the preferred technique based on local expertise and availabilityConditional recommendation, moderate quality evidences

Abstract

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Contents of the original publication

The section headings of the original.

  • Background
  • Material and methods
  • Results
  • Diagnosis
  • Non-operative management
  • Surgical treatment
  • Antibiotic therapy
  • Discussion
  • Conclusion

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