From Clinic to Recovery · First Edition
Chapter 05 — Appendicitis and Appendicectomy
Dr. Tamer Rushdy Elalfy · 21 min read
In this chapter
Appendicitis is the most common reason for emergency abdominal surgery, and the consultation is very different from the planned clinic visit of Chapter 4. The patient is often young, in pain, frightened, fasting, and seen at night, frequently with family on the telephone rather than in the room. There is less time, but the duties are the same: to explain the diagnosis, to offer the reasonable options, including antibiotics for some patients, to disclose the material risks, and to confirm that the patient has understood. This chapter shows how to do that well under time pressure.
Learning objectives After reading this chapter you should be able to:
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Table 5.1. Appendicitis and appendicectomy at a glance.
| At a glance | |
|---|---|
| Operation | Laparoscopic (keyhole) appendicectomy under general anesthesia |
| Alternative for some patients | Antibiotics first, for uncomplicated appendicitis confirmed on imaging |
| Hospital stay | Usually 1 day for uncomplicated appendicitis; often 3 to 5 days if the appendix has burst |
| Back to school or office work | About 1 to 2 weeks; longer after perforation |
| Risks every patient should hear | Infection, conversion to open surgery, a normal appendix, and an unexpected tumor in the pathology |
| The key counseling message | “Removing the appendix is a reliable cure. Antibiotics avoid an operation for many people, but about half need one within a few years.” |
STEP 1 Explaining the disease and the treatment
5.1 Consent when time is short
Emergency consent is still informed consent. Three practical steps make it possible.
- Treat pain first. A patient in severe pain cannot weigh information. Giving analgesia, including opioids, does not increase the risk of a missed or wrong diagnosis in acute abdominal pain [1], and it often makes the conversation possible.
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Check capacity. Pain, fever, sepsis, and sedating medicines can all affect understanding. If capacity is in doubt, wait until analgesia has worked, assess it, and document the assessment (Section 1.10).
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Involve the right people. Ask the patient whom they want involved. A relative can join by telephone or video, and so can a professional interpreter. Confirm the decision with the patient directly.
Women of childbearing age are offered a pregnancy test before imaging and surgery. Patients under the age of legal consent are managed as described in Chapter 25.
5.2 Choosing the treatment
The decision depends on whether the appendicitis is uncomplicated or complicated, and on the patient’s preferences (Figure 5.1). Current guidelines support laparoscopic appendicectomy as the standard treatment, and an antibiotics-first strategy as a safe alternative for selected adults with uncomplicated appendicitis confirmed on imaging, provided they are told about the risk of recurrence [2].
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 5.1. Choosing the treatment for acute appendicitis with the patient.
The antibiotics-first figures need to be stated plainly. In the largest trial, about 3 in 10 patients treated with antibiotics had an appendicectomy within 90 days, rising to about 4 in 10 when an appendicolith was present [3]. By 1 year, about 4 in 10 had had an appendicectomy, and by 3 to 4 years about 5 in 10 [4]. In a European trial, about 4 in 10 had had an appendicectomy by 5 years [5]. Patients treated with antibiotics missed fewer days of work at first, but a second illness and a second admission are a real burden for many.
Timing also matters to patients waiting overnight. For uncomplicated appendicitis, delaying surgery by up to 24 hours after admission does not appear to increase the risk of perforation or of complications [6]. Patients with signs of perforation, peritonitis, or sepsis need surgery without unnecessary delay.
5.3 The counseling script
Script: explaining appendicitis and the treatment What the appendix is. “The appendix is a small, finger-shaped tube attached to the large bowel, low on the right side of the tummy. You can live normally without it.” What has gone wrong. “It has become blocked and inflamed. If it is not treated, it can burst and cause infection inside the tummy. That is why we treat it today.” The operation. “You will be fully asleep. We make three small cuts, use a camera, and remove the appendix. Most people go home the next day. If the appendix has burst, you may need antibiotics and a few more days in hospital.” The other option. “Because your scan shows a simple inflamed appendix, antibiotics alone are also an option. They avoid an operation now for most people, but about half need the operation within a few years, and the appendix stays in place.” If things are different inside. “Sometimes the appendix looks normal, or we find another cause. We may need a larger cut to finish safely. We will tell you exactly what we found and did.” Checking. “Can you tell me in your own words what we plan to do, and what the other choice is?” |
When the appendix is found to be normal, the surgeon looks for another cause. Whether a normal-looking appendix is removed varies between surgeons, and patients should know before the operation that it may happen. In a large UK study, a normal appendix was removed in about 12 in 100 men and 28 in 100 women who had an appendicectomy [7]; careful clinical scoring and imaging reduce this.
5.4 When the appendix has burst or formed an abscess
Perforation changes the recovery and the risks. After surgery for complex appendicitis, 2 days of intravenous antibiotics was as effective as 5 days in a large trial, with fewer side effects, and about 1 in 10 patients developed an infection, usually an abscess, within 90 days [8]. Patients should be prepared for a longer stay, slower return of appetite, and the possibility of a drain or further procedure.
When an abscess or inflammatory mass is found, initial treatment is usually antibiotics, with drainage if needed. The appendix may then be removed weeks later (interval appendicectomy). One reason is the risk of an underlying tumor: in a large prospective study, a tumor was found in about 14 in 100 patients with an appendiceal abscess, compared with about 2 in 100 with uncomplicated appendicitis, and interval appendicectomy was recommended for patients older than 35 years [9, 10].
Setting expectations honestly “Your appendix had already burst, so the infection spread inside your tummy. We have cleaned it, but you will need antibiotics and a few more days here. About 1 in 10 people in your situation develop a collection of infection afterward. If that happens, it is usually treated with antibiotics or a small drain, not another big operation.” |
STEP 2 Preparation, medicines, and recovery
5.5 Before the operation
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Fasting and fluids. Explain when the patient can no longer eat or drink, and give intravenous fluids. Avoid unnecessarily long fasts; the anesthesia team decides on clear fluids if surgery is delayed.
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Medicines. Record all medicines, including blood thinners, diabetes medicines, and weight-loss injections, and tell the anesthesia team (Chapters 18, 22, and 23). An emergency does not leave time for the usual stopping intervals, so these are managed individually.
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Antibiotics. A single preoperative dose is standard. Explain that further antibiotics are needed only if the appendix has burst.
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Fasting for Ramadan. Patients who are fasting need to stop for treatment. Illness is a recognized reason not to fast; patients can be referred to their religious adviser if they wish.
5.6 After the operation and discharge
After uncomplicated appendicitis, most patients eat and walk the same day and go home the next day; some go home the same day. After perforation, appetite and bowel function return more slowly, and discharge follows when the patient is eating, the pain is controlled with tablets, and fever has settled. Complete the personal instruction card (Appendix A), confirm the warning signs with teach-back, and say how the pathology result will be given.
5.7 Recovery timeline
Table 5.2 and Figure 5.2 give typical times. In the largest trial, patients who had an appendicectomy missed on average about 9 days of work [3]. Recovery after perforation or open surgery takes longer.
Table 5.2. Typical recovery times after appendicectomy.
| Activity | Uncomplicated, keyhole | Perforated or complicated |
|---|---|---|
| Walking | The same day | From the first day |
| Eating normally | The same day | Within 2 to 3 days, as appetite returns |
| Showering | Day 2 | Day 2, unless a drain is in place |
| Driving | About 1 week, when safe | About 2 weeks |
| School or office work | About 1 to 2 weeks | About 2 to 3 weeks |
| Swimming | About 2 weeks | About 3 weeks, when wounds are healed |
| Heavy lifting, manual work | About 3 to 4 weeks | About 4 to 6 weeks |
| Sport and gym | About 3 to 4 weeks | About 4 to 6 weeks |
| Prayer | From the first day; bowing and prostration within about a week | Pray seated until comfortable |
| Ramadan fasting | When eating normally, usually 1 to 2 weeks | After antibiotics are finished and appetite has returned |
| Flying | Short flights after about 1 week | After about 2 weeks; ask before long flights |
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 5.2. Recovery after uncomplicated and complicated appendicitis, for use with patients.
STEP 3 Questions patients ask
“Can I just take antibiotics instead of having the operation?”
If your scan shows a simple inflamed appendix, yes, that is a reasonable choice. About 7 in 10 people avoid an operation in the first 3 months, but about half need the operation within 3 to 4 years [3, 4]. If there is a small stone in the appendix, antibiotics fail more often, and we usually advise the operation.
“Why can’t I have the operation right now? I have been waiting all night.”
I understand it is hard to wait. For a simple appendicitis, a wait of up to a day does not make it more likely to burst or to cause complications [6]. If your condition changes, we will move faster.
“Can I have something for the pain before you decide? Won’t it hide the problem?”
Yes, you can, and you should. Pain relief does not stop us from making the right diagnosis [1].
“Do I need my appendix?”
No. You can live a normal, healthy life without it.
“What if my appendix turns out to be normal?”
That happens to some people, more often women, because other conditions can look the same [7]. We will look for another cause during the operation and tell you what we found.
“Why do I need more antibiotics after the operation?”
Only if the appendix had burst. Then a short course helps clear infection inside the tummy. Two days of drip antibiotics works as well as five for most people [8].
“The appendix had burst. What does that mean for me?”
You will stay longer, recover more slowly, and have a higher chance of a collection of infection, about 1 in 10 [8]. Most people still recover fully.
“Why do I need another operation later?”
When an abscess is treated with antibiotics, the appendix is still there. In people over about 35, a hidden tumor is found in a significant number, so we usually advise removing the appendix a few weeks later [9].
“Can appendicitis come back after the appendix is removed?”
No. Very rarely, a small stump of the appendix left behind becomes inflamed, but this is uncommon.
“I am pregnant. Is it safe?”
Appendicitis in pregnancy needs prompt treatment. Keyhole surgery can be done safely in any trimester by an experienced team [11]. Antibiotics alone have not been well studied in pregnancy.
“Why is my appendix sent to the laboratory?”
Every appendix is checked under a microscope. Almost all results show only inflammation. About 1 or 2 in 100 show a small tumor, most of which are cured by removing the appendix; a few need further treatment [9].
“I was fasting for Ramadan. Can I continue?”
You need to stop fasting for your treatment and recovery. Illness is a recognized reason to delay fasting. You can fast again when you are eating normally and no longer need regular medicines.
STEP 4 Risks, warning signs, and consent
5.8 Material risks
Table 5.3 groups the risks into the bands of Section 1.5. Risks are higher after perforation, in older or frail patients, and with obesity. Replace figures marked “unit data” with your own audit figures.
Table 5.3. Material risks of appendicectomy. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Wound and shoulder-tip pain; nausea | Many patients, for a few days | “Most people are sore for a few days. It settles with regular pain medicine.” |
| Common | Infection or abscess after perforated appendicitis | About 1 in 10 within 90 days [8] | “About 1 in 10 people whose appendix had burst develop a collection of infection.” |
| Common (in some groups) | A normal appendix removed | About 12 in 100 men and 28 in 100 women in one UK study [7] | “Sometimes the appendix turns out to be normal. We will look for another cause.” |
| Less common | Wound infection or abscess after uncomplicated appendicitis | About 1 to 3 in 100 [unit data] | “A few people develop a wound infection or a collection that needs antibiotics or a drain.” |
| Less common | Conversion to open surgery | About [X] in 100; higher after perforation [unit data] | “A few people need a larger cut to finish safely.” |
| Less common | Unexpected tumor in the appendix | About 1 to 2 in 100; about 14 in 100 with an abscess [9] | “Rarely, the laboratory finds a small tumor. Most need no further treatment.” |
| Rare but serious | Injury to bowel, bladder, or a blood vessel; bleeding needing reoperation | Fewer than 1 in 100 [unit data] | “Rarely, an injury or bleeding needs a further operation.” |
| Rare but serious | Bowel blockage from adhesions, months or years later | About [X] in 100 [unit data] | “Scar tissue inside can rarely cause a blockage later.” |
| Rare but serious | Blood clots; death | Very rare in healthy adults; higher after perforation and in frail patients [unit data] | “For someone in your health, serious problems like this are very rare.” |
If the patient chooses antibiotics first
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5.9 Consent checklist
Before the patient signs ☐ Pain treated and capacity confirmed; the people the patient wants involved are present or on the telephone. ☐ The diagnosis explained, including whether the appendicitis appears uncomplicated or complicated. ☐ Options discussed: keyhole appendicectomy and, where suitable, antibiotics first, with recurrence figures. ☐ Possible findings and changes: a normal appendix, another cause, a drain, or conversion to open surgery. ☐ Risks from Table 5.3, with unit figures where available. ☐ Who will perform the operation, including trainee involvement under supervision. ☐ Pregnancy status confirmed where relevant; medicines and fasting recorded. ☐ The pathology result: how and when the patient will hear it. ☐ Teach-back done, and the patient guide given in the patient’s language. |
5.10 Warning signs
An abscess usually appears between the fifth and tenth day, often after discharge. It may show as fever, pain that returns after improving, or diarrhea and frequent urges to pass stool when the collection lies in the pelvis.
Table 5.4. Green, amber, and red warning signs after appendicectomy.
| Level | Signs after appendicectomy | What to do |
|---|---|---|
| Green | Wound and shoulder pain that improves each day Mild bloating and tiredness Small bruises around the wounds | Expected. Follow the guide and take pain medicines as advised. |
| Amber | A wound that becomes red, hot, swollen, or leaks fluid Temperature of 38 °C or more without other red signs Diarrhea or frequent urges to pass stool in the second week Unable to keep fluids down for 12 hours | Call the clinic or contact number the same day. |
| Red | Tummy pain that is getting worse, or comes back after improving, with fever A swollen tummy, repeated vomiting, or not passing wind Fever with shivering Chest pain, breathlessness, or a hot, swollen calf Heavy bleeding from a wound | Go to the emergency department or call an ambulance now. Bring this guide. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Appendicitis and Having Your Appendix Removed For adults and older teenagers, and their families. Keep it after you go home. |
What is the appendix?
The appendix is a small tube, about the size of a finger. It is joined to the large bowel, low on the right side of your tummy. You can live a normal life without it.
What is appendicitis?
Appendicitis means the appendix is blocked and swollen. It causes tummy pain, often starting near the belly button and moving to the lower right side. If it is not treated, it can burst and spread infection inside the tummy.
Your treatment choices
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Operation (the usual treatment). The appendix is removed by keyhole surgery. This cures the problem.
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Antibiotics only (for some people). If your scan shows a simple appendicitis, antibiotics may be enough. Most people avoid an operation at first, but about half need it within a few years.
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Your surgeon will explain which choices suit you. Ask as many questions as you need.
What happens in the operation?
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You will be fully asleep.
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The surgeon makes 3 small cuts and uses a small camera to remove the appendix.
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It usually takes less than 1 hour. Most people go home the next day.
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If the appendix has burst, you will need antibiotics and may stay a few more days.
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Sometimes the appendix looks normal, or the surgeon finds another problem. We will tell you what we found.
1. Pain and pain medicines
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Your tummy will be sore for a few days. Some people have shoulder pain for 1 to 2 days, from the gas used in the operation.
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Take your pain medicines regularly at first, as we told you.
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Strong pain medicines can make you sleepy and constipated. Do not drive while you take them.
2. Your wounds
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Keep the dressings clean and dry for 2 days.
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Some bruising is normal.
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If you have stitches or clips to take out, the date is on your card.
3. Eating, drinking, and your bowels
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Start with light meals and eat normally when you feel ready.
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If your appendix had burst, your appetite may take a few days to come back.
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Drink water, eat fruit and vegetables, and walk to avoid constipation.
4. Rest, washing, and clothes
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You may feel tired for 1 to 2 weeks. Rest, but get up and walk often.
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You can shower after 2 days. Pat the wounds dry.
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Do not soak in a bath or swim until the wounds have healed.
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Wear loose clothes.
5. Getting back to normal
These are usual times. If your appendix had burst, it may take longer. Your own plan is on your card.
| Activity | Usually from |
|---|---|
| Walking | The same day. Walk a little more each day. |
| Showering | After 2 days |
| Prayer | From the first day. Pray sitting if bowing or kneeling hurts. |
| Driving | About 1 week, when you can stop suddenly without pain and are not taking strong pain medicines |
| School or office work | About 1 to 2 weeks |
| Swimming | About 2 weeks, when the wounds have healed |
| Heavy lifting, sport, and gym | About 3 to 4 weeks. Start gently. |
| Fasting in Ramadan | When you are eating normally and no longer need regular medicines |
| Flying | Short flights after about 1 week if you feel well. Ask us before a long flight. |
6. Follow-up and results
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Your appendix is checked in the laboratory. Most results show only inflammation.
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We will tell you the result: ______________________________
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Your follow-up appointment or phone call is on your card.
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Wound or shoulder pain that gets better each day; tiredness; small bruises | This is normal. Keep following this guide. |
| AMBER | A red, hot, or leaking wound; temperature of 38 °C or more; diarrhea or needing to pass stool often in the second week; cannot keep drinks down | Call us today. |
| RED | Tummy pain that gets worse or comes back, with fever; a swollen tummy; vomiting again and again; fever with shivering; chest pain or short of breath; a hot, swollen leg; heavy bleeding | Go to the emergency department now. Take this guide with you. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ My questions: ____________________________________________________________ [Unit name] [Guide version and review date] |
References
1. Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2011;(1):CD005660.
2. Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):27.
3. CODA Collaborative; Flum DR, Davidson GH, Monsell SE, et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020;383(20):1907-1919.
4. CODA Collaborative; Davidson GH, Flum DR, Monsell SE, et al. Antibiotics versus appendectomy for acute appendicitis: longer-term outcomes. N Engl J Med. 2021;385(25):2395-2397.
5. Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320(12):1259-1265.
6. van Dijk ST, van Dijk AH, Dijkgraaf MG, Boermeester MA. Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis. Br J Surg. 2018;105(8):933-945.
7. RIFT Study Group on behalf of the West Midlands Research Collaborative. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2020;107(1):73-86.
8. de Wijkerslooth EML, Boerma EG, van Rossem CC, et al. 2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial. Lancet. 2023;401(10374):366-376.
9. Salminen R, Alajääski J, Rautio T, et al. Appendiceal tumor prevalence in patients with periappendicular abscess. JAMA Surg. 2025;160(5):526-534.
10. Mällinen J, Rautio T, Grönroos J, et al. Risk of appendiceal neoplasm in periappendicular abscess in patients treated with interval appendectomy vs follow-up with magnetic resonance imaging: 1-year outcomes of the Peri-Appendicitis Acuta randomized clinical trial. JAMA Surg. 2019;154(3):200-207.
11. Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc. 2017;31(10):3767-3782.
Note: references are numbered within this chapter for the pilot. Frequencies marked “unit data” should be replaced with the author’s own audit figures before publication.