Introduction and Context
Acute appendicitis remains the quintessential abdominal surgical emergency. Affecting millions of individuals worldwide, it is the leading cause of emergency hospital admissions and surgical interventions. For decades, the standard response was immediate surgical removal. However, as medical science progresses, the nuances of diagnosis and management have become increasingly complex.
Despite its prevalence, significant variability has persisted in how appendicitis is treated across different healthcare systems. Questions regarding the necessity of surgery for all cases, the timing of operations, and the role of advanced imaging have led to a push for standardized, evidence-based protocols. The World Society of Emergency Surgery (WSES) first introduced the Jerusalem Guidelines in 2016 and updated them in 2020. The 2025 Edition represents the most comprehensive update yet, utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to synthesize the latest evidence. These guidelines aim to reduce unwarranted variability, improve patient outcomes, and provide a framework for clinicians to navigate the diagnostic and therapeutic challenges of this common condition.
New Guideline Highlights
The 2025 Jerusalem Guidelines provide 35 distinct recommendations across six key clinical domains. The primary themes emphasize a personalized approach to patient care, moving away from a ‘one-size-fits-all’ surgical model.
Key takeaways include:
- Diagnostic Accuracy: Increased reliance on clinical risk scores combined with selective imaging to minimize negative appendectomy rates.
- Nonoperative Management (NOM): The recognition of antibiotic therapy as a safe alternative for uncomplicated appendicitis in specific patient populations, provided there is shared decision-making.
- The 24-Hour Window: Evidence now supports that delaying appendectomy for uncomplicated cases by up to 24 hours does not increase the risk of perforation or adverse outcomes.
- Standardization of Technique: Laparoscopic appendectomy is confirmed as the gold standard for virtually all patient groups.
- Antibiotic Stewardship: A strict limit on postoperative antibiotics (2-3 days) for complicated disease to reduce the risk of resistance and complications like C. difficile.
Updated Recommendations and Key Changes
The 2025 update introduces several shifts from the 2020 version, driven by high-quality randomized clinical trials and systematic reviews published in the last five years.
Comparison of Key Changes:
- Risk Scoring: While the 2020 guidelines mentioned several scores, the 2025 edition places a stronger emphasis on the Appendicitis Inflammatory Response (AIR) score as the most accurate tool for risk stratification, outperforming the Alvarado score in many modern cohorts.
- Surgical Timing: Previous guidance often urged surgery ‘as soon as possible.’ The new guidelines explicitly state that a delay of up to 24 hours is acceptable for uncomplicated cases, allowing for better theater scheduling and daytime operating.
- Antibiotic Duration: The 2025 guidelines have shortened the recommended postoperative antibiotic course for complicated appendicitis (perforated or gangrenous) from 4–7 days down to 2–3 days, citing evidence that longer courses do not prevent intra-abdominal abscesses.
- Follow-up Protocols: New, specific recommendations have been added regarding the necessity of follow-up imaging or colonoscopy after nonoperative management of complicated appendicitis with abscess/phlegmon to screen for underlying neoplasms, particularly in patients over 40.
Topic-by-Topic Recommendations
1. Diagnosis and Risk Stratification
Clinical suspicion remains the starting point. The guidelines recommend using clinical risk scores to categorize patients into low, intermediate, or high risk.
- Low Risk: Patients with an AIR score of 0-4 can often be safely discharged with clear instructions for follow-up.
- Intermediate Risk: These patients require further evaluation, usually via imaging.
- High Risk: In adult males, a high score may justify surgery without further imaging, though in women and children, imaging is still generally preferred to rule out gynecological or pediatric mimics.
2. Imaging Pathways
Imaging should be used judiciously.
- Adults: Contrast-enhanced Computed Tomography (CT) remains the gold standard due to its high sensitivity and specificity.
- Children and Pregnant Women: Ultrasound (US) is the first-line modality to avoid ionizing radiation. If US is inconclusive, Magnetic Resonance Imaging (MRI) is the preferred second-line option.
3. Nonoperative Management (NOM)
For patients with uncomplicated appendicitis (no signs of perforation, fecalith, or tumor), NOM with antibiotics is a viable alternative to surgery. However, clinicians must inform patients of the approximately 25-30% recurrence rate within one year. NOM is particularly recommended for patients who have significant surgical contraindications or those who strongly prefer to avoid an operation.
4. Surgical Standards
Laparoscopic appendectomy is recommended over open surgery for all patients, including those with obesity, the elderly, and pregnant women. The benefits include reduced postoperative pain, shorter hospital stays, and lower wound infection rates. In the case of complicated appendicitis (perforation), the laparoscopic approach also allows for better peritoneal lavage.
5. Special Populations
- Pregnancy: Appendicitis is the most common non-obstetric emergency during pregnancy. The guidelines emphasize that surgery should not be delayed due to pregnancy, and laparoscopy is safe in all trimesters.
- Older Patients (≥65): This group often presents with atypical symptoms. There is a lower threshold for CT imaging, and a higher suspicion for malignancy mimicking appendicitis.
- Obesity: Laparoscopy is strongly preferred to avoid the high wound complication rates associated with open surgery in patients with a BMI ≥30.
Practical Application: A Fictional Vignette
*Sarah, a 28-year-old software engineer, presented to the emergency department with a 12-hour history of migrating abdominal pain, nausea, and a low-grade fever. Her AIR score was calculated at 6 (Intermediate Risk). Following the 2025 guidelines, the surgical team ordered a targeted ultrasound which was inconclusive, followed by a low-dose CT scan that confirmed uncomplicated acute appendicitis. Given that Sarah had a major project deadline, the team discussed both laparoscopic appendectomy and nonoperative management. Sarah chose surgery. Because she arrived at midnight and her condition was stable (uncomplicated), her surgery was scheduled for 8:00 AM the next morning, adhering to the ’24-hour safe delay’ recommendation. She underwent a successful laparoscopic appendectomy and was discharged the same day without postoperative antibiotics.*
Expert Commentary and Insights
The WSES expert panel emphasizes that while these guidelines provide a gold standard, they must be adapted to local resources. One of the major points of consensus was the move toward ‘patient-centered care.’ This involves discussing the pros and cons of antibiotics versus surgery, especially for uncomplicated cases.
However, a point of ongoing controversy remains the management of the ‘appendiceal fecalith.’ Some experts argue that the presence of a fecalith on imaging should be a relative contraindication for NOM due to a much higher failure and recurrence rate. The 2025 guidelines suggest a cautious approach, leaning toward surgery when a fecalith is present.
Furthermore, the panel highlighted the critical importance of post-treatment surveillance in older patients. As Dr. Mauro Podda, the lead author, noted, “We are seeing an increasing overlap between complicated appendicitis and right-sided colon cancers in the elderly. Standardization of follow-up after nonoperative management of an abscess is not just about the appendix; it’s about not missing a malignancy.”
Practical Implications
For healthcare systems, the implementation of these guidelines suggests several shifts:
1. **Resource Optimization:** Allowing a 24-hour delay for uncomplicated surgery can reduce the strain on night-shift surgical teams and improve the efficiency of daytime operating rooms.
2. **Reduced Hospital Stays:** With better laparoscopic techniques and less reliance on long-term postoperative antibiotics, patients are being discharged faster, often within 24 hours.
3. **Diagnostic Precision:** By utilizing AIR scores and standardized imaging pathways, hospitals can significantly reduce ‘negative’ appendectomies (where a healthy appendix is removed), thereby saving costs and avoiding unnecessary risks for patients.
In conclusion, the 2025 WSES Jerusalem Guidelines offer a sophisticated, evidence-based roadmap. They challenge the old ’emergency surgery for all’ dogma and replace it with a nuanced strategy that prioritizes diagnostic accuracy, surgical excellence, and informed patient choice.
References
1. Podda M, Ceresoli M, De Simone B, et al. Diagnosis and Treatment of Acute Appendicitis: 2025 Edition of the World Society of Emergency Surgery Jerusalem Guidelines. JAMA Surg. 2026;161(1). doi:10.1001/jamasurg.2025.6218.
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;15:27.
3. Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340–2348.
4. Davidson GH, Flum DR, Talan DA. Antibiotics for Appendicitis in the COVID-19 Era and Beyond. JAMA. 2020;324(24):2481-2483.
