What are the key indications for referring a patient with suspected appendicitis to a surgical specialist?

Key indications for referring a patient with suspected appendicitis to a surgical specialist include:

• Persistent or worsening abdominal pain suggestive of appendicitis that does not improve with initial assessment or treatment in primary care.
• Signs of complicated appendicitis such as severe abdominal pain with guarding, rigidity, or signs of peritonitis, which may indicate perforation or abscess formation requiring urgent surgical evaluation.
• Systemic signs of sepsis including altered mental state, tachycardia, hypotension, or other markers of systemic infection, necessitating urgent hospital assessment.
• Clinical features suggestive of an intra-abdominal mass or palpable tenderness in the right lower quadrant that raises suspicion of complications.
• Failure to improve or diagnostic uncertainty after initial primary care assessment, warranting further imaging and specialist input.

These indications align with the general principles for referral in acute abdominal conditions where complicated disease or systemic involvement is suspected, as outlined in NICE guidance on acute abdominal pain and diverticulitis management, which recommend same-day hospital assessment for complicated presentations and consideration of surgical intervention ¹.