Surgical consultation should be pursued early in the appendicitis workup when there is high clinical suspicion. Delays in surgical consultation and intervention of more than 12–18 h from the time of emergency department presentation have been associated with a greater incidence of advanced disease, a longer length of stay, and higher costs. Young men with classic symptoms, a classic disease course, and an otherwise normal exam may be spared imaging in favor of operative intervention. Women may have gynecologic pathologies which mimic acute appendicitis. These should be ruled out to minimize the nontherapeutic appendectomy rate. MRI and ultrasound may help spare patients the ionizing radiation associated with computed tomography. While all patients should be resuscitated and started on empiric antibiotics, patients with phlegmon/abscess should be treated nonsurgically with antibiotics and percutaneous drainage if appropriate. Patients with generalized purulent peritonitis with sepsis require prompt surgical exploration following resuscitation. Sepsis and septic shock may be the initial presentation of acute appendicitis, especially in high-risk populations such as the elderly and those with immunocompromise.