acute appendicitis in adults: clinical manifestations and diagnosis

05-12-13 12:58Acute appendicitis in adults: Clinical manifestations and diagnosis

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AuthorRonald F Martin, MD

Section EditorMartin Weiser, MD

Deputy EditorRosemary B Duda, MD, MPH, FACS

Acute appendicitis in adults: Clinical manifestations and diagnosis

Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Nov 2013. | This topic last updated: nov 6, 2013.

INTRODUCTION — Appendicitis, an inflammation of the vestigial vermiform appendix, is one of the most commoncauses of the acute abdomen and one of the most frequent indications for an emergent abdominal surgical procedureworldwide [1,2].

The clinical manifestations and diagnosis of appendicitis in adults will be reviewed here. The management ofappendicitis in adults and appendicitis in pregnancy and children are discussed separately. (See "Acute appendicitis inadults: Management" and "Acute appendicitis in pregnancy" and "Acute appendicitis in children: Clinical manifestationsand diagnosis".)

ANATOMY — The vermiform appendix is located at the base of the cecum, near the ileocecal valve where the taeniacoli converge on the cecum (figure 1) [3,4]. The appendix is a true diverticulum of the cecum. In contrast to acquireddiverticular disease, which consists of a protuberance of a subset of the enteric wall layers, the appendiceal wallcontains all of the layers of the colonic wall: mucosa, submucosa, muscularis (longitudinal and circular), and the serosalcovering [5].

The appendiceal orifice opens into the cecum. Its blood supply, the appendiceal artery, is a terminal branch of theileocolic artery, which traverses the length of the mesoappendix and terminates at the tip of the organ (figure 2) [4].

The attachment of the appendix to the base of the cecum is constant. However, the tip may migrate to the retrocecal,subcecal, preileal, postileal, and pelvic positions. These normal anatomic variations can complicate the diagnosis as thesite of pain and findings on the clinical examination will reflect the anatomic position of the appendix.

The presence of B and T lymphoid cells in the mucosa and submucosa of the lamina propria make the appendixhistologically distinct from the cecum [5]. These cells create a lymphoid pulp that aids immunologic function byincreasing lymphoid products such as IgA and operating as part of the gut-associated lymphoid tissue system [3].Lymphoid hyperplasia can cause obstruction of the appendix and lead to appendicitis. The lymphoid tissue undergoesatrophy with age [6].

EPIDEMIOLOGY — Appendicitis occurs most frequently in the second and third decades of life. The incidence isapproximately 233/100,000 population and is highest in the 10 to 19 year-old age group [7] . It is also higher among men(male to female ratio of 1.4:1), who have a lifetime incidence of 8.6 percent compared to 6.7 percent for women [7].

PATHOGENESIS — The natural history of appendicitis is similar to that of other inflammatory processes involving hollowvisceral organs. Initial inflammation of the appendiceal wall is followed by localized ischemia, perforation, and thedevelopment of a contained abscess or generalized peritonitis.

Appendiceal obstruction has been proposed as the primary cause of appendicitis [3,8-11]. Obstruction is frequently

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implicated but not always identified. A study of patients with appendicitis showed that there was elevated intraluminalpressure in only one-third of the patients with nonperforated appendicitis [12].

Appendiceal obstruction may be caused by fecaliths (hard fecal masses), calculi, lymphoid hyperplasia, infectiousprocesses, and benign or malignant tumors. However, some patients with a fecalith have a histologically normalappendix and the majority of patients with appendicitis do not have a fecalith [13,14].

When obstruction of the appendix is the cause of appendicitis, the obstruction leads to an increase in luminal andintramural pressure, resulting in thrombosis and occlusion of the small vessels in the appendiceal wall, and stasis oflymphatic flow. As the appendix becomes engorged, the visceral afferent nerve fibers entering the spinal cord at T8-T10are stimulated, leading to vague central or periumbilical abdominal pain [8]. Well-localized pain occurs later in the coursewhen inflammation involves the adjacent parietal peritoneum.

The mechanism of luminal obstruction varies depending upon the patient's age. In the young, lymphoid follicularhyperplasia due to infection is thought to be the main cause. In older patients, luminal obstruction is more likely to becaused by fibrosis, fecaliths, or neoplasia (carcinoid, adenocarcinoma, or mucocele). In endemic areas, parasites cancause obstruction in any age group. (See "Cancer of the appendix and pseudomyxoma peritonei".)

Once obstructed, the lumen becomes filled with mucus and distends, increasing luminal and intramural pressure. Thisresults in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. As lymphatic and vascularcompromise progress, the wall of the appendix becomes ischemic and then necrotic.

Bacterial overgrowth occurs within the diseased appendix. Aerobic organisms predominate early in the course, whilemixed infection is more common in late appendicitis [15]. Common organisms involved in gangrenous and perforatedappendicitis include Escherichia coli, Peptostreptococcus, Bacteroides fragilis, and Pseudomonas species [16].Intraluminal bacteria subsequently invade the appendiceal wall and further propagate a neutrophilic exudate. The influxof neutrophils causes a fibropurulent reaction on the serosal surface, irritating the surrounding parietal peritoneum [6].This results in stimulation of somatic nerves, causing pain at the site of peritoneal irritation [5].

During the first 24 hours after symptoms develop, approximately 90 percent of patients develop inflammation andperhaps necrosis of the appendix, but not perforation. The type of luminal obstruction may be a predictor of perforationof an acutely inflamed appendix. Fecaliths were six times more common than true calculi in the appendix, but calculiwere more often associated with perforated appendicitis or periappendiceal abscess (45 percent) than were fecaliths (19percent). This is presumably due to the rigidity of true calculi as compared with the softer, more crushable fecaliths [13].

Once significant inflammation and necrosis occur, the appendix is at risk of perforation, which leads to localized abscessformation or diffuse peritonitis. The time course to perforation is variable. One study showed that 20 percent of patientsdeveloped perforation less than 24 hours after the onset of symptoms [17]. Sixty-five percent of patients in whom theappendix perforated had symptoms for longer than 48 hours.

CLINICAL FEATURES

Clinical manifestations

History — Abdominal pain is the most common symptom, and is reported in nearly all confirmed cases ofappendicitis [18,19]. The clinical presentation of acute appendicitis is described as a constellation of the following classicsymptoms:

Right lower quadrant (right anterior iliac fossa) abdominal pain●Anorexia●Nausea and vomiting●




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In the classic presentation, the patient describes the onset of abdominal pain as the first symptom. The pain is typicallyperiumbilical in nature with subsequent migration to the right lower quadrant as the inflammation progresses [18].Although considered a classic symptom, migratory pain occurs only in 50 to 60 percent of patients with appendicitis[8,20]. Nausea and vomiting, if they occur, usually follow the onset of pain. Fever-related symptoms generally occur laterin the course of illness.

In many patients, initial features are atypical or nonspecific, and can include:

Because the early symptoms of appendicitis are often subtle, patients and clinicians may minimize their importance. Thesymptoms of appendicitis vary depending upon the location of the tip of the appendix (figure 1) (see 'Anatomy' above).For example, an inflamed anterior appendix produces marked, localized pain in the right lower quadrant, while aretrocecal appendix may cause a dull abdominal ache [21]. The location of the pain may also be atypical in patients whohave the tip of the appendix located in the pelvis, which can cause tenderness below McBurney's point. Such patientsmay complain of urinary frequency and dysuria or rectal symptoms, such as tenesmus and diarrhea.

Physical examination — The early signs of appendicitis are often subtle. Low-grade fever reaching 101.0°F(38.3°C) may be present. The physical examination may be unrevealing in the very early stages of appendicitis since thevisceral organs are not innervated with somatic pain fibers.

However, as the inflammation progresses, involvement of the overlying parietal peritoneum causes localized tendernessin the right lower quadrant and can be detected on the abdominal examination. Rectal examination, although oftenadvocated, has not been shown to provide additional diagnostic information in cases of appendicitis. In women, rightadnexal area tenderness may be present on pelvic examination, and differentiating between tenderness of pelvic originversus that of appendicitis may be challenging. High-grade fever (>101.0°F/38.3°C) occurs as inflammation progresses.(See "Differential diagnosis of abdominal pain in adults".)

Patients with a retrocecal appendix may not exhibit marked localized tenderness in the right lower quadrant since theappendix does not come into contact with the anterior parietal peritoneum (figure 1) [21]. The rectal and/or pelvicexamination is more likely to elicit positive signs than the abdominal examination. Tenderness may be more prominenton pelvic examination, and may be mistaken for adnexal tenderness.

Several findings on physical examination have been described to facilitate diagnosis, but these findings pre-dateddefinitive imaging for appendicitis, and the wide variation in their sensitivity and specificity suggests that they be usedwith caution to broaden, or narrow, a differential diagnosis. There are no physical findings, taken alone, or in concert,that definitively confirm a diagnosis of appendicitis.

Commonly described physical signs include:

Indigestion●Flatulence●Bowel irregularity●Diarrhea●Generalized malaise●

McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the anterior superior iliacspine (ASIS) on a straight line from the ASIS to the umbilicus [22]. (Sensitivity 50 to 94 percent; specificity 75 to 86percent [23-25]).

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Rovsing's sign refers to pain in the right lower quadrant with palpation of the left lower quadrant. This sign is alsocalled indirect tenderness and is indicative of right-sided local peritoneal irritation [26]. (Sensitivity 22 to 68 percent;specificity 58 to 96 percent [24,27-29]).

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Laboratory findings — A mild leukocytosis (white blood cell count >10,000 cells/microL) is present in most patients withacute appendicitis [32]. Approximately 80 percent of patients have a leukocytosis and a left shift (increase in total WBCcount, bands [immature neutrophils], and neutrophils) in the differential [33-35]. The sensitivity and specificity of anelevated WBC in acute appendicitis is 80 percent and 55 percent respectively.

Acute appendicitis is unlikely when the white blood cell (WBC) count is normal, except in the very early course of theillness [35-37]. In comparison, mean WBC counts are higher in patients with a gangrenous (necrotic) or perforatedappendix [38]:

Mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been noted to be a marker for appendiceal perforationwith a sensitivity of 70 percent and a specificity of 86 percent [39]. This compares favorably with a sensitivity andspecificity of an elevated WBC of 80 percent and 55 percent respectively.

Imaging studies

Computed tomography findings — The following findings suggest acute appendicitis on standard abdominalcomputed tomography (CT) scanning with contrast including (image 1 and image 2) [40-42]:

Ultrasound findings — The most accurate ultrasound finding for acute appendicitis is an appendiceal diameter of>6 mm (image 3 and image 4) [8,43,44].

Plain radiograph findings — Plain radiographs are usually not helpful for establishing the diagnosis of appendicitis(image 5). However, the following radiographic findings have been associated with acute appendicitis:

The psoas sign is associated with a retrocecal appendix. This is manifested by right lower quadrant pain withpassive right hip extension. The inflamed appendix may lie against the right psoas muscle, causing the patient toshorten the muscle by drawing up the right knee. Passive extension of the iliopsoas muscle with hip extensioncauses right lower quadrant pain. (Sensitivity 13 to 42 percent; specificity 79 to 97 percent [27,30,31]).

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The obturator sign is associated with a pelvic appendix. This test is based on the principle that the inflamedappendix may lay against the right obturator internus muscle. When the clinician flexes the patient's right hip andknee followed by internal rotation of the right hip, this elicits right lower quadrant pain, (Sensitivity 8 percent;specificity 94 percent [30]). The sensitivity is low enough that experienced clinicians no longer perform thisassessment.

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Acute − 14,500 ± 7,300 cells/microL●Gangrenous − 17,100 ± 3,900 cells/microL●Perforated − 17,900 ± 2,100 cells/microL (see 'Perforated appendix' below)●

Enlarged appendiceal diameter >6 mm with an occluded lumen●Appendiceal wall thickening (>2 mm)●Periappendiceal fat stranding●Appendiceal wall enhancement●Appendicolith (seen in approximately 25 percent of patients)●

Right lower quadrant appendicolith●Localized right lower quadrant ileus●Loss of the psoas shadow●Free air (occasionally)●Deformity of cecal outline●Right lower quadrant soft tissue density●






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Magnetic resonance imaging — Magnetic resonance imaging (MRI) can assist with the evaluation of acuteabdominal and pelvic pain during pregnancy (image 6) [45,46]. A normal appendix is visualized as a tubular structureless than or equal to 6 mm in diameter and filled with air and/or oral contrast material [47]. An enlarged fluid-filledappendix (>7 mm in diameter) is considered an abnormal finding, while an appendix with a diameter of 6 to 7 mm isconsidered an inconclusive finding [47]. (See "Approach to abdominal pain and the acute abdomen in pregnant andpostpartum women" and "Acute appendicitis in pregnancy".)

DIAGNOSIS — The diagnosis of acute appendicitis is generally made from the history and clinical examination; thediagnosis is supported by the laboratory and/or imaging findings. The patient presenting with acute abdominal painshould undergo a thorough physical examination, including a digital rectal examination. Women should undergo a pelvicexamination. (See "History and physical examination in adults with abdominal pain".)

An experienced examiner can make the correct diagnosis of appendicitis without imaging [48]. Several studies havefound the diagnostic accuracy of clinical evaluation alone to be 75 to 90 percent [18,30,49,50]. The diagnostic accuracyof the clinical examination may depend on the experience of the examining clinician [51-56]. Patients in whomappendicitis is considered to be extremely likely after assessment by an experienced clinician should proceed directly toappendectomy without further radiologic testing. (See "Acute appendicitis in adults: Management".)

The diagnosis of acute appendicitis can be difficult and a delay can result in perforation rates as high as 80 percent[57,58]. The challenging clinical settings include [59]:

No single feature or combination of features is a highly accurate predictor of acute appendicitis, although prediction rulesbased upon combinations of features may have some clinical utility [3,18,19,40,60-62].

Diagnostic scoring systems — Several scoring systems have been proposed to standardize the correlation of clinicaland laboratory variables. The Alvarado score is the most widely used diagnostic aid for the diagnosis of appendicitis andhas been modified slightly since it was introduced [63,64]. However, clinical judgment remains paramount. For example,a low modified Alvarado score (<4) is less sensitive than clinical judgement. In a prospective study of 261 adult patientswith clinically suspicious appendicitis, whom 53 patients (20 percent) had a final diagnosis of appendicitis, the lowmodified Alvarado score was less sensitive compared with unstructured clinical judgement (72 versus 93 percentsensitivity) [65].

The modified Alvarado scale assigns a score to each of the following diagnostic criteria:

A low Alvarado score (<5) has more diagnostic utility to “rule out” appendicitis than a high score (≥7) does to “rule in” thediagnosis. In a systematic review of 42 retrospective and prospective studies that included over 8300 patients withsuspected acute appendicitis and/or right iliac fossa pain, overall 99 percent of patients with acute appendicitis had a

Children less than 3 years of age. (See "Acute appendicitis in children: Clinical manifestations and diagnosis".)●Adults older than age 60 years. (See "Acute appendicitis in adults: Management", section on 'Elderly patients'.)●Women in the second and third trimesters of pregnancy, due to the displacement of the appendix by the uterus andthe resulting changes in the physical examination. (See "Acute appendicitis in pregnancy".)

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Migratory right iliac fossa pain (1 point)●Anorexia (1 point)●Nausea/vomiting (1 point)●Tenderness in the right iliac fossa (2 points)●Rebound tenderness in the right iliac fossa (1 point)●Fever >37.5°C (1 point)●Leukocytosis (2 points)●

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score of ≥5 [66]. However, a high score (≥7) alone had poor diagnostic predictive utility as the overall sensitivity was 82percent and the specificity was 81 percent. The Alvarado score was most accurate in men but over-predicted theprobability of acute appendicitis in women in all risk groups.

A management guide based upon total points includes:

Because of the diagnostic challenges of diagnosing acute appendicitis in women, some authors have advocateddiagnostic laparoscopy to minimize the high false-negative rate in women regardless of score [64], while others havesuggested using CT scans to help with the diagnosis of patients with an equivocal clinical presentation and a scorebetween 4 to 6 [67]. (See 'Imaging' below.)

Several other scoring systems have been described as well, but none are typically in common use [68-70]. A systematicreview of several published scoring systems showed a diagnostic sensitivity of 53 to 99 percent and specificity of 30 to99 percent [71]. As a general rule, the addition of these decision aids to clinical judgment has the potential to improvespecificity and lead to lower false-positive rates in diagnosis of acute appendicitis, but decision aids cannot definitivelydetermine or exclude the possibility of appendicitis [71].

DIAGNOSTIC EVALUATION

Imaging — Imaging modalities such as computed tomography (CT) and ultrasonography (US) are increasingly used tosupport the clinical diagnosis of acute appendicitis. Although some studies suggest that the increased use of imaginghas decreased the nontherapeutic appendectomy rate (NAR) for acute appendicitis [72,73], many surgeons will andshould proceed with surgical exploration, in the absence of imaging, if there is strong clinical support for appendicitis.(See 'Clinical manifestations' above.)

Based upon prospective trials and retrospective data, imaging studies do not improve the overall diagnostic accuracy foracute appendicitis (image 7 and image 8); the diagnostic accuracy of an experienced surgeon is comparable to CT scanimaging in the assessment of patients with an equivocal presentation of acute appendicitis [18,49,50,52]. However, in aretrospective review, the CT scan changed the treatment plan in 58 percent of patients [74]. Differences in studies may,in part, be due to the experience of the surgeons and the populations being evaluated. A prospective study of 2763patients found that the sensitivity, specificity, positive predictive value, and negative predictive value of preoperativeevaluations included [50]:

A patient with a score of 0 to 3 could be considered to have a low risk of appendicitis and would be discharged withadvice to return if there was no improvement in symptoms, subject to social circumstances.

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A patient with a score of 4 to 6 would be admitted for observation and re-examination. If the score remains thesame after 12 hours, operative intervention is recommended.

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A male patient with a score of 7 to 9 would proceed to appendectomy.●

A female patient who is not pregnant with a score of 7 to 9 would undergo diagnostic laparoscopy, thenappendectomy if indicated by the intraoperative findings. The surgical management of appendicitis duringpregnancy is discussed separately. (See "Acute appendicitis in pregnancy".)

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Ultrasonography ●99.1, 91.7, 96.5, and 97.7 percent, respectively•

Computed tomography●96.4, 95.4, 95.6, and 96.3 percent, respectively•

Clinical examination ●99.0, 76.1, 88.1, and 97.6 percent, respectively•


















Diagnostic imaging is unnecessary when the clinical diagnosis of acute appendicitis is nearly certain for either presenceor absence of appendicitis. Diagnostic imaging should be performed and is most likely to alter treatment when thediagnosis of appendicitis is clinically suspected but unclear. Diagnostic imaging may be useful in children, elder adults,or women of childbearing age with an unclear presentation. Similarly, patients with comorbidities such as diabetes,obesity, and immunocompromise may have a higher occurrence of atypical presentation of acute appendicitis. Thesepopulations are more likely to present with unclear symptoms such as vague abdominal pain. (See "Acute appendicitis inchildren: Diagnostic imaging" and "Acute appendicitis in adults: Management", section on 'Special considerations' and"Acute appendicitis in pregnancy", section on 'Diagnosis'.)

Computed tomography — Based upon retrospective reviews, adult women are more than twice as likely as men tohave a nontherapeutic appendectomy for acute appendicitis [73,75-78], and therefore women may benefit from apreoperative CT scan if the diagnosis is uncertain (image 1 and image 2). A retrospective review of 1425 consecutivepatients undergoing an appendectomy found that adult women evaluated with a preoperative CT scan had a significantlylower nontherapeutic appendectomy rate (NAR) compared with adult women without a preoperative diagnostic CT scan(21 versus 8 percent) [73]. There was no reduction in NAR for men or children.

Preoperative CT protocols for imaging include:

In most clinical settings, if there is sufficient diagnostic concern and uncertainty to warrant a CT scan to diagnoseappendicitis, a full abdominal-pelvic CT with IV and oral contrast should be performed or a decision should be made toproceed to the operating room for abdominal exploration by laparotomy or laparoscopy.

Standard CT scan with contrast — A commonly used protocol involves a standard abdominal and pelvic CTscan (16-MDCT or higher) with intravenous and oral contrast. (See "Principles of computed tomography of the chest".)

A number of findings suggest acute appendicitis on standard abdominal CT scanning [40-42]:

The sensitivity and specificity of CT with IV and oral contrast for acute appendicitis is in the range of 91 to 98 and 75 to93 percent, respectively [18,49,61,74,79-81]. Air in the appendix or a contrast-filled lumen in a normal appearingappendix virtually excludes the diagnosis. However, a nonvisualized appendix does not rule out appendicitis. This isparticularly important to remember in patients who have had symptoms for a short duration, since only minimalinflammatory changes may be present in the right lower quadrant.

An advantage of a complete abdominal CT scan is that it permits visualization of the entire abdomen. An alternativediagnosis is found in up to 15 percent of patients [74]. Furthermore, a CT scan can assist in the treatment plan forpatients with a palpable abdominal mass, such as those in whom an appendiceal phlegmon or abscess may havedeveloped. These features are more likely in patients who present after having prolonged symptoms (four to five days).(See "Acute appendicitis in adults: Management".)

A drawback of the standard CT protocol is that it takes up to two hours to administer oral contrast. In addition, a CT scaninvolves radiation exposure and intravenous contrast, with the potential for contrast-induced renal nephropathy. Cost and

Standard abdominal-pelvic CT with IV and oral contrast●Focused appendiceal CT with rectal contrast●Non-contrast CT●

Enlarged appendiceal diameter >6 mm with an occluded lumen●Appendiceal wall thickening (>2 mm)●Periappendiceal fat stranding●Appendiceal wall enhancement●Appendicolith (seen in approximately 25 percent of patients)●

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availability are also considerations, particularly in resource-poor settings.

Appendiceal CT — A focused appendiceal CT scan can be performed with rectal contrast alone and thin cutsthrough the right iliac fossa. Because full oral contrast is not given, the scan can be performed within 15 minutes. Rectalcontrast provides good visualization of the pericecal region without the need to wait for oral contrast to reach the rightlower quadrant, which may be an unpleasant procedure for the patient.

In a report using a limited appendiceal CT scan with rectal contrast, the sensitivity of the most common findings for acuteappendicitis were as follows [40]:

One study reported that a focal appendiceal CT had 98 percent accuracy and sensitivity with rectal contrast along alimited area (15 cm) of the pelvis centered 3 cm superior to the cecal tip [19,82].

The relevance of focal appendiceal imaging is questionable outside of large medical centers, as this technique requirespersonnel to administer rectal contrast and a radiologist on site for the verification of positioning. In addition, anappendiceal CT scan only evaluates the appendix, and the images may be unrevealing in the presence of otherabdominal pathology.

Unenhanced CT — The administration of contrast for imaging adds time, expense, and risk of an allergicreaction. A number of studies have suggested that adequate imaging can be obtained without contrast. In variousreports, unenhanced CT had a sensitivity of 88 to 96 percent, specificity of 91 to 98 percent, and diagnostic accuracy of94 to 97 percent for appendicitis, with the added advantage of total exam time of 5 to 15 minutes [52,83,84].

Test characteristics may depend at least in part upon the patient's body habitus [18]. Some radiologists maintain that ifthe BMI exceeds 25 that the CT is less accurate and therefore oral contrast is necessary.

An important limitation of unenhanced CT is the diminished ability to diagnose other abdominal pathology, potentiallydiminishing the role of the examination in patients in whom there is diagnostic uncertainty (eg, elder patients, women,atypical presentation).

Unenhanced CT may be of some value in patients who have renal failure or clinical instability. However, for most patientswhere there is sufficient diagnostic uncertainty to warrant a CT scan for appendicitis, a full abdominal-pelvic CT with IVand oral contrast should be performed or a decision should be made to proceed to the operating room for abdominalexploration.

Ultrasonography — Ultrasound (US) is reliable to confirm the clinical diagnosis of acute appendicitis, but is notreliable to exclude the diagnosis (image 9 and image 10) [85]. Accuracy is diminished in obese patients.

At least eight sonographic findings suggestive of internal inflammatory changes of the appendix have been described[8,43,44]. The most accurate ultrasound finding for acute appendicitis is an appendiceal diameter of >6 mm with asensitivity, specificity, negative predictive value and positive predictive value of 98 percent [43,44]. In various reports, thesensitivity and specificity by US in the diagnosis of appendicitis ranged from 35 to 98 percent and 71 to 98 percent,respectively [18,52,73,76].

Advantages of US compared with CT imaging include:

Right lower abdominal quadrant fat stranding (100 percent sensitivity)●Focal cecal thickening (69 percent specificity)●Adenopathy (63 percent sensitivity)●

Results may be obtained more efficiently (institution and practitioner dependent)●No radiation exposure●





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Disadvantages of US compared with CT imaging include:

Imaging costs — The use of preoperative imaging studies in the diagnosis of acute appendicitis has increased withtime, from 32 percent (1995 through 1999) to 95 percent (2001 through 2008), at one representative academic institution[73]. The increase in the use of CT scanning for the diagnosis of appendicitis has been largely justified by theassumption that it decreases the rates of perforated appendicitis as well as nontherapeutic appendectomies [86,87]. Intwo studies that performed cost analysis, one showed that the cost of a nontherapeutic appendectomy was 16 timesmore expensive than a focused appendiceal CT scan, while another reported that an appendectomy was 22 times moreexpensive than nonenhanced CT scanning, implying cost savings if a reduction in nontherapeutic appendectomy ratescould be achieved [84,88]. However, in one retrospective review, most patients undergoing a nontherapeuticappendectomy had a preoperative CT scan, and more than 50 percent of those patients had CT interpretations that werepositive for, or could not exclude, acute appendicitis [73].

Several studies have failed to demonstrate a significant reduction in the overall institutional rates for nontherapeuticappendectomies despite the increased use of CT scan over time [61,74,75,77,79,89-91]. Results of studies that includedanalysis of perforated appendicitis are mixed. One study showed an observed rate of appendiceal perforation of 9percent in patients who underwent routine CT imaging compared with 25 percent in patients in whom CT scanning wasnot used [77]. Other studies have demonstrated a fairly constant rate of perforated appendix over time despite theincreased use of CT scan [73,75,91].

Cost analysis for studies such as these is complicated by the value of CT scanning in patients in whom therapeuticappendectomy was performed; as a result, the cost savings depend upon an absolute rate reduction for nontherapeuticappendectomies [74,92]. Additionally, cost calculations depend upon local institutional variables and surgeon variables;selected institutional observations may not be applicable to all practices.

Laboratory tests — Laboratory tests serve a supportive role in the diagnosis of appendicitis. No single laboratory test orcombination of tests is an absolute marker for appendicitis [43,89].

A complete blood count (CBC) with a differential should be obtained, but cannot be used to confirm or exclude thediagnosis of appendicitis. A mild leukocytosis and a left shift (increase in total white blood cell count, bands [immatureneutrophils], and neutrophils) can be present in acute appendicitis as well as other acute etiologies of abdominal pain.

A pregnancy test should be performed for all women of childbearing age.

Although mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been noted to be a marker for appendicealperforation with a sensitivity of 70 percent and a specificity of 86 percent [39], the test is not discriminatory and generallynot helpful in the evaluation of patients suspected of acute appendicitis.

Exploratory laparotomy/laparoscopy — The acceptable nontherapeutic appendectomy rate (NAR) varies dependingupon the age and sex of the patient. For example, in young healthy males with right lower quadrant pain, the negativeappendectomy rate (NAR) should be less than 10 percent, while a rate that approaches 20 percent is reasonable inyoung women in whom other pelvic processes can make accurate diagnosis more difficult (eg, pelvic inflammatorydiseases, tubo-ovarian abscess) [83,93].

No significant difference in NAR was noted in comparing laparoscopic and open appendectomy [73]. A low NAR has

No use of intravenous or intestinal contrast agents●

Less diagnostic accuracy●Less likely to reveal an accurate alternative diagnosis●Accuracy is operator dependent●Technical challenges: Patients with a large body habitus and/or a large amount of overlying bowel gas●





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been achieved in some centers that use close in-hospital observation [94].

DIFFERENTIAL DIAGNOSIS — A variety of inflammatory and infectious conditions in the right lower quadrant canmimic the signs and symptoms of acute appendicitis. (See "Differential diagnosis of abdominal pain in adults".)

Perforated appendix — During the first 24 hours after the onset of abdominal pain and associated symptoms,approximately 90 percent of patients develop inflammation and perhaps necrosis of the appendix, but not perforation.Once significant inflammation and necrosis occur, the appendix is at risk of perforation, which leads to localized abscessformation or diffuse peritonitis. The time course to perforation is variable. One study showed that 20 percent of patientsdeveloped perforation less than 24 hours after the onset of symptoms [17]. Sixty-five percent of patients in whom theappendix perforated had symptoms for longer than 48 hours.

A perforated appendix must be considered in a patient whose temperature exceeds 103.0°F (39.4°C), the WBC count isgreater than 15,000 cells/microL, and imaging studies reveal a fluid collection in the right lower quadrant. (See'Pathogenesis' above and 'Laboratory findings' above and 'Imaging' above.)

Cecal diverticulitis — Cecal diverticulitis usually occurs in young adults and presents with signs and symptoms that canbe virtually identical to those of acute appendicitis. Right-sided diverticulitis occurs in only 1.5 percent of patients inWestern countries, but is more common in Asian populations (accounting for as many as 75 percent of cases ofdiverticulitis). Patients with right-sided diverticulitis tend to be younger than those with left-sided disease and often aremisdiagnosed with acute appendicitis. Computed tomographic (CT) scanning of the abdomen with IV and oral contrast isthe diagnostic test of choice in patients suspected of having acute diverticulitis. (See "Clinical manifestations anddiagnosis of acute diverticulitis in adults" and "Treatment of acute diverticulitis", section on 'Right-sided (cecal)diverticulitis'.)

Meckel's diverticulitis — Meckel's diverticulitis presents in a fashion similar to acute appendicitis. A Meckel'sdiverticulum is a congenital remnant of the omphalomesenteric duct and is located on the small intestine two feet fromthe ileocecal valve [95,96]. Meckel's diverticulitis should be included in the differential diagnosis as the small bowel maymigrate into the right lower quadrant and mimic the symptoms of appendicitis. If an inflamed appendix is not found onabdominal exploration for acute appendicitis, the surgeon should search for an inflamed Meckel's diverticulum. (See"Meckel’s diverticulum", section on 'Clinical presentations'.)

Acute ileitis — Acute ileitis, due most commonly to an acute self-limited bacterial infection (Yersinia, Campylobacter,Salmonella, and others), should be considered when acute diarrhea is a prominent symptom. Other clinicalmanifestations of acute yersiniosis include abdominal pain, fever, nausea and/or vomiting. Yersiniosis cannot be readilydistinguished clinically from other causes of acute diarrhea that present with these symptoms. However, localization ofabdominal pain to the right lower quadrant along with acute diarrhea may be a diagnostic clue for yersiniosis. (See"Clinical manifestations and diagnosis of Yersinia infections", section on 'Acute yersiniosis'.)

Acute yersiniosis presenting with right lower abdominal pain, fever, vomiting, leukocytosis, and understated diarrhea maybe confused with acute appendicitis. At surgery, findings include visible inflammation around the appendix and terminalileum and inflammation of the mesenteric lymph nodes; the appendix itself is generally normal. Yersinia can be culturedfrom the appendix and involved lymph nodes. (See "Clinical manifestations and diagnosis of Yersinia infections", sectionon 'Pseudoappendicitis'.)

Crohn's disease — Crohn's disease can present with symptoms similar to appendicitis, particularly when localized tothe distal ileum. Fatigue, prolonged diarrhea with abdominal pain, weight loss, and fever, with or without gross bleeding,are the hallmarks of Crohn's disease. An acute exacerbation of Crohn’s disease can mimic acute appendicitis and maybe indistinguishable by clinical evaluation and imaging.

Crohn's disease should be suspected in patients who have persistent pain after surgery, especially if the appendix is


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histologically normal. (See "Clinical manifestations, diagnosis and prognosis of Crohn disease in adults".)

Gynecologic and obstetrical conditions — The following gynecologic diseases may present with symptoms and/orclinical findings that are included in the differential of acute appendicitis:

Tubo-ovarian abscess — A tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube, ovary,and, occasionally, other adjacent pelvic organs (eg, bowel, bladder). These abscesses are found most commonly inreproductive age women and typically result from upper genital tract infection. Tubo-ovarian abscess is usually acomplication of pelvic inflammatory disease. The classic presentation includes acute lower abdominal pain, fever, chills,and vaginal discharge. However, fever is not present in all patients, some patients report only low-grade nocturnal feversor chills, and not all women present in an acute fashion. Clinical history and CT imaging can help differentiate TOA fromacute appendicitis (picture 1). (See "Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess",section on 'Clinical presentation'.)

Pelvic inflammatory disease — Lower abdominal pain is the cardinal presenting symptom in women with PIDalthough the character of the pain may be quite subtle. The recent onset of pain that worsens during coitus or with jarringmovement may be the only presenting symptom of PID; the onset of pain during or shortly after menses is particularlysuggestive. On physical examination, only about one-half of patients with PID have fever. Abdominal examinationreveals diffuse tenderness greatest in the lower quadrants, which may or may not be symmetrical. Rebound tendernessand decreased bowel sounds are common. On pelvic examination, the finding of a purulent endocervical dischargeand/or acute cervical motion and adnexal tenderness with bimanual examination is strongly suggestive of PID. Clinicalhistory and CT imaging can help differentiate PID from acute appendicitis (See "Clinical features and diagnosis of pelvicinflammatory disease".)

Ruptured ovarian cyst — Rupture of an ovarian cyst is a common occurrence in women of reproductive age andmay be associated with the sudden onset of unilateral lower abdominal pain. The pain often begins during strenuousphysical activity, such as exercise or sexual intercourse and may be accompanied by light vaginal bleeding due to a dropin secretion of ovarian hormones and subsequent endometrial sloughing. Blood from the rupture site may seep into theovary, which can cause pain from stretching of the ovarian cortex, or it may flow into the abdomen, which has an irritanteffect on the peritoneum. Serous or mucinous fluid released upon cyst rupture is not very irritating; the patient mayremain asymptomatic despite accumulation of a large volume of intraperitoneal fluid. On the other hand, spillage ofsebaceous material upon rupture of a dermoid cyst causes a marked granulomatous reaction and chemical peritonitis,which is usually quite painful.

The right lower quadrant is most commonly affected, possibly because the rectosigmoid colon protects the left ovaryfrom the effects of abdominal trauma. Rupture of a simple cyst usually results in only mild to moderate tenderness ondeep palpation. If the cyst has not completely collapsed, an adnexal mass may be palpable on bimanual examination. Atthe other end of the spectrum, release of sebaceous material or blood into the abdomen may cause overt peritonitis withrigidity of the abdominal wall and rebound tenderness. Cervical motion tenderness may also be present.

Intraabdominal hemorrhage may be associated with Cullen's sign (ie, periumbilical ecchymoses). Clinical history and CTimaging can help differentiate a ruptured ovarian cyst from acute appendicitis (image 11 and image 12). (See "Evaluationand management of ruptured ovarian cyst".)

Mittelschmerz — Mittelschmerz refers to midcycle pain in an ovulatory woman caused by normal follicularenlargement just prior to ovulation or to normal follicular bleeding at ovulation. The pain is typically mild and unilateral; itoccurs midway between menstrual periods and lasts for a few hours to a couple of days. Fluid or blood is released fromthe ruptured egg follicle and can cause irritation of the lining of the abdominal wall. (See "Physiology of the normalmenstrual cycle".)

Ovarian and fallopian tube torsion — Ovarian torsion refers to the twisting of the ovary on its ligamentous

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supports, often resulting in impedance of its blood supply (picture 2). Isolated fallopian tube torsion is uncommon (picture3). Expedient diagnosis is important to preserve ovarian function and prevent adverse sequelae. However, the diagnosiscan be challenging because the symptoms are relatively nonspecific.

The most common symptom of ovarian torsion is sudden onset lower abdominal pain, often associated with waves ofnausea and vomiting. Fever, although an uncommon finding in ovarian torsion, may be a marker of necrosis, particularlyin the setting of an increased white blood cell count. Clinical history and CT imaging can help differentiate the diagnosisfrom acute appendicitis (picture 4). (See "Ovarian and fallopian tube torsion".)

Endometriosis — Endometriosis is defined as the presence of endometrial glands and stroma at extrauterine sites.These ectopic endometrial implants are usually located in the pelvis, but can occur nearly anywhere in the body (picture5).

Common symptoms of endometriosis include pelvic pain (which is usually chronic and often more severe during mensesor at ovulation), dysmenorrhea, deep dyspareunia, cyclical bowel or bladder symptoms, abnormal menstrual bleeding,and infertility. There are often no abnormal findings on physical examination; when findings are present, the mostcommon is tenderness upon palpation of the posterior fornix. Ultrasound is mostly useful for diagnosing ovarianendometriomas; it lacks adequate resolution for visualizing adhesions and superficial peritoneal/ovarian implants, whichare more common than endometriomas. (See "Pathogenesis, clinical features, and diagnosis of endometriosis".)

Ovarian hyperstimulation syndrome — Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complicationof ovulation induction therapy and may be accompanied by or mistaken for cyst rupture. Clinical findings includebloating, nausea, vomiting, diarrhea, lethargy, shortness of breath, and rapid weight gain.

Severe ovarian hyperstimulation syndrome is characterized by large ovarian cysts, ascites, and, in some patients,pleural and/or pericardial effusion, electrolyte imbalance (hyponatremia, hyperkalemia), hypovolemia, and hypovolemicshock. Marked hemoconcentration, increased blood viscosity, and thromboembolic phenomena including disseminatedintravascular coagulation occur in the most severe cases. (See "Classification and treatment of ovarian hyperstimulationsyndrome".)

Ectopic pregnancy — Ectopic pregnancy has clinical symptoms and sonographic features similar to those of aruptured ovarian cyst. In women with acute pelvic pain or abnormal vaginal bleeding, a positive pregnancy test stronglysuggests the presence of an ectopic pregnancy if an intrauterine pregnancy cannot be visualized sonographically. If anintrauterine pregnancy is visualized, then pelvic pain and intraperitoneal fluid could be due to a ruptured ovarian cyst (eg,corpus luteum cyst, theca lutein cyst) or heterotopic pregnancy. (See "Clinical manifestations, diagnosis, andmanagement of ectopic pregnancy", section on 'Heterotopic pregnancy'.)

Acute endometritis — Acute endometritis occurs after an obstetrical delivery or, rarely, after an invasive uterineprocedure. The diagnosis is largely based upon the presence of fever, gradual onset of uterine tenderness, foul uterinedischarge, and leukocytosis in an at-risk setting. (See "Postpartum endometritis" and "Endometritis unrelated topregnancy".)

Urologic conditions

Renal colic — Pain is the most common symptom and varies from a mild and barely noticeable ache to discomfortthat is so intense that it requires parenteral analgesics. The pain typically waxes and wanes in severity, and develops inwaves or paroxysms that are related to movement of the stone in the ureter and associated ureteral spasm. Paroxysmsof severe pain usually last 20 to 60 minutes. Pain is thought to occur primarily from urinary obstruction with distention ofthe renal capsule. (See "Diagnosis and acute management of suspected nephrolithiasis in adults" and "Acutemanagement of nephrolithiasis in children".)

Testicular torsion — Testicular torsion is a urologic emergency that is more common in neonates and postpubertal




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boys, although it can occur at any age. Testicular torsion results from inadequate fixation of the testis to the tunicavaginalis. If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently broad-based or absent, the testismay torse (twist) on the spermatic cord, potentially producing ischemia from reduced arterial inflow and venous outflowobstruction. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion' and "Evaluation ofthe acute scrotum in adults", section on 'Testicular torsion'.)

Epididymitis — Epididymitis occurs more frequently among late adolescents, but also occurs in younger boys whodeny sexual activity and is most common cause of scrotal pain in adults in the outpatient setting. Several factors maypredispose postpubertal boys to develop subacute epididymitis, including sexual activity, heavy physical exertion, anddirect trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in prepubertal boys is associated with structuralanomalies of the urinary tract. In acute infectious epididymitis, palpation reveals induration and swelling of the involvedepididymis with exquisite tenderness. More advanced cases often present with testicular swelling and pain (epididymo-orchitis) with scrotal wall erythema and a reactive hydrocele. (See "Causes of scrotal pain in children and adolescents",section on 'Epididymitis' and "Evaluation of the acute scrotum in adults", section on 'Epididymitis'.)

Torsion of the appendix testis or appendix epididymis — The appendix testis is a small vestigial structure on theanterosuperior aspect of the testis (an embryologic remnant of the Müllerian duct system). The appendix epididymis is avestigial remnant of the Wolffian duct that is located at the head of the epididymis. The pedunculated shape of theseappendages predisposes them to torsion, which can produce scrotal pain that ranges from mild to severe. Most cases oftorsion of the appendix testis occur between the ages of 7 and 14 years, and rarely occur in adults. (See "Causes ofscrotal pain in children and adolescents", section on 'Torsion of the appendix testis or appendix epididymis' and"Evaluation of the acute scrotum in adults", section on 'Torsion of the appendix testis'.)

TREATMENT — The management of acute appendicitis in children and adults is discussed in detail separately. (See"Acute appendicitis in children: Management" and "Acute appendicitis in adults: Management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyondthe Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, andthey answer the four or five key questions a patient might have about a given condition. These articles are best forpatients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient educationpieces are longer, more sophisticated, and more detailed. These articles are written at the 10 to 12 grade readinglevel and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics toyour patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” andthe keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS — Appendicitis is one of the most common causes of the acute abdomen andone of the most frequent indications for an emergent abdominal surgical procedure worldwide.

th th

th th

Basics topics (see "Patient information: Appendicitis in adults (The Basics)").●

The tip of the appendix can be found in a retrocecal or pelvic location, as well as medial, lateral, anterior orposterior to the cecum. Anatomic variability can complicate the diagnosis, as clinical presentation will reflect theanatomic position of the appendix. (See 'Anatomy' above.)

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Appendiceal obstruction plays a role in the pathogenesis of appendicitis, but it is not required for the developmentof appendicitis. (See 'Pathogenesis' above.)

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The classic symptoms of appendicitis include right lower quadrant abdominal pain, anorexia, fever, nausea andvomiting. The abdominal pain is initially periumbilical in nature with subsequent migration to the right lowerquadrant as the inflammation progresses (see 'Clinical manifestations' above). Patients with appendicitis can also

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ACKNOWLEDGMENT — We are saddened by the untimely death of John Marx, MD, who passed away in July 2012.We wish to acknowledge Dr. Marx's dedication and his many contributions to UpToDate, in particular, his work as editor-in-chief for Emergency Medicine and as a section editor and author for Adult Trauma. We would also like toacknowledge Dr. Carrie Black, who contributed to an earlier version of this topic review

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present with atypical or nonspecific symptoms, such as indigestion, flatulence, bowel irregularity, and generalizedmalaise; and not all patients will have migratory abdominal pain.

The constellation of findings from history, physical examination, and laboratory studies will usually lead anexperienced examiner to the correct diagnosis of appendicitis without diagnostic imaging (see 'Diagnosis' above). Aclinical diagnosis can be more challenging in women, who may benefit from the addition of radiologic imaging whenthe diagnosis is unclear.

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Diagnostic imaging should be performed when the diagnosis of appendicitis is suspected but unclear (eg, elderlypatients, patients with comorbid illnesses, women of childbearing age). We perform a standard abdominal CT scanwith intravenous and oral contrast. (See 'Standard CT scan with contrast' above.)

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The differential diagnosis of right lower quadrant abdominal pain includes inflammatory disease processes (eg,Crohn’s disease, ruptured cyst), infectious diseases (eg, acute ileitis, tubo-ovarian abscess), and obstetricalconditions (eg, ectopic pregnancy). (See 'Differential diagnosis' above.)

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appendicitis. Am J Surg 2002; 183:547.53. Liu CC, Lu CL, Yen DH, et al. Diagnosis of appendicitis in the ED: comparison of surgical and nonsurgical

residents. Am J Emerg Med 2001; 19:109.54. Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in the diagnosis of

acute appendicitis compared with the general surgery resident. Eur J Emerg Med 2003; 10:296.55. Kharbanda AB, Fishman SJ, Bachur RG. Comparison of pediatric emergency physicians' and surgeons' evaluation

and diagnosis of appendicitis. Acad Emerg Med 2008; 15:119.56. Yen K, Karpas A, Pinkerton HJ, Gorelick MH. Interexaminer reliability in physical examination of pediatric patients

with abdominal pain. Arch Pediatr Adolesc Med 2005; 159:373.57. Daehlin L. Acute appendicitis during the first three years of life. Acta Chir Scand 1982; 148:291.58. Horattas MC, Guyton DP, Wu D. A reappraisal of appendicitis in the elderly. Am J Surg 1990; 160:291.59. Pittman-Waller VA, Myers JG, Stewart RM, et al. Appendicitis: why so complicated? Analysis of 5755 consecutive

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to diagnose an acute appendicitis? Curr Surg 2006; 63:464.62. Townsend, CM, Beauchamp, RD, Evers, BM, Mattox, KL. Sabiston Textbook of Surgery, 18th ed, Saunders

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66. Ohle R, O'Reilly F, O'Brien KK, et al. The Alvarado score for predicting acute appendicitis: a systematic review.BMC Med 2011; 9:139.

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70. Enochsson L, Gudbjartsson T, Hellberg A, et al. The Fenyö-Lindberg scoring system for appendicitis increasespositive predictive value in fertile women--a prospective study in 455 patients randomized to either laparoscopic oropen appendectomy. Surg Endosc 2004; 18:1509.

71. Liu JL, Wyatt JC, Deeks JJ, et al. Systematic reviews of clinical decision tools for acute abdominal pain. HealthTechnol Assess 2006; 10:1.

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Topic 1386 Version 16.0











GRAPHICS

Variations in the position of the appendix



Blood supply to the colon and rectum

The blood supply to the colon originates from the superior mesenteric arteryand the inferior mesenteric artery. The blood supply to the rectum originatesfrom the superior rectal artery.



CT scan normal appendix

CT scan depicts a normal appendix. The figure on the left shows an appendiceal lumencontaining air and wall thickness of 3 mm (yellow arrow). The figure on the rightshows the tip of the normal appendix (green arrow) that measures 6 mm and noassociated induration.



CT scan acute appendicitis

The CT scan was obtained using oral and intravenous contrast from a patient whopresented with right lower quadrant abdominal pain. These figures show an inflammedappendix that measures 21 mm in diameter and contains an appendicolith and fluidthat is likely purulent.(A) Shows an appendicolith in the appendix using a white arrow.(B) Shows the appendicolith, an overlay of orange to show fluid inside the appendix,and a yellow arrow indicates free fluid.(C) Shows the enlarged appendix and fluid without an overlay.(D) Shows a colored overlay: red circle depicts the enhancing appendiceal wall;orange depicts the intra-appendiceal fluid; yellow depicts the free fluid.



Normal appendix by ultrasound imaging

The gray scale ultrasound (A, and magnified in B) and Doppler image (C) of theappendix are projected in the transverse plane. Images A and B show a normalappendix measuring almost 6 mm in maximum transverse dimension (arrow). Theappendix was compressible and no hyperemia was demonstrated (arrow) on theDoppler image (C). These findings are consistent with a normal appendix by ultrasound.



Acute appendicitis ultrasound

The patient is a 19-year-old female who presented to the emergency department withright lower quadrant pain. The gray scale ultrasound of the appendix is projected in thelongitudinal (A) and transverse planes (B). A noncompressible appendix measuresalmost 20 mm in diameter, consistent with a diagnosis of acute appendicitis. Theechogenic mucosal and submucosal portions of the wall have become discontinuous(red arrows) suggesting disruption as a result of sloughing. Luminal air (yellow arrows)results in posterior shadowing.



Appendicolith on abdominal films

This plain film of the abdomen reveals a 1.2 cm calcific density, anappendicolith. The patient presented with right lower quadrant painand was diagnosed with acute appendicitis.



Magnetic resonance image of appendicitis inpregnancy

T2 weighted magnetic resonance image of a woman withappendicitis at 9 weeks of gestation. The appendix was fluid-filledand measured 7 mm (arrow). The gestational sac (gs) is seenlower in the pelvis.Courtesy of Deborah Levine, MD.



CT scan equivocal appendicitis

The patient is a 56-year-old male who presents with right lower quadrant pain. The CTscan of the lower abdomen in the axial plane (A) and the magnified view of theappendix (B) show a normal sized appendix with surrounding induration (red arrow).The periappendiceal induration raises the possibility of appendicitis. The associatedthickening of the posterior peritoneum (orange arrow) suggests an acute process inthe right lower quadrant. However, the epicenter of induration (yellow arrow in A andB) in the region of the tip of the liver (L) and ascending colon (C) suggests that theprocess likely originates in that region. Thus the process around the appendix issecondary and not primary to the appendix.



Ultrasound equivocal appendicitis

The gray scale ultrasound of the appendix is projected in the longitudinal (A) andtransverse planes (B). The appearance of the appendix is near normal except for adiameter that measures 7.6 mm in the long axis, and a diameter that measuresbetween 7 and 9 mm in the transverse plane. Since this diameter should be 6 mm orless, the diagnosis of appendicitis is entertained. There is no loculated fluid around theappendix and no free fluid present in the peritoneal cavity. The echogenic line of themucosa and submucosa is intact and the lumen is distended with complex material(arrow). The findings of the enlarged diameter with no other specific pathognomonicfeatures make the diagnosis of acute appendicitis equivocal.



Normal appendix on ultrasound

Ultrasound image of a normal appendix (red arrow and markers).The appendix is located at the confluence of the taenia coli (whitearrows) and is seen in relationship to the cecum (COE). Fluidfilled small bowel (DD) and iliac vessels (VI) are also indicated.Courtesy of Christoph F Dietrich, MD.



Doppler ultrasound of appendicitis

In this doppler ultrasound image of appendicitis, the appendixappears edematous (9 x 8 mm) and hypervascular. The layers ofthe wall are still detectable. Continued inflammation may befollowed by localized ischemia (which may be visualized by colorDoppler imaging) and necrosis. Sonographic findings wereconfirmed at surgery.Courtesy of Christoph F Dietrich, MD.



Tuboovarian abscess

Gross intraoperative photograph of a left tuboovarian abscess ina patient with pelvic inflammatory disease.Courtesy of Mitchel Hoffman, MD.



Ruptured ovarian cyst

Computed tomography. Arrows indicate free blood within peritonealcavity surrounding liver and spleen.Courtesy of William J Mann, Jr, MD.



Adnexal mass

Computed tomography. Arrow indicates poorly defined adnexal mass,which at exploration was ruptured corpus luteum cyst and clot.Courtesy of William J Mann, Jr, MD.



Ovarian and tubal torsion demonstrating markedvascular engorgement as well as increased sizeand distension

Anatomy was restored and both structures were salvaged despitenon-viable appearance.Reproduced with permission from: Pediatric and Adolescent Gynecology, 6thed, Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott Williams & Wilkins,Philadelphia 2012. Copyright © 2012 Lippincott Williams & Wilkins.

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Tubal torsion demonstrating severe distension of thedistal tube

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6thed, Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott Williams & Wilkins,Philadelphia 2012. Copyright © 2012 Lippincott Williams & Wilkins.

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Enlarged left ovary found torsed upon laparotomydemonstrating a dark, dusky appearancesecondary to venous lymphatic congestion in thesetting of continued arterial perfusion

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6thed, Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott Williams & Wilkins,Philadelphia 2012. Copyright © 2012 Lippincott Williams & Wilkins.

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Peritoneal endometriosis

The peritoneum in this woman with endometriosis is studded withreddish, irregularly shaped implants.Reprinted with permission. Copyright 1990 Syntex Laboratories, Inc. Allrights reserved.

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