acute appendicitis[1]

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Acute Appendicitis Review and Update

D MIKE HARDIN JR MDTexas AampM University Health Science Center Temple Texas

Appendicitis is common with a lifetime occurrence of 7 percent Abdominal pain and anorexia are thepredominant symptoms The most important physical examination finding is right lower quadrant tenderness to

palpation A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and

supporting the presence or absence of appendicitis while appendiceal computed tomographic scans and

ultrasonography can be helpful in equivocal cases Delay in diagnosing appendicitis increases the risk of

perforation and complications Complication and mortality rates are much higher in children and the elderly (Am

Fam Physician 1999602027-34)

A ppendicitis is the most common acute surgical condition of the abdomen1 Approximately 7 percent of the

population will have appendicitis in their lifetime2 with the peak incidence occurring between the ages of 10 and30 years3

Despite technologic advances the diagnosis of appendicitis is still based primarily on the patients history and the

physical examination Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent

complications 4 The mortality rate in nonperforated appendicitis is less than 1 percent but it may be as high as 5

percent or more in young and elderly patients in whom diagnosis may often be delayed thus making perforation

more likely1

Pathogenesis

TABLE 1 Common Symptoms of Appendicitis

Common symptomsFrequency()

Abdominal pain ~100

Anorexia ~100

Nausea 90

Vomiting 75

Pain migration 50

Classic symptom sequence (vagueperiumbilical pain toanorexianauseaunsustainedvomiting to migration of pain to rightlower quadrant to low-grade fever)

50



The appendix is a long diverticulum that extends from the

inferior tip of the cecum5 Its lining is interspersed with

lymphoid follicles3 Most of the time the appendix has an

intraperitoneal location (either anterior or retrocecal) and

thus may come in contact with the anterior parietal peritoneum when it is inflamed Up to 30 percent of the time

the appendix may be hidden from the anterior peritoneum by being in a pelvic retroileal or retrocolic

(retroperitoneal retrocecal) position6 The hidden position of the appendix notably changes the clinical

manifestations of appendicitis

Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis Obstruction has

multiple causes including lymphoid hyperplasia (related to viral illnesses including upper respiratory infection

mononucleosis gastroenteritis) fecaliths parasites foreign bodies Crohns disease primary or metastatic cancer

and carcinoid syndrome Lymphoid hyperplasia is more common in children and young adults accounting for the

increased incidence of appendicitis in these age groups15

History and Physical Examination

Abdominal pain is the most common symptom of appendicitis 3 In multiple studies3-5 specific characteristics of the

abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis ( Table

1) A thorough review of the history of the abdominal pain and of the patients recent genitourinary gynecologic

and pulmonary history should be obtained

Anorexia nausea and vomiting are symptoms that are commonly associated with acute appendicitis The classic

history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50

percent of patients1 Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis1

TABLE 2 Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis

Symptomsign Positive likelihood ratio (LR+) Symptomsign

Negativelikelihoodratio (LR-)

Right lower quadrant

(RLQ) pain

80 RLQ painsect 0 to 028dagger

Pain migration 32 No similar painpreviously||

03

Pain before vomiting 28 Pain migration 05

Anorexia nausea andvomiting

Much lower LR+ than RLQ pain painmigration and pain before vomiting

Guarding 0 to 054dagger

Rigidity 376 Rebound tenderness 0 to 086dagger

Psoas sign 238 Fever rigidity and

--Onset of symptoms typically within past 24 to36 hoursInformation from references 3 through 5



psoas signpara

Rebound tenderness 11 to 63dagger

Fever 19Dagger

Guarding and rectaltenderness

Much lower LR+ than rigidity psoassign and rebound tenderness

NOTE LR is the amount by which the odds of a disease change with new information as follows

Likelihood ratio Degree of change in probability

gt10 or lt01 Large (often conclusive)

5 to 10 or 01 to 02 Moderate

2 to 5 or 02 to 05 Small (but sometimes important)

1 to 2 or 05 to 1 Small (rarely important)

--These symptoms and signs have much lower LR+dagger--Ratios are presented in ranges for signs and symptoms that had widely varying results in studiesDagger--Fever had only borderline LR+

sect--That is the absence of RLQ pain significantly lowers the odds of having appendicitis||--That is the history of experiencing a similar pain previously lowers the odds of having appendicitispara--These signs have higher LR-Information from references 7 8 and 19

In a recent meta-analysis7 likelihood ratios were calculated for many of these symptoms (Table 2) A likelihood

ratio is the amount by which the odds of a disease change with new information (eg physical examination

findings laboratory results)8 This change can be positive or negative Symptoms such as anorexia nausea and

vomiting commonly occur in acute appendicitis however the presence of these symptoms does not necessarily

increase the likelihood of appendicitis nor does their absence decrease the likelihood of the diagnosis Moreover

other symptoms have more notable positive and

negative likelihood ratios (Table 2)

TABLE 3 Common Signs of Appendicitis

bull Right lower quadrant pain on palpation (the singlemost important sign)bull Low-grade fever (38degC [or 1004degF])--absence of feveror high fever can occurbull Peritoneal signs

bull Localized tenderness to percussionbull Guardingbull Other confirmatory peritoneal signs (absence of thesesigns does not exclude appendicitis)bull Psoas sign--pain on extension of right thigh(retroperitoneal retrocecal appendix)bull Obturator sign--pain on internal rotation of right thigh(pelvic appendix)bull Rovsings sign--pain in right lower quadrant with



A careful systematic examination of the abdomen is

essential While right lower quadrant tenderness to

palpation is the most important physical examination

finding other signs may help confirm the diagnosis

(Table 3) The abdominal examination should begin

with inspection followed by auscultation gentle

palpation (beginning at a site distant from the pain) and

finally abdominal percussion The rebound tenderness that is associated with peritoneal irritation has been shown

to be more accurately identified by percussion of the abdomen than by palpation with quick release 1

As previously noted the location of the appendix varies When the appendix is hidden from the anterior

peritoneum the usual symptoms and signs of acute appendicitis may not be present Pain and tenderness can

occur in a location other than the right lower quadrant 6 A retrocecal appendix in a retroperitoneal location may

cause flank pain In this case stretching the iliopsoas muscle can elicit pain The psoas sign is elicited in this

manner the patient lies on the left side while the examiner extends the patients right thigh ( Figures 1a and 1b) In

contrast a patient with a pelvic appendix may show no abdominal signs but the rectal examination may elicit

tenderness in the cul-de-sac In addition an obturator sign (pain on passive internal rotation of the flexed right

thigh) may be present in a patient with a pelvic appendix3 ( Figures 2a and 2b)

FIGURE 1A The psoas sign Pain on passiveextension of the right thigh Patient lies on left sideExaminer extends patients right thigh while applyingcounter resistance to the right hip (asterisk)

FIGURE 2A The obturator sign Pain on passive internalrotation of the flexed thigh Examiner moves lower leg laterallywhile applying resistance to the lateral side of the knee(asterisk) resulting in internal rotation of the femur

palpation of left lower quadrantbull Dunphys sign--increased pain with coughingbull Flank tenderness in right lower quadrant(retroperitoneal retrocecal appendix)bull Patient maintains hip flexion with knees drawn up forcomfort

Information from references 3 through 5



FIGURE 1B Anatomic basis for the psoas signinflamed appendix is in a retroperitoneal location incontact with the psoas muscle which is stretched bythis maneuver

FIGURE 2B Anatomic basis for the obturator sign inflamedappendix in the pelvis is in contact with the obturator internusmuscle which is stretched by this maneuver

The differential diagnosis of appendicitis is broad but the patients history and the remainder of the physical

examination may clarify the diagnosis (Table 4) Because many gynecologic conditions can mimic appendicitis a

pelvic examination should be performed on all women with abdominal pain Given the breadth of the differential

diagnosis the pulmonary genitourinary and rectal examinations are equally important Studies have shown

however that the rectal examination provides useful information only when the diagnosis is unclear and thus can

be reserved for use in such cases5

TABLE 4 Differential Diagnosis of Acute Appendicitis

Gastrointestinal Abdominal paincause unknownCholecystitis

GynecologicEctopicpregnancyEndometriosis

PulmonaryPleuritisPneumonia(basilar)



Laboratory and Radiologic Evaluation

If the patients history and the physical examination do

not clarify the diagnosis laboratory and radiologic

evaluations may be helpful A clear diagnosis of

appendicitis obviates the need for further testing and

should prompt immediate surgical referral

Laboratory Tests

The white blood cell (WBC) count is elevated (greater

than 10000 per mm3 [100 3 109 per L]) in 80 percent of

all cases of acute appendicitis9 Unfortunately the WBC

is elevated in up to 70 percent of patients with other

causes of right lower quadrant pain10 Thus an elevated

WBC has a low predictive value Serial WBC

measurements (over 4 to 8 hours) in suspected cases

may increase the specificity as the WBC count often

increases in acute appendicitis (except in cases of

perforation in which it may initially fall)5

In addition 95 percent of patients have neutrophilia1 and in the elderly an elevated band count greater than 6

percent has been shown to have a high predictive value for appendicitis9 In general however the WBC count and

differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low

specificities

A more recently suggested laboratory evaluation is determination of the C-reactive protein level An elevated C-

reactive protein level (greater than 08 mg per dL) is common in appendicitis but studies disagree on its

sensitivity and specificity45 An elevated C-reactive protein level in combination with an elevated WBC count and

neutrophilia are highly sensitive (97 to 100 percent) Therefore if all three of these findings are absent the chance

of appendicitis is low5

In patients with appendicitis a urinalysis may demonstrate changes such as mild pyuria proteinuria and

hematuria1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose

appendicitis

Crohns diseaseDiverticulitisDuodenal ulcerGastroenteritisIntestinalobstruction

IntussusceptionMeckelsdiverticulitisMesentericlymphadenitisNecrotizingenterocolitisNeoplasm(carcinoidcarcinomalymphoma)Omental torsionPancreatitis

Perforated viscusVolvulus

Ovarian torsionPelvicinflammatorydiseaseRupturedovarian cyst

(follicularcorpusluteum)Tubo-ovarianabscessSystemic DiabeticketoacidosisPorphyriaSickle celldiseaseHenoch-Schoumlnlein

purpura

PulmonaryinfarctionGenitourinary Kidney stoneProstatitisPyelonephritis

TesticulartorsionUrinary tractinfectionWilms tumorOther ParasiticinfectionPsoas abscessRectus sheathhematoma

Reprinted with permission from Graffeo CSCounselman FL Appendicitis Emerg Med Clin North Am 199614653-71



Radiologic Evaluation

The options for radiologic evaluation of patients with suspected

appendicitis have expanded in recent years enhancing and

sometimes replacing previously used radiologic studies

Plain radiographs while often revealing abnormalities in acute

appendicitis lack specificity and are more helpful in diagnosing

other causes of abdominal pain Likewise barium enema is now

used infrequently because of the advances in abdominal imaging 5

Ultrasonography and computed tomographic (CT) scans are helpful

in evaluating patients with suspected appendicitis11 Ultrasonography

is appropriate in patients in which the diagnosis is equivocal by

history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in

pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is

noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory

bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can

cause false-positive ultrasonography results12

FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix

TABLE 5 Comparison of Ultrasound and

Appendiceal CT Evaluation of

Suspected Appendicitis

Comparisongradedultrasound

Appendicealcomputedtomographicscan

Sensitivity 85 90 to 100

Specificity 92 95 to 97

Use Evaluatepatients withequivocaldiagnosis ofappendicitis

Evaluatepatients withequivocaldiagnosis ofappendicitis

Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females

More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal



CT specifically the technique of appendiceal CT is more

accurate than ultrasonography (Table 5) Appendiceal CT

consists of a focused helical appendiceal CT after a

Gastrografin-saline enema (with or without oral contrast) and

can be performed and interpreted within one hour

Intravenous contrast is unnecessary12 The accuracy of CT is

due in part to its ability to identify a normal appendix better

than ultrasonography13 An inflamed appendix is greater than 6

mm in diameter but the CT also demonstrates

periappendiceal inflammatory changes14 ( Figures 4 and 5) If

appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be

more accurate than ultrasonography12

Treatment

The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of

appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is

acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies

have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients

eventually required appendectomy3

Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or

laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while

therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16

While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal

activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open

appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted

Better forchildren

appendix

Disadvantages OperatordependentTechnicallyinadequate

studies due togasPain

CostIonizingradiationContrast

Information from references 11 13 20



FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)

FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)

Complications

Appendiceal rupture accounts for a majority of the complications of

appendicitis Factors that increase the rate of perforation are

delayed presentation to medical care17 age extremes (young and

old)18 and hidden location of appendix6 A brief period of in-hospital

observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve

diagnostic accuracy18

Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms

may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a

more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined

mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may

elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3

A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative

management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval

appendectomy six weeks to three months later 1

Special Considerations

The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients

The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis



While appendicitis is uncommon in young children it poses special

difficulties in this age group Young children are unable to relate a history often have abdominal pain from other

causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high

as 50 percent in this group1

In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation

Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC

count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising

to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is

the standard for treatment3

Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be

diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation

combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a

mortality rate of up to 5 percent or more1

Final Comment

Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is

a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of

appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further

evaluation and many times surgical consultation

The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for

help with the manuscript

Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White

Memorial Hospital Temple Tex



Appendicitis (Pediatric GI)

Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal

sonogram of a child whose appendix appeared normal

Imaging



Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower

quadrant pain) from appendicitis (Fig 4)

CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis

CT findings of normal appendix

Visualized in 67-100

AT posteromedial aspect of cecum Diameter of up to 10 mm

CT findings of Abnormal appendix

Distended lumen (appendix gt7 mm in diameter)

Circumferential wall thickening

Target sign homogeneously enhancing wall with mural stratification

Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and

normal cecal apex



Read the rest of this entry raquo

Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal

appendix Target sign

Acute appendicitis Laparocopic diagnosis



Perforated duodenal ulcer

Acute cholecystitis



Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)



While looking through the archives of ultrasound images I came across a couple of instances of common

diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts

if I stick with the theme

Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =

Transabdominal sonography)

Rarely we do get to see a classical appendicolith on ultrasonography



What is quite rare is thishellip

Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -

Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain

While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who

have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed

abstract were the first in the world to attempt this are from my hometown Coimbatore



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Location of the appendix in the digestive system

Appendicitis is a condition characterized by inflammation of the appendix It is a medical

emergency All cases require removal of the inflamed appendix either by laparotomy or

laparoscopy Untreated mortality is high mainly because of peritonitis and shock

Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been

recognized as one of the most common causes of severe acute abdominal pain worldwide

A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis

Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and

atypical The typical history includes pain starting centrally (periumbilical) before localizing

to the right iliac fossa (the lower right side of the abdomen) this is due to the poor

localizing (spatial) property of visceral nerves from the mid-gut followed by the

involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The

pain is usually associated with loss of appetite and fever although the latter isnt a

necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise

Atypical symptoms may include pain beginning and staying in the right iliac fossa

diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact

with the bladder there is frequency of urination With post-ileal appendix marked retching



may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve

discomfort) is also experienced in some cases

Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to

patientmdash

so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion

Signs These include localized findings in the right iliac fossa The abdominal wall becomes very

sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a

retrocecal appendix however even deep pressure in the right lower quadrant may fail to

elicit tenderness (silent appendix) the reason being that the cecum distended with gas

prevents the pressure exerted by the palpating hand from reaching the inflamed appendix

Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in

the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)

and this is the least painful way to localize the inflamed appendix If the abdomen on

palpation is also involuntarily guarded (rigid) there should be a strong suspicion of

peritonitis requiring urgent surgical intervention

Other signs are

Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the

Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute

appendicitis Pressure over the descending colon causes pain in the right lower quadrant

of the abdomen

Psoas sign

This is right lower-quadrant pain that is reproduced with the patient lying on his left side

and then extending the hip Because extension elicits pain the patient will lie with the right

hip flexed for pain relief

Obturator sign

If an inflamed appendix is in contact with the obturator internus spasm of the muscle can

be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in

the hypogastrium



Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a

primary obstruction of the appendix lumen Once this obstruction occurs the appendix

subsequently becomes filled with mucus and swells increasing pressures within the

lumen and the walls of the appendix resulting in thrombosis and occlusion of the small

vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this

point As the former progresses the appendix becomes ischemic and then necrotic As

bacteria begin to leak out through the dying walls pus forms within and around the

appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst

appendix) causing peritonitis which may lead to septicemia and eventually death

Among the causative agents such as foreign bodies trauma intestinal worms

lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with

appendicitis is significantly higher in developed than in developing countries and an

appendiceal fecalith is commonly associated with complicated appendicitis Also fecal

stasis and arrest may play a role as demonstrated by a significantly lower number of

bowel movements per week in patients with acute appendicitis compared with healthy

controls

The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal

retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and

colon cancer exceedingly rare in communities exempt for appendicitis Also acute

appendicitis has been shown to occur antecedent to cancer in the colon and rectum

Several studies offer evidence that a low fiber intake is involved in the pathogenesis of

appendicitis

This is in accordance with the occurrence of a right sided fecal reservoir and the fact that

dietary fiber reduces transit time

Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an

elevation of neutrophilic white blood cells Atypical histories often require imaging with

ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age

as ectopic pregnancies and appendicitis present with similar symptoms The

consequences of missing an ectopic pregnancy are serious and potentially life



threatening Furthermore the general principles of approaching abdominal pain in women

(in so much that it is different from the approach in men) should be appreciated

Ultrasound

Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis

especially in children In some cases (15 approximately) however ultrasonography of

the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This

is especially true of early appendicitis before the appendix has become significantly

distended and in adults where larger amounts of fat and bowel gas make actually seeing

the appendix technically difficult Despite these limitations in experienced hands

sonographic imaging can often distinguish between appendicitis and other diseases with

very similar symptoms such as inflammation of lymph nodes near the appendix or pain

originating from other pelvic organs such as the ovaries or fallopian tubes

Computed tomography

In places where it is readily available CT scan has become frequently used especially in

adults whose diagnosis is not obvious on history and physical Concerns about radiation

however exist which tends to limit its use in pregnant women and children A properly



performed CT scan with modern equipment has a detection rate (sensitivity) of over 95

and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast

(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than

6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The

inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early

appendicitis and a clue that appendicitis may be present even when the appendix is not

well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients

and in children both of whom tend to lack significant fat within the abdomen The utility of

CT scanning is made clear however by the impact it has had on negative appendectomy

rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased

the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3

according to data from the Massachusetts General Hospital

According to a systematic review from UC-San Francisco comparing ultrasound vs CT

scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults

and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood

ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)

Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive

likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)

Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of

appendiceal rupture among patients with acute appendicitis according to a cohort study

MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared

with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a

tenfold higher expression in all groups with appendicitis compared with controls (plt0001)

A number of clinical and laboratory based scoring systems have been devised to assist

diagnosis The most widely used is Alvarado score

Alvarado score

A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more

is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT

scan further reduces the rate of negative appendicectomy

Differential diagnosis

In children



Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception

Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in

the absence of other symptoms can occur in children with UTI) new-onset Crohns

disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse

distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps

Mittelschmerz pelvic inflammatory disease ectopic pregnancy

In adults

regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath

hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis

in women pelvic inflammatory disease ectopic pregnancy endometriosis

torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)

In elderly

diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia

leaking aortic aneurysm

Management

Inflamed appendix removal by open surgery

Before surgery

The treatment begins by keeping the patient from eating or drinking in preparation for

surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and

thus reduce the spread of infection in the abdomen and postoperative complications in the

abdomen or wound Equivocal cases may become more difficult to assess with antibiotic

treatment and benefit from serial examinations If the stomach is empty (no food in the

past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be



used

Pain management

Pain from appendicitis can be severe Strong pain medications (ie narcotic pain

medications) are recommended for pain management prior to surgery Morphine is

generally the standard of care in adults and children in the treatment of pain from

appendicitis prior to surgery

In the past (and in some medical textbooks that are still published today) it has been

commonly accepted that pain medication no t be given until the surgeon has the chance to

evaluate the patient so as to not corrupt the findings of the physical examination This

line of practice combined with the fact that surgeons may sometimes take hours to come

to evaluate the patient especially if he or she is in the middle of surgery or has to drive in

from home often leads to a situation that is ethically questionable at best More recently

due to better understanding of the importance of pain control in patients it has been

shown that the physical examination is actually not that dramatically disturbed when pain

medication is given prior to medical evaluation Individual hospitals and clinics have

adapted to this new approach of pain management of appendicitis by developing a

compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20

to 30 minutes before active pain management is initiated Many surgeons also advocate

this new approach of providing pain management immediately rather than only after

surgical evaluationSurgery

thumb|The stitches on a patient the day after having his appendix removed by surgeryThe

surgical procedure for the removal of the appendix is called an appendicectomy (also

known as an appendectomy ) Often now the operation can be performed via a laparoscopic

approach or via three small incisions with a camera to visualize the area of interest in the

abdomen If the findings reveal suppurative appendicitis with complications such as

rupture abscess adhesions etc conversion to open laparotomy may be necessary An

open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron

diagonal incision is used most commonly

In March 2008 an American woman had her appendix removed via her vagina in a medical

first



According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic

and open procedures laparoscopic procedures seem to have various advantages over the

open procedure Wound infections were less likely after laparoscopic appendicectomy

than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to

421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic

procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9

mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened

by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after

laparoscopic procedures than after open procedures While the operation costs of

laparoscopic procedures were significantly higher the costs outside hospital were

reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups

There is debate whether emergency appendicectomy (within 6 hours of admission)

reduces the risk of perforation or complication versus urgent appendicectomy (greater

than 6 hours after admission) According to a retrospective case review study no

significant differences in perforation rate among the two groups were noted (P=397)

Various complications (abscess formation re-admission) showed no significant

differences (P=0667 0999) According to this study beginning antibiotic therapy and

delaying appendicectomy from the middle of the night to the next day does not

significantly increase the risk of perforation or other complications This finding is

important not simply for the convenience of the surgeons and staff involved but for the

fact that there have been other studies that have shown that surgeries taking place during

the night when people may be more tired and there are fewer staff available have higher

rates of surgical complications These findings may fit a theory that acute (typical)

appendicitis and suppurative (atypical) appendicitis are two distinct disease processes

Findings at the time of surgery suggest that perforation occurs at the onset of symptoms

in atypical cases(1)

Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in

complicated cases

After surgery

Hospital lengths of stay typically range from overnight to a few days but can be a few



weeks if complications occur

Prognosis Most appendicitis patients recover easily with surgical treatment but complications can

occur if treatment is delayed or if peritonitis occurs Recovery time depends on age

condition complications and other circumstances including the amount of alcohol

consumption but usually is between 10 and 28 days For young children (around 10 years

old) the recovery takes three weeks

The real possibility of life-threatening peritonitis is the reason why acute appendicitis

warrants speedy evaluation and treatment The patient may have to undergo a medical

evacuation Appendectomies have occasionally been performed in emergency conditions

(ie outside of a proper hospital) when a timely medical evaluation was impossible

Typical acute appendicitis responds quickly to appendectomy and occasionally will

resolve spontaneously If appendicitis resolves spontaneously it remains controversial

whether an elective interval appendectomy should be performed to prevent a recurrent

episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is

more difficult to diagnose and is more apt to be complicated even when operated early In

either condition prompt diagnosis and appendectomy yield the best results with full

recovery in two to four weeks usually Mortality and severe complications are unusual but

do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when

appendix is not removed early during infection and omentum and intestine get adherent to

it forming a palpable lump During this period operation is risky unless there is pus

formation evident by fever and toxicity or by USG Medical management treats the

condition

An unusual complication of an appendectomy is stump appendicitis inflammation

occurs in the remnant appendiceal stump left after a prior incomplete appendectomy



The appendix is a long diverticulum that extends from the

inferior tip of the cecum5 Its lining is interspersed with

lymphoid follicles3 Most of the time the appendix has an

intraperitoneal location (either anterior or retrocecal) and

thus may come in contact with the anterior parietal peritoneum when it is inflamed Up to 30 percent of the time

the appendix may be hidden from the anterior peritoneum by being in a pelvic retroileal or retrocolic

(retroperitoneal retrocecal) position6 The hidden position of the appendix notably changes the clinical

manifestations of appendicitis

Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis Obstruction has

multiple causes including lymphoid hyperplasia (related to viral illnesses including upper respiratory infection

mononucleosis gastroenteritis) fecaliths parasites foreign bodies Crohns disease primary or metastatic cancer

and carcinoid syndrome Lymphoid hyperplasia is more common in children and young adults accounting for the

increased incidence of appendicitis in these age groups15

History and Physical Examination

Abdominal pain is the most common symptom of appendicitis 3 In multiple studies3-5 specific characteristics of the

abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis ( Table

1) A thorough review of the history of the abdominal pain and of the patients recent genitourinary gynecologic

and pulmonary history should be obtained

Anorexia nausea and vomiting are symptoms that are commonly associated with acute appendicitis The classic

history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50

percent of patients1 Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis1

TABLE 2 Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis

Symptomsign Positive likelihood ratio (LR+) Symptomsign

Negativelikelihoodratio (LR-)

Right lower quadrant

(RLQ) pain

80 RLQ painsect 0 to 028dagger

Pain migration 32 No similar painpreviously||

03

Pain before vomiting 28 Pain migration 05

Anorexia nausea andvomiting

Much lower LR+ than RLQ pain painmigration and pain before vomiting

Guarding 0 to 054dagger

Rigidity 376 Rebound tenderness 0 to 086dagger

Psoas sign 238 Fever rigidity and

--Onset of symptoms typically within past 24 to36 hoursInformation from references 3 through 5



psoas signpara


Fever 19Dagger


































































Laboratory Tests














specificities








appendicitis






purpura
















































Treatment












Better forchildren

appendix









Complications

































Final Comment














Imaging














normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition





psoas signpara


Fever 19Dagger


































































Laboratory Tests














specificities








appendicitis






purpura
















































Treatment












Better forchildren

appendix









Complications

































Final Comment














Imaging














normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition
















































Laboratory Tests














specificities








appendicitis






purpura
















































Treatment












Better forchildren

appendix









Complications

































Final Comment














Imaging














normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition















































Treatment












Better forchildren

appendix









Complications

































Final Comment














Imaging














normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition







Complications

































Final Comment














Imaging














normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition


















Final Comment














Imaging














normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition








Imaging














normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition
















normal cecal apex










Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition












Acute cholecystitis

























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition



























top-health-sitecom



wwwaskcom



Healthlinecom






HealthKosmixcom











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition











Amazoncombooks























patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition








patientmdash












Other signs are




of the abdomen

Psoas sign




Obturator sign



the hypogastrium


















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition




















controls






appendicitis












Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition







Ultrasound










Computed tomography































Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition






























Alvarado score





In children









In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition











In adults





In elderly



Management


Before surgery









used

Pain management




























first






























complicated cases

After surgery

























condition





used

Pain management




























first






























complicated cases

After surgery

























condition
































complicated cases

After surgery

























condition


























condition



acute appendicitis[1]

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