Acute Appendicitis in Adults: Clinical Manifestations and Diagnosis

Acute appendicitis in adults: Clinical manifestations and diagnosis
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Official reprint from UpToDate www.uptodate.com 2013 UpToDate
Acute appendicitis in adults: Clinical manifestations and diagnosis Author Ronald F Martin, MD 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 common causes of the acute abdomen and one of the most frequent indications for an emergent abdominal surgical procedure worldwide [1,2]. The clinical manifestations and diagnosis of appendicitis in adults will be reviewed here. The management of appendicitis in adults and appendicitis in pregnancy and children are discussed separately. (See "Acute appendicitis in adults: Management" and "Acute appendicitis in pregnancy" and "Acute appendicitis in children: Clinical manifestations and diagnosis".) ANATOMY The vermiform appendix is located at the base of the cecum, near the ileocecal valve where the taenia coli converge on the cecum (figure 1) [3,4]. The appendix is a true diverticulum of the cecum. In contrast to acquired diverticular disease, which consists of a protuberance of a subset of the enteric wall layers, the appendiceal wall contains all of the layers of the colonic wall: mucosa, submucosa, muscularis (longitudinal and circular), and the serosal covering [5]. The appendiceal orifice opens into the cecum. Its blood supply, the appendiceal artery, is a terminal branch of the ileocolic 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 the site 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 appendix histologically distinct from the cecum [5]. These cells create a lymphoid pulp that aids immunologic function by increasing 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 undergoes atrophy with age [6]. EPIDEMIOLOGY Appendicitis occurs most frequently in the second and third decades of life. The incidence is approximately 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 hollow visceral organs. Initial inflammation of the appendiceal wall is followed by localized ischemia, perforation, and the development 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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Section Editor Martin Weiser, MD
Deputy Editor Rosemary B Duda, MD, MPH, FACS
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implicated but not always identified. A study of patients with appendicitis showed that there was elevated intraluminal pressure in only one-third of the patients with nonperforated appendicitis [12]. Appendiceal obstruction may be caused by fecaliths (hard fecal masses), calculi, lymphoid hyperplasia, infectious processes, and benign or malignant tumors. However, some patients with a fecalith have a histologically normal appendix 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 and intramural pressure, resulting in thrombosis and occlusion of the small vessels in the appendiceal wall, and stasis of lymphatic flow. As the appendix becomes engorged, the visceral afferent nerve fibers entering the spinal cord at T8-T10 are stimulated, leading to vague central or periumbilical abdominal pain [8]. Well-localized pain occurs later in the course when inflammation involves the adjacent parietal peritoneum. The mechanism of luminal obstruction varies depending upon the patient's age. In the young, lymphoid follicular hyperplasia due to infection is thought to be the main cause. In older patients, luminal obstruction is more likely to be caused by fibrosis, fecaliths, or neoplasia (carcinoid, adenocarcinoma, or mucocele). In endemic areas, parasites can cause 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. This results in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. As lymphatic and vascular compromise 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, while mixed infection is more common in late appendicitis [15]. Common organisms involved in gangrenous and perforated appendicitis include Escherichia coli, Peptostreptococcus, Bacteroides fragilis, and Pseudomonas species [16]. Intraluminal bacteria subsequently invade the appendiceal wall and further propagate a neutrophilic exudate. The influx of 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 and perhaps necrosis of the appendix, but not perforation. The type of luminal obstruction may be a predictor of perforation of an acutely inflamed appendix. Fecaliths were six times more common than true calculi in the appendix, but calculi were more often associated with perforated appendicitis or periappendiceal abscess (45 percent) than were fecaliths (19 percent). 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 abscess formation or diffuse peritonitis. The time course to perforation is variable. One study showed that 20 percent of patients developed perforation less than 24 hours after the onset of symptoms [17]. Sixty-five percent of patients in whom the appendix 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 of appendicitis [18,19]. The clinical presentation of acute appendicitis is described as a constellation of the following classic symptoms: ! 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 typically periumbilical 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 later in the course of illness. In many patients, initial features are atypical or nonspecific, and can include: ! Indigestion ! Flatulence ! Bowel irregularity ! Diarrhea ! Generalized malaise Because the early symptoms of appendicitis are often subtle, patients and clinicians may minimize their importance. The symptoms 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 a retrocecal appendix may cause a dull abdominal ache [21]. The location of the pain may also be atypical in patients who have the tip of the appendix located in the pelvis, which can cause tenderness below McBurney's point. Such patients may 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 101.0F (38.3C) may be present. The physical examination may be unrevealing in the very early stages of appendicitis since the visceral organs are not innervated with somatic pain fibers. However, as the inflammation progresses, involvement of the overlying parietal peritoneum causes localized tenderness in the right lower quadrant and can be detected on the abdominal examination. Rectal examination, although often advocated, has not been shown to provide additional diagnostic information in cases of appendicitis. In women, right adnexal area tenderness may be present on pelvic examination, and differentiating between tenderness of pelvic origin versus that of appendicitis may be challenging. High-grade fever (>101.0F/38.3C) 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 the appendix does not come into contact with the anterior parietal peritoneum (figure 1) [21]. The rectal and/or pelvic examination is more likely to elicit positive signs than the abdominal examination. Tenderness may be more prominent on pelvic examination, and may be mistaken for adnexal tenderness. Several findings on physical examination have been described to facilitate diagnosis, but these findings pre-dated definitive imaging for appendicitis, and the wide variation in their sensitivity and specificity suggests that they be used with 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: ! McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus [22]. (Sensitivity 50 to 94 percent; specificity 75 to 86 percent [23-25]). ! Rovsing's sign refers to pain in the right lower quadrant with palpation of the left lower quadrant. This sign is also called 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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! The psoas sign is associated with a retrocecal appendix. This is manifested by right lower quadrant pain with passive right hip extension. The inflamed appendix may lie against the right psoas muscle, causing the patient to shorten the muscle by drawing up the right knee. Passive extension of the iliopsoas muscle with hip extension causes right lower quadrant pain. (Sensitivity 13 to 42 percent; specificity 79 to 97 percent [27,30,31]). ! The obturator sign is associated with a pelvic appendix. This test is based on the principle that the inflamed appendix may lay against the right obturator internus muscle. When the clinician flexes the patient's right hip and knee 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 this assessment. Laboratory findings A mild leukocytosis (white blood cell count >10,000 cells/microL) is present in most patients with acute appendicitis [32]. Approximately 80 percent of patients have a leukocytosis and a left shift (increase in total WBC count, bands [immature neutrophils], and neutrophils) in the differential [33-35]. The sensitivity and specificity of an elevated 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 the illness [35-37]. In comparison, mean WBC counts are higher in patients with a gangrenous (necrotic) or perforated appendix [38]: ! 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) Mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been noted to be a marker for appendiceal perforation with a sensitivity of 70 percent and a specificity of 86 percent [39]. This compares favorably with a sensitivity and specificity of an elevated WBC of 80 percent and 55 percent respectively. Imaging studies Computed tomography findings The following findings suggest acute appendicitis on standard abdominal computed tomography (CT) scanning with contrast including (image 1 and image 2) [40-42]: ! 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) 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: ! 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 acute abdominal and pelvic pain during pregnancy (image 6) [45,46]. A normal appendix is visualized as a tubular structure less than or equal to 6 mm in diameter and filled with air and/or oral contrast material [47]. An enlarged fluid-filled appendix (>7 mm in diameter) is considered an abnormal finding, while an appendix with a diameter of 6 to 7 mm is considered an inconclusive finding [47]. (See "Approach to abdominal pain and the acute abdomen in pregnant and postpartum women" and "Acute appendicitis in pregnancy".) DIAGNOSIS The diagnosis of acute appendicitis is generally made from the history and clinical examination; the diagnosis is supported by the laboratory and/or imaging findings. The patient presenting with acute abdominal pain should undergo a thorough physical examination, including a digital rectal examination. Women should undergo a pelvic examination. (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 have found the diagnostic accuracy of clinical evaluation alone to be 75 to 90 percent [18,30,49,50]. The diagnostic accuracy of the clinical examination may depend on the experience of the examining clinician [51-56]. Patients in whom appendicitis is considered to be extremely likely after assessment by an experienced clinician should proceed directly to appendectomy 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]: ! 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 and the resulting changes in the physical examination. (See "Acute appendicitis in pregnancy".) No single feature or combination of features is a highly accurate predictor of acute appendicitis, although prediction rules based 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 clinical and laboratory variables. The Alvarado score is the most widely used diagnostic aid for the diagnosis of appendicitis and has 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 patients with clinically suspicious appendicitis, whom 53 patients (20 percent) had a final diagnosis of appendicitis, the low modified Alvarado score was less sensitive compared with unstructured clinical judgement (72 versus 93 percent sensitivity) [65]. The modified Alvarado scale assigns a score to each of the following diagnostic criteria: ! 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 >37.5C (1 point) ! Leukocytosis (2 points) A low Alvarado score (<5) has more diagnostic utility to rule out appendicitis than a high score (#7) does to rule in the diagnosis. In a systematic review of 42 retrospective and prospective studies that included over 8300 patients with suspected acute appendicitis and/or right iliac fossa pain, overall 99 percent of patients with acute appendicitis had a
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score of #5 [66]. However, a high score (#7) alone had poor diagnostic predictive utility as the overall sensitivity was 82 percent and the specificity was 81 percent. The Alvarado score was most accurate in men but over-predicted the probability of acute appendicitis in women in all risk groups. A management guide based upon total points includes: ! A patient with a score of 0 to 3 could be considered to have a low risk of appendicitis and would be discharged with advice to return if there was no improvement in symptoms, subject to social circumstances. ! A patient with a score of 4 to 6 would be admitted for observation and re-examination. If the score remains the same after 12 hours, operative intervention is recommended. ! 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, then appendectomy if indicated by the intraoperative findings. The surgical management of appendicitis during pregnancy is discussed separately. (See "Acute appendicitis in pregnancy".) Because of the diagnostic challenges of diagnosing acute appendicitis in women, some authors have advocated diagnostic laparoscopy to minimize the high false-negative rate in women regardless of score [64], while others have suggested using CT scans to help with the diagnosis of patients with an equivocal clinical presentation and a score between 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 systematic review of several published scoring systems showed a diagnostic sensitivity of 53 to 99 percent and specificity of 30 to 99 percent [71]. As a general rule, the addition of these decision aids to clinical judgment has the potential to improve specificity and lead to lower false-positive rates in diagnosis of acute appendicitis, but decision aids cannot definitively determine or exclude the possibility of appendicitis [71]. DIAGNOSTIC EVALUATION Imaging Imaging modalities such as computed tomography (CT) and ultrasonography (US) are increasingly used to support the clinical diagnosis of acute appendicitis. Although some studies suggest that the increased use of imaging has decreased the nontherapeutic appendectomy rate (NAR) for acute appendicitis [72,73], many surgeons will and should 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 for acute appendicitis (image 7 and image 8); the diagnostic accuracy of an experienced surgeon is comparable to CT scan imaging in the assessment of patients with an equivocal presentation of acute appendicitis [18,49,50,52]. However, in a retrospective 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 2763 patients found that the sensitivity, specificity, positive predictive value, and negative predictive value of preoperative evaluations included [50]: ! 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
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Diagnostic imaging is unnecessary when the clinical diagnosis of acute appendicitis is nearly certain for either presence or absence of appendicitis. Diagnostic imaging should be performed and is most likely to alter treatment when the diagnosis 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. These populations are more likely to present with unclear symptoms such as vague abdominal pain. (See "Acute appendicitis in children: 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 to have a nontherapeutic appendectomy for acute appendicitis [73,75-78], and therefore women may benefit from a preoperative CT scan if the diagnosis is uncertain (image 1 and image 2). A retrospective review of 1425 consecutive patients undergoing an appendectomy found that adult women evaluated with a preoperative CT scan had a significantly lower 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: ! Standard abdominal-pelvic CT with IV and oral contrast ! Focused appendiceal CT with rectal contrast ! Non-contrast CT In most clinical settings, if there is sufficient diagnostic concern and uncertainty to warrant a CT scan to diagnose appendicitis, a full abdominal-pelvic CT with IV and oral contrast should be performed or a decision should be made to proceed 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 CT scan (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]: ! 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) The sensitivity and specificity of CT with IV and oral contrast for acute appendicitis is in the range of 91 to 98 and 75 to 93 percent, respectively [18,49,61,74,79-81]. Air in the appendix or a contrast-filled lumen in a normal appearing appendix virtually excludes the diagnosis. However, a nonvisualized appendix does not rule out appendicitis. This is particularly important to remember in patients who have had symptoms for a short duration, since only minimal inflammatory 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 alternative diagnosis is found in up to 15 percent of patients [74]. Furthermore, a CT scan can assist in the treatment plan for patients with a palpable abdominal mass, such as those in whom an appendiceal phlegmon or abscess may have developed. 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 scan involves radiation exposure and intravenous contrast, with the potential for contrast-induced renal nephropathy. Cost and
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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 cuts through the right iliac fossa. Because full oral contrast is not given, the scan can be performed within 15 minutes. Rectal contrast provides good visualization of the pericecal region without the need to wait for oral contrast to reach the right lower 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 acute appendicitis were as follows [40]: ! Right lower abdominal quadrant fat stranding (100 percent sensitivity) ! Focal cecal thickening (69 percent specificity) ! Adenopathy (63 percent sensitivity) One study reported that a focal appendiceal CT had 98 percent accuracy and sensitivity with rectal contrast along a limited 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 requires personnel to administer rectal contrast and a radiologist on site for the verification of positioning. In addition, an appendiceal CT scan only evaluates the appendix, and the images may be unrevealing in the presence of other abdominal pathology. Unenhanced CT The administration of contrast for imaging adds time, expense, and risk of an allergic reaction. A number of studies have suggested that adequate imaging can be obtained without contrast. In various reports, unenhanced CT had a sensitivity of 88 to 96 percent, specificity of 91 to 98 percent, and diagnostic accuracy of 94 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 if the 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, potentially diminishing 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 patients where there is sufficient diagnostic uncertainty to warrant a CT scan for appendicitis, a full abdominal-pelvic CT with IV and oral contrast should be performed or a decision should be made to proceed to the operating room for abdominal exploration. Ultrasonography Ultrasound (US) is reliable to confirm the clinical diagnosis of acute appendicitis, but is not reliable 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 a sensitivity, specificity, negative predictive value and positive predictive value of 98 percent [43,44]. In various reports, the sensitivity 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: ! Results may be obtained more efficiently (institution and practitioner dependent) ! No radiation exposure
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! No use of intravenous or intestinal contrast agents Disadvantages of US compared with CT imaging include: ! 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 Imaging costs The use of preoperative imaging studies in the diagnosis of acute appendicitis has increased with time, 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 the assumption that it decreases the rates of perforated appendicitis as well as nontherapeutic appendectomies [86,87]. In two studies that performed cost analysis, one showed that the cost of a nontherapeutic appendectomy was 16 times more expensive than a focused appendiceal CT scan, while another reported that an appendectomy was 22 times more expensive than nonenhanced CT scanning, implying cost savings if a reduction in nontherapeutic appendectomy rates could be achieved [84,88]. However, in one retrospective review, most patients undergoing a nontherapeutic appendectomy had a preoperative CT scan, and more than 50 percent of those patients had CT interpretations that were positive for, or could not exclude, acute appendicitis [73]. Several studies have failed to demonstrate a significant reduction in the overall institutional rates for nontherapeutic appendectomies despite the increased use of CT scan over time [61,74,75,77,79,89-91]. Results of studies that included analysis of perforated appendicitis are mixed. One study showed an observed rate of appendiceal perforation of 9 percent in patients who underwent routine CT imaging compared with 25 percent in patients in whom CT scanning was not used [77]. Other studies have demonstrated a fairly constant rate of perforated appendix over time despite the increased 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 therapeutic appendectomy was performed; as a result, the cost savings depend upon an absolute rate reduction for nontherapeutic appendectomies [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 or combination 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 the diagnosis of appendicitis. A mild leukocytosis and a left shift (increase in total white blood cell count, bands [immature neutrophils], 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 appendiceal perforation with a sensitivity of 70 percent and a specificity of 86 percent [39], the test is not discriminatory and generally not helpful in the evaluation of patients suspected of acute appendicitis. Exploratory laparotomy/laparoscopy The acceptable nontherapeutic appendectomy rate (NAR) varies depending upon the age and sex of the patient. For example, in young healthy males with right lower quadrant pain, the negative appendectomy rate (NAR) should be less than 10 percent, while a rate that approaches 20 percent is reasonable in young women in whom other pelvic processes can make accurate diagnosis more difficult (eg, pelvic inflammatory diseases, tubo-ovarian abscess) [83,93]. No significant difference in NAR was noted in comparing laparoscopic and open appendectomy [73]. A low NAR has
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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 can mimic 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 abscess formation or diffuse peritonitis. The time course to perforation is variable. One study showed that 20 percent of patients developed perforation less than 24 hours after the onset of symptoms [17]. Sixty-five percent of patients in whom the appendix perforated had symptoms for longer than 48 hours. A perforated appendix must be considered in a patient whose temperature exceeds 103.0F (39.4C), the WBC count is greater 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 can be virtually identical to those of acute appendicitis. Right-sided diverticulitis occurs in only 1.5 percent of patients in Western countries, but is more common in Asian populations (accounting for as many as 75 percent of cases of diverticulitis). Patients with right-sided diverticulitis tend to be younger than those with left-sided disease and often are misdiagnosed with acute appendicitis. Computed tomographic (CT) scanning of the abdomen with IV and oral contrast is the diagnostic test of choice in patients suspected of having acute diverticulitis. (See "Clinical manifestations and diagnosis 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's diverticulum is a congenital remnant of the omphalomesenteric duct and is located on the small intestine two feet from the ileocecal valve [95,96]. Meckel's diverticulitis should be included in the differential diagnosis as the small bowel may migrate into the right lower quadrant and mimic the symptoms of appendicitis. If an inflamed appendix is not found on abdominal exploration for acute appendicitis, the surgeon should search for an inflamed Meckel's diverticulum. (See "Meckels 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 clinical manifestations of acute yersiniosis include abdominal pain, fever, nausea and/or vomiting. Yersiniosis cannot be readily distinguished clinically from other causes of acute diarrhea that present with these symptoms. However, localization of abdominal 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 may be confused with acute appendicitis. At surgery, findings include visible inflammation around the appendix and terminal ileum and inflammation of the mesenteric lymph nodes; the appendix itself is generally normal. Yersinia can be cultured from the appendix and involved lymph nodes. (See "Clinical manifestations and diagnosis of Yersinia infections", section on 'Pseudoappendicitis'.) Crohn's disease Crohn's disease can present with symptoms similar to appendicitis, particularly when localized to the 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 Crohns disease can mimic acute appendicitis and may be 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/or clinical 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 in reproductive age women and typically result from upper genital tract infection. Tubo-ovarian abscess is usually a complication 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 fevers or chills, and not all women present in an acute fashion. Clinical history and CT imaging can help differentiate TOA from acute 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 PID although the character of the pain may be quite subtle. The recent onset of pain that worsens during coitus or with jarring movement may be the only presenting symptom of PID; the onset of pain during or shortly after menses is particularly suggestive. On physical examination, only about one-half of patients with PID have fever. Abdominal examination reveals diffuse tenderness greatest in the lower quadrants, which may or may not be symmetrical. Rebound tenderness and decreased bowel sounds are common. On pelvic examination, the finding of a purulent endocervical discharge and/or acute cervical motion and adnexal tenderness with bimanual examination is strongly suggestive of PID. Clinical history and CT imaging can help differentiate PID from acute appendicitis (See "Clinical features and diagnosis of pelvic inflammatory disease".) Ruptured ovarian cyst Rupture of an ovarian cyst is a common occurrence in women of reproductive age and may be associated with the sudden onset of unilateral lower abdominal pain. The pain often begins during strenuous physical activity, such as exercise or sexual intercourse and may be accompanied by light vaginal bleeding due to a drop in secretion of ovarian hormones and subsequent endometrial sloughing. Blood from the rupture site may seep into the ovary, which can cause pain from stretching of the ovarian cortex, or it may flow into the abdomen, which has an irritant effect on the peritoneum. Serous or mucinous fluid released upon cyst rupture is not very irritating; the patient may remain asymptomatic despite accumulation of a large volume of intraperitoneal fluid. On the other hand, spillage of sebaceous 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 ovary from the effects of abdominal trauma. Rupture of a simple cyst usually results in only mild to moderate tenderness on deep palpation. If the cyst has not completely collapsed, an adnexal mass may be palpable on bimanual examination. At the other end of the spectrum, release of sebaceous material or blood into the abdomen may cause overt peritonitis with rigidity 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 CT imaging can help differentiate a ruptured ovarian cyst from acute appendicitis (image 11 and image 12). (See "Evaluation and management of ruptured ovarian cyst".) Mittelschmerz Mittelschmerz refers to midcycle pain in an ovulatory woman caused by normal follicular enlargement just prior to ovulation or to normal follicular bleeding at ovulation. The pain is typically mild and unilateral; it occurs midway between menstrual periods and lasts for a few hours to a couple of days. Fluid or blood is released from the ruptured egg follicle and can cause irritation of the lining of the abdominal wall. (See "Physiology of the normal menstrual 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 (picture 3). Expedient diagnosis is important to preserve ovarian function and prevent adverse sequelae. However, the diagnosis can 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 of nausea and vomiting. Fever, although an uncommon finding in ovarian torsion, may be a marker of necrosis, particularly in the setting of an increased white blood cell count. Clinical history and CT imaging can help differentiate the diagnosis from 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 (picture 5). Common symptoms of endometriosis include pelvic pain (which is usually chronic and often more severe during menses or 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 most common is tenderness upon palpation of the posterior fornix. Ultrasound is mostly useful for diagnosing ovarian endometriomas; it lacks adequate resolution for visualizing adhesions and superficial peritoneal/ovarian implants, which are more common than endometriomas. (See "Pathogenesis, clinical features, and diagnosis of endometriosis".) Ovarian hyperstimulation syndrome Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of ovulation induction therapy and may be accompanied by or mistaken for cyst rupture. Clinical findings include bloating, 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 hypovolemic shock. Marked hemoconcentration, increased blood viscosity, and thromboembolic phenomena including disseminated intravascular coagulation occur in the most severe cases. (See "Classification and treatment of ovarian hyperstimulation syndrome".) Ectopic pregnancy Ectopic pregnancy has clinical symptoms and sonographic features similar to those of a ruptured ovarian cyst. In women with acute pelvic pain or abnormal vaginal bleeding, a positive pregnancy test strongly suggests the presence of an ectopic pregnancy if an intrauterine pregnancy cannot be visualized sonographically. If an intrauterine 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, and management of ectopic pregnancy", section on 'Heterotopic pregnancy'.) Acute endometritis Acute endometritis occurs after an obstetrical delivery or, rarely, after an invasive uterine procedure. The diagnosis is largely based upon the presence of fever, gradual onset of uterine tenderness, foul uterine discharge, and leukocytosis in an at-risk setting. (See "Postpartum endometritis" and "Endometritis unrelated to pregnancy".) Urologic conditions Renal colic Pain is the most common symptom and varies from a mild and barely noticeable ache to discomfort that is so intense that it requires parenteral analgesics. The pain typically waxes and wanes in severity, and develops in waves or paroxysms that are related to movement of the stone in the ureter and associated ureteral spasm. Paroxysms of severe pain usually last 20 to 60 minutes. Pain is thought to occur primarily from urinary obstruction with distention of the renal capsule. (See "Diagnosis and acute management of suspected nephrolithiasis in adults" and "Acute management 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 tunica vaginalis. If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently broad-based or absent, the testis may torse (twist) on the spermatic cord, potentially producing ischemia from reduced arterial inflow and venous outflow obstruction. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion' and "Evaluation of the acute scrotum in adults", section on 'Testicular torsion'.) Epididymitis Epididymitis occurs more frequently among late adolescents, but also occurs in younger boys who deny sexual activity and is most common cause of scrotal pain in adults in the outpatient setting. Several factors may predispose postpubertal boys to develop subacute epididymitis, including sexual activity, heavy physical exertion, and direct trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in prepubertal boys is associated with structural anomalies of the urinary tract. In acute infectious epididymitis, palpation reveals induration and swelling of the involved epididymis with exquisite tenderness. More advanced cases often present with testicular swelling and pain (epididymoorchitis) 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 the anterosuperior aspect of the testis (an embryologic remnant of the Mllerian duct system). The appendix epididymis is a vestigial remnant of the Wolffian duct that is located at the head of the epididymis. The pedunculated shape of these appendages predisposes them to torsion, which can produce scrotal pain that ranges from mild to severe. Most cases of torsion of the appendix testis occur between the ages of 7 and 14 years, and rarely occur in adults. (See "Causes of scrotal 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 Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level 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 to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) ! Basics topics (see "Patient information: Appendicitis in adults (The Basics)"). SUMMARY AND RECOMMENDATIONS Appendicitis is one of the most common causes of the acute abdomen and one of the most frequent indications for an emergent abdominal surgical procedure worldwide. ! The tip of the appendix can be found in a retrocecal or pelvic location, as well as medial, lateral, anterior or posterior to the cecum. Anatomic variability can complicate the diagnosis, as clinical presentation will reflect the anatomic position of the appendix. (See 'Anatomy' above.) ! Appendiceal obstruction plays a role in the pathogenesis of appendicitis, but it is not required for the development of appendicitis. (See 'Pathogenesis' above.) ! The classic symptoms of appendicitis include right lower quadrant abdominal pain, anorexia, fever, nausea and vomiting. The abdominal pain is initially periumbilical in nature with subsequent migration to the right lower quadrant as the inflammation progresses (see 'Clinical manifestations' above). Patients with appendicitis can also
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present with atypical or nonspecific symptoms, such as indigestion, flatulence, bowel irregularity, and generalized malaise; and not all patients will have migratory abdominal pain. ! The constellation of findings from history, physical examination, and laboratory studies will usually lead an experienced examiner to the correct diagnosis of appendicitis without diagnostic imaging (see 'Diagnosis' above). A clinical diagnosis can be more challenging in women, who may benefit from the addition of radiologic imaging when the diagnosis is unclear. ! Diagnostic imaging should be performed when the diagnosis of appendicitis is suspected but unclear (eg, elderly patients, patients with comorbid illnesses, women of childbearing age). We perform a standard abdominal CT scan with intravenous and oral contrast. (See 'Standard CT scan with contrast' above.) ! The differential diagnosis of right lower quadrant abdominal pain includes inflammatory disease processes (eg, Crohns disease, ruptured cyst), infectious diseases (eg, acute ileitis, tubo-ovarian abscess), and obstetrical conditions (eg, ectopic pregnancy). (See 'Differential diagnosis' above.) 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 editorin-chief for Emergency Medicine and as a section editor and author for Adult Trauma. We would also like to acknowledge Dr. Carrie Black, who contributed to an earlier version of this topic review Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Williams GR. Presidential Address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg 1983; 197:495. 2. Fitz, RH. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Am J Med Sci 1886; 92:321. 3. Jaffe, BM, Berger, DH. The Appendix. In: Schwartz Principles of Surgery, 8th ed, Schwartz, SI, Brunicardi, CF (Ed), McGraw-Hill Health Pub. Division, New York 2005. 4. Buschard K, Kjaeldgaard A. Investigation and analysis of the position, fixation, length and embryology of the vermiform appendix. Acta Chir Scand 1973; 139:293. 5. Mulholland, MW, Lillemoe, KD, Doherty, GM, et al. Greenfield's Surgery, 4th ed, Lippincott Williams & Wilkins, Philadelphia, PA 2005. 6. Kumar, V, Abbas, AK, Fausto, N. Robbins and Cotran: Pathologic Basis of Disease, 7th ed, Saunders Elsevier, Philadelphia, PA 2007. 7. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132:910. 8. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215:337. 9. Burkitt DP. The aetiology of appendicitis. Br J Surg 1971; 58:695. 10. Butler C. Surgical pathology of acute appendicitis. Hum Pathol 1981; 12:870. 11. Miranda R, Johnston AD, O'Leary JP. Incidental appendectomy: frequency of pathologic abnormalities. Am Surg 1980; 46:355. 12. Arnbjrnsson E, Bengmark S. Obstruction of the appendix lumen in relation to pathogenesis of acute appendicitis. Acta Chir Scand 1983; 149:789. 13. Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet 1990; 171:185.
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14. Jones BA, Demetriades D, Segal I, Burkitt DP. The prevalence of appendiceal fecaliths in patients with and without appendicitis. A comparative study from Canada and South Africa. Ann Surg 1985; 202:80. 15. Lau WY, Teoh-Chan CH, Fan ST, et al. The bacteriology and septic complication of patients with appendicitis. Ann Surg 1984; 200:576. 16. Bennion RS, Baron EJ, Thompson JE Jr, et al. The bacteriology of gangrenous and perforated appendicitis-revisited. Ann Surg 1990; 211:165. 17. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995; 221:278. 18. Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg 2001; 136:556. 19. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology 1997; 202:139. 20. Chung CH, Ng CP, Lai KK. Delays by patients, emergency physicians, and surgeons in the management of acute appendicitis: retrospective study. Hong Kong Med J 2000; 6:254. 21. Guidry SP, Poole GV. The anatomy of appendicitis. Am Surg 1994; 60:68. 22. McBurney, C. Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J 1889; 50:676. 23. Golledge J, Toms AP, Franklin IJ, et al. Assessment of peritonism in appendicitis. Ann R Coll Surg Engl 1996; 78:11. 24. Andersson RE, Hugander AP, Ghazi SH, et al. Diagnostic value of disease history, clinical presentation, and inflammatory parameters of appendicitis. World J Surg 1999; 23:133. 25. Lane R, Grabham J. A useful sign for the diagnosis of peritoneal irritation in the right iliac fossa. Ann R Coll Surg Engl 1997; 79:128. 26. Rovsing, NT. Indirektes Hervorrufen des typischen Schmerzes an McBurney's Punkt. Ein Beitrag zur diagnostik der Appendicitis und Typhlitis. Zentralblatt fr Chirurgie, Leipzig, 1907; 34:1257. 27. Izbicki JR, Knoefel WT, Wilker DK, et al. Accurate diagnosis of acute appendicitis: a retrospective and prospective analysis of 686 patients. Eur J Surg 1992; 158:227. 28. Alshehri MY, Ibrahim A, Abuaisha N, et al. Value of rebound tenderness in acute appendicitis. East Afr Med J 1995; 72:504. 29. Jahn H, Mathiesen FK, Neckelmann K, et al. Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis. Eur J Surg 1997; 163:433. 30. Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg 1984; 200:567. 31. John H, Neff U, Kelemen M. Appendicitis diagnosis today: clinical and ultrasonic deductions. World J Surg 1993; 17:243. 32. Silen, W. Cope's Early Diagnosis of the Acute Abdomen, 19th edition, Oxford University Press 1996. p.70. 33. Coleman C, Thompson JE Jr, Bennion RS, Schmit PJ. White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis. Am Surg 1998; 64:983. 34. Tehrani HY, Petros JG, Kumar RR, Chu Q. Markers of severe appendicitis. Am Surg 1999; 65:453. 35. Thompson MM, Underwood MJ, Dookeran KA, et al. Role of sequential leucocyte counts and C-reactive protein measurements in acute appendicitis. Br J Surg 1992; 79:822. 36. Grnroos JM, Grnroos P. Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis. Br J Surg 1999; 86:501. 37. Br J Surg 1999; 86:501. 38. Guraya SY, Al-Tuwaijri TA, Khairy GA, Murshid KR. Validity of leukocyte count to predict the severity of acute appendicitis. Saudi Med J 2005; 26:1945. 39. Sand M, Bechara FG, Holland-Letz T, et al. Diagnostic value of hyperbilirubinemia as a predictive factor for
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appendiceal perforation in acute appendicitis. Am J Surg 2009; 198:193. 40. Rao PM, Rhea JT, Novelline RA. Sensitivity and specificity of the individual CT signs of appendicitis: experience with 200 helical appendiceal CT examinations. J Comput Assist Tomogr 1997; 21:686. 41. Whitley S, Sookur P, McLean A, Power N. The appendix on CT. Clin Radiol 2009; 64:190. 42. Choi D, Park H, Lee YR, et al. The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiol 2003; 44:574. 43. Kessler N, Cyteval C, Gallix B, et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology 2004; 230:472. 44. Jeffrey RB Jr, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases. Radiology 1988; 167:327. 45. Spalluto LB, Woodfield CA, DeBenedectis CM, Lazarus E. MR imaging evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes. Radiographics 2012; 32:317. 46. Oto A, Ernst RD, Ghulmiyyah LM, et al. MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain. Abdom Imaging 2009; 34:243. 47. Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR imaging evaluation of acute appendicitis in pregnancy. Radiology 2006; 238:891. 48. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004; 91:28. 49. Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt) 2003; 4:231. 50. Park JS, Jeong JH, Lee JI, et al. Accuracies of diagnostic methods for acute appendicitis. Am Surg 2013; 79:101. 51. Kosloske AM, Love CL, Rohrer JE, et al. The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation. Pediatrics 2004; 113:29. 52. Morris KT, Kavanagh M, Hansen P, et al. The rational use of computed tomography scans in the diagnosis of 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 appendectomies. Am Surg 2000; 66:548. 60. Hale DA, Molloy M, Pearl RH, et al. Appendectomy: a contemporary appraisal. Ann Surg 1997; 225:252. 61. Ceydeli A, Lavotshkin S, Yu J, Wise L. When should we order a CT scan and when should we rely on the results 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 Elsevier, Philadelphia, PA 2007. 63. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15:557. 64. Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl 1994; 76:418. 65. Meltzer AC, Baumann BM, Chen EH, et al. Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis. Ann Emerg Med 2013; 62:126.
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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. 67. McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007; 25:489. 68. Horzi$ M, Salamon A, Kopljar M, et al. Analysis of scores in diagnosis of acute appendicitis in women. Coll Antropol 2005; 29:133. 69. Ohmann C, Franke C, Yang Q. Clinical benefit of a diagnostic score for appendicitis: results of a prospective interventional study. German Study Group of Acute Abdominal Pain. Arch Surg 1999; 134:993. 70. Enochsson L, Gudbjartsson T, Hellberg A, et al. The Feny-Lindberg scoring system for appendicitis increases positive predictive value in fertile women--a prospective study in 455 patients randomized to either laparoscopic or open 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. Health Technol Assess 2006; 10:1. 72. SCOAP Collaborative, Cuschieri J, Florence M, et al. Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 2008; 248:557. 73. Wagner PL, Eachempati SR, Soe K, et al. Defining the current negative appendectomy rate: for whom is preoperative computed tomography making an impact? Surgery 2008; 144:276. 74. Schuler JG, Shortsleeve MJ, Goldenson RS, et al. Is there a role for abdominal computed tomographic scans in appendicitis? Arch Surg 1998; 133:373. 75. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A populationbased analysis. JAMA 2001; 286:1748. 76. Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll Surg 2005; 201:933. 77. Jones K, Pea AA, Dunn EL, et al. Are negative appendectomies still acceptable? Am J Surg 2004; 188:748. 78. Wilson EB. Surgical evaluation of appendicitis in the new era of radiographic imaging. Semin Ultrasound CT MR 2003; 24:65. 79. Perez J, Barone JE, Wilbanks TO, et al. Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis. Am J Surg 2003; 185:194. 80. Gaitini D, Beck-Razi N, Mor-Yosef D, et al. Diagnosing acute appendicitis in adults: accuracy of color Doppler sonography and MDCT compared with surgery and clinical follow-up. AJR Am J Roentgenol 2008; 190:1300. 81. Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 2004; 141:537. 82. Rao PM, Rhea JT, Novelline RA, et al. Helical CT combined with contrast material administered only through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol 1997; 169:1275. 83. Ege G, Akman H, Sahin A, et al. Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis. Br J Radiol 2002; 75:721. 84. Lane MJ, Katz DS, Ross BA, et al. Unenhanced helical CT for suspected acute appendicitis. AJR Am J Roentgenol 1997; 168:405. 85. Lee SL, Ho HS. Ultrasonography and computed tomography in suspected acute appendicitis. Semin Ultrasound CT MR 2003; 24:69. 86. Romero J, Sanabria A, Angarita M, Varn JC. Cost-effectiveness of computed tomography and ultrasound in the diagnosis of appendicitis. Biomedica 2008; 28:139. 87. Morse BC, Roettger RH, Kalbaugh CA, et al. Abdominal CT scanning in reproductive-age women with right lower quadrant abdominal pain: does its use reduce negative appendectomy rates and healthcare costs? Am Surg 2007; 73:580. 88. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998; 338:141.
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89. Johansson EP, Rydh A, Riklund KA. Ultrasound, computed tomography, and laboratory findings in the diagnosis of appendicitis. Acta Radiol 2007; 48:267. 90. Rao PM, Rhea JT, Rattner DW, et al. Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates. Ann Surg 1999; 229:344. 91. DeArmond GM, Dent DL, Myers JG, et al. Appendicitis: selective use of abdominal CT reduces negative appendectomy rate. Surg Infect (Larchmt) 2003; 4:213. 92. Lin KH, Leung WS, Wang CP, Chen WK. Cost analysis of management in acute appendicitis with CT scanning under a hospital global budgeting scheme. Emerg Med J 2008; 25:149. 93. Colson M, Skinner KA, Dunnington G. High negative appendectomy rates are no longer acceptable. Am J Surg 1997; 174:723. 94. White JJ, Santillana M, Haller JA Jr. Intensive in-hospital observation: a safe way to decrease unnecessary appendectomy. Am Surg 1975; 41:793. 95. Lee TH, Kim JO, Kim JJ, et al. A case of intussuscepted Meckel's diverticulum. World J Gastroenterol 2009; 15:5109. 96. Banli O, Karakoyun R, Altun H. Ileo-ileal intussusception due to inverted Meckel's diverticulum. Acta Chir Belg 2009; 109:516. Topic 1386 Version 16.0
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GRAPHICS Variations in the position of the appendix
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Blood supply to the colon and rectum
The blood supply to the colon originates from the superior mesenteric artery and the inferior mesenteric artery. The blood supply to the rectum originates from the superior rectal artery.
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CT scan normal appendix
CT scan depicts a normal appendix. The figure on the left shows an appendiceal lumen containing air and wall thickness of 3 mm (yellow arrow). The figure on the right shows the tip of the normal appendix (green arrow) that measures 6 mm and no associated induration.
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CT scan acute appendicitis
The CT scan was obtained using oral and intravenous contrast from a patient who presented with right lower quadrant abdominal pain. These figures show an inflammed appendix that measures 21 mm in diameter and contains an appendicolith and fluid that 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.
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Normal appendix by ultrasound imaging
The gray scale ultrasound (A, and magnified in B) and Doppler image (C) of the appendix are projected in the transverse plane. Images A and B show a normal appendix measuring almost 6 mm in maximum transverse dimension (arrow). The appendix was compressible and no hyperemia was demonstrated (arrow) on the Doppler image (C). These findings are consistent with a normal appendix by ultrasound.
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Acute appendicitis ultrasound
The patient is a 19-year-old female who presented to the emergency department with right lower quadrant pain. The gray scale ultrasound of the appendix is projected in the longitudinal (A) and transverse planes (B). A noncompressible appendix measures almost 20 mm in diameter, consistent with a diagnosis of acute appendicitis. The echogenic 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.
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Appendicolith on abdominal films
This plain film of the abdomen reveals a 1.2 cm calcific density, an appendicolith. The patient presented with right lower quadrant pain and was diagnosed with acute appendicitis.
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Magnetic resonance image of appendicitis in pregnancy
T2 weighted magnetic resonance image of a woman with appendicitis at 9 weeks of gestation. The appendix was fluid-filled and measured 7 mm (arrow). The gestational sac (gs) is seen lower in the pelvis.
Courtesy of Deborah Levine, MD.
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CT scan equivocal appendicitis
The patient is a 56-year-old male who presents with right lower quadrant pain. The CT scan of the lower abdomen in the axial plane (A) and the magnified view of the appendix (B) show a normal sized appendix with surrounding induration (red arrow). The periappendiceal induration raises the possibility of appendicitis. The associated thickening of the posterior peritoneum (orange arrow) suggests an acute process in the right lower quadrant. However, the epicenter of induration (yellow arrow in A and B) in the region of the tip of the liver (L) and ascending colon (C) suggests that the process likely originates in that region. Thus the process around the appendix is secondary and not primary to the appendix.
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Ultrasound equivocal appendicitis
The gray scale ultrasound of the appendix is projected in the longitudinal (A) and transverse planes (B). The appearance of the appendix is near normal except for a diameter that measures 7.6 mm in the long axis, and a diameter that measures between 7 and 9 mm in the transverse plane. Since this diameter should be 6 mm or less, the diagnosis of appendicitis is entertained. There is no loculated fluid around the appendix and no free fluid present in the peritoneal cavity. The echogenic line of the mucosa and submucosa is intact and the lumen is distended with complex material (arrow). The findings of the enlarged diameter with no other specific pathognomonic features make the diagnosis of acute appendicitis equivocal.
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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 (white arrows) and is seen in relationship to the cecum (COE). Fluid filled small bowel (DD) and iliac vessels (VI) are also indicated.
Courtesy of Christoph F Dietrich, MD.
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Doppler ultrasound of appendicitis
In this doppler ultrasound image of appendicitis, the appendix appears edematous (9 x 8 mm) and hypervascular. The layers of the wall are still detectable. Continued inflammation may be followed by localized ischemia (which may be visualized by color Doppler imaging) and necrosis. Sonographic findings were confirmed at surgery.
Courtesy of Christoph F Dietrich, MD.
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Tuboovarian abscess
Gross intraoperative photograph of a left tuboovarian abscess in a patient with pelvic inflammatory disease.
Courtesy of Mitchel Hoffman, MD.
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Ruptured ovarian cyst
Computed tomography. Arrows indicate free blood within peritoneal cavity surrounding liver and spleen.
Courtesy of William J Mann, Jr, MD.
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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.
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Ovarian and tubal torsion demonstrating marked vascular engorgement as well as increased size and distension
Anatomy was restored and both structures were salvaged despite non-viable appearance.
Reproduced with permission from: Pediatric and Adolescent Gynecology, 6th ed, Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. Copyright 2012 Lippincott Williams & Wilkins.
http://www.lww.com
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Tubal torsion demonstrating severe distension of the distal tube
http://www.lww.com
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Enlarged left ovary found torsed upon laparotomy demonstrating a dark, dusky appearance secondary to venous lymphatic congestion in the setting of continued arterial perfusion
http://www.lww.com
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Peritoneal endometriosis
The peritoneum in this woman with endometriosis is studded with reddish, irregularly shaped implants.
Reprinted with permission. Copyright 1990 Syntex Laboratories, Inc. All rights reserved.
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Acute Appendicitis in Adults: Clinical Manifestations and Diagnosis

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Acute Appendicitis in Adults: Clinical Manifestations and Diagnosis

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Acute appendicitis in adults: Clinical manifestations and diagnosis

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Section Editor Martin Weiser, MD

Deputy Editor Rosemary B Duda, MD, MPH, FACS