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World J Surg (2010) 34:210–215

DOI 10.1007/s00268-009-0349-z

Pain as the Only Consistent Sign of Acute Appendicitis:


Lack of Inflammatory Signs Does Not Exclude the Diagnosis
Olivier Monneuse • S. Abdalla • F. Pilleul •

V. Hervieu • L. Gruner • E. Tissot •


X. Barth

Published online: 30 December 2009


Ó Société Internationale de Chirurgie 2009

Abstract Results A total of 15.6% of the patients with a preoper-


Background The clinical diagnosis of acute appendicitis ative diagnosis of acute appendicitis had isolated rebound
in adults remains tricky, but radiological examinations are tenderness in the right lower quadrant, i.e., they were
very helpful to determine the diagnosis even when the adult afebrile and their white blood cell counts and C-reactive
patient presents atypically. This study was designed to protein levels were normal. In 96.1% of the cases, the
quantify the proportion of patients with a preoperative ultrasonography examination, sometimes complemented
diagnosis of acute appendicitis that had isolated right lower by an intravenous contrasted computed tomography scan if
quadrant pain without biological inflammatory signs and the ultrasonography result was equivocal, fit the histopa-
then to determine which imaging examination led to the thological diagnosis of acute appendicitis.
determination of the diagnosis. Conclusions The diagnosis of acute appendicitis cannot
Methods In this monocentric study based on retrospec- be excluded when an adult patient presents with isolated
tively collected data, we analyzed a series of 326 patients rebound tenderness in the right lower quadrant even
with a preoperative diagnosis of acute appendicitis and without fever and biological inflammatory signs. In our
isolated those who were afebrile and had isolated right study, ultrasonography and computed tomography were
lower quadrant pain and normal white blood cell counts very helpful when making the final diagnosis.
and C-reactive protein levels. We determined whether the
systematic ultrasonography examination was informative
enough or a complementary intravenous contrast media Introduction
computed tomography scan was necessary to determine the
diagnosis, and whether the final pathological diagnosis fit Acute appendicitis (AA) is a common surgical emergency
the preoperative one. in adults. The diagnosis is usually based on clinical and
biological criteria making up the clinical presentation of
acute appendicitis: fever[100°F, rebound tenderness in the
right lower quadrant, and leucocytosis.
O. Monneuse (&)  S. Abdalla  L. Gruner  E. Tissot 
Technical progress in ultrasonography (US) [1, 2] and
X. Barth
Surgical Emergency and Trauma Department, Hôpital Edouard intravenous contrast computed tomography (CT) [3] now
Herriot, Pavillon G visceral, 5 place d’Arsonval, 69437 Lyon allow clinicians to make the diagnosis of AA with visual
Cedex 03, France evidence and questions the use and the accuracy of bio-
e-mail: olivier.monneuse@chu-lyon.fr logical parameters, such as white blood cell (WBC) count
F. Pilleul and C-reactive protein (CRP) level [4–6]. Active obser-
Radiology Department, Hôpital Edouard Herriot, vation also is efficient when associated with repeated
Lyon Cedex 03, France clinical, biological, and radiological examinations [7, 8],
but induces a significant increase in cost.
V. Hervieu
Pathology Department, Hôpital Edouard Herriot, In the Department of Emergency Surgery of Edouard
Lyon Cedex 03, France Herriot Hospital in Lyon, France, we are frequently

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World J Surg (2010) 34:210–215 211

confronted with the diagnosis of acute appendicitis. We


retrospectively observed that among patients with a pre-
operative diagnosis of AA who were subsequently oper-
ated on for this pathology, some of them presented only
with pain located in the right lower quadrant and without
fever, leucocytosis, or any increase in the CRP level.
Very few studies have put forward similar observations
[9]. The main purpose of our study was to quantify the
exact proportion of the patients without fever, leucocy-
tosis, or increase in the CRP level among patients with a
preoperative diagnosis of AA. We double-checked that
the histopathological diagnosis fit the preoperative diag-
nosis of AA and that the final diagnosis matched the
radiological one.

Patients and methods

This study was a descriptive, monocentric study based on


retrospectively collected data: from January 2002 to March
2005, we included 326 consecutive patients from our
database (aged 18–80 years; 184 men = 56.3%) who had a
preoperative diagnosis of AA and who underwent an
appendectomy in our surgical emergency department of
Edouard Herriot Hospital.
On admission, all patients underwent physical exami-
nation, which included abdominal palpation and a mea- Fig. 1 a US examination identified an acute appendicitis with
enlarged appendix (diameter 6 mm) and periappendiceal inflamma-
surement of their auricular temperature. The auricular
tion (with star). b Acute appendicitis with fluid retention in the distal
temperature was measured with an electronic thermometer. lumen (white arrow) caused by an appendicolith (star)
Their WBC counts and CRP levels also were determined
on admission. We considered them to be afebrile if their
body temperature was B99.5°F (37.5°C). According to the intravenous (IV) contrast media—Somatom, Siemens 10
standard values of our laboratory, the WBC count was detectors, helical acquisition—without digestive prepara-
considered as normal when it was B12.109/l and the CRP tion. This examination also was performed in the emer-
level was considered as normal when it was B5 IU/l. gency room by resident or staff radiologists before the
All patients, with or without inflammatory signs, decision was made to hospitalize the patient. Every US
underwent the same diagnostic imaging protocol: each examination or CT with IV contrast media performed by
patient had an ultrasound (US) examination that explored a resident radiologist was validated by a senior staff
the whole anterior abdominal wall with a percutaneous radiologist. The CT criteria were all the same as the US
probe (Elegra, Siemens) initially using a 3.5-MHz convex criteria except for the incompressibility of the appendix.
array transducer and it was completed by a 7.5-MHz For the US and CT with IV contrast media, the diagnosis
linear array transducer. This examination was performed of AA was made when the patient presented with at least
in the emergency room before the decision was made to three of the four direct signs or two direct signs associ-
hospitalize the patient. The US examinations were per- ated with the indirect sign.
formed by resident or staff radiologists. The US criteria With a preoperative diagnosis of AA, all 326 patients
for making the diagnosis of AA were the following direct were operated on using general anesthesia and underwent
signs: thickness of the appendix wall [5 mm, widening of appendectomy by laparoscopy or laparotomy depending on
the appendix, noncompressible appendix, and inflamma- the decision of the operator. The resected appendix was
tion of the periappendiceal fat (Fig. 1a). Indirect signs systematically sent for pathological examination.
included the presence of a stercolith in the appendix The histopathological protocol consisted of a standard-
(Fig. 1b). When the final diagnosis could not be made ized sampling. The resected appendix was fixed in 10%
based on the US examination, patients underwent an buffered formalin, the base of the appendix was stained
additional CT scan of the abdomen and pelvis with with ink as a marker, and the pathologist proceeded to the

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macroscopic examination of the whole piece. Then, sam- Results


ples of the appendix were impacted in paraffin and cut into
5-lm-thick slices. The slices were stained with hematox- Among the 326 patients who had a preoperative diagnosis
ylin, phloxine, and saffron and were interpreted by the of AA, we recorded that 51 of them (15.6%, 26 men; aged
pathologist. The diagnosis of isolated acute appendicitis 18–80 (median, 27.5) years) complained of isolated pain in
(IAA) was made when the histopathological examination the right lower quadrant (Table 1). Clinical examination
of the appendix showed acute inflammatory lesions with a revealed right lower quadrant tenderness in 19 patients
focal layout characterized by edema associated with (37.3%) or right lower quadrant guarding in 32 patients
polymorphic inflammatory infiltration in nonulcerated (62.7%), but no fever. The biological examinations
mucosa. The diagnosis of complicated acute appendicitis revealed neither hyperleukocytosis nor an increase in the
(CAA) was made when the histopathological examination CRP level. The duration of the symptoms before arrival at
of the appendix showed acute inflammatory lesions char- the hospital was B24 h for 24 patients (47.1%), between 24
acterized by polymorphic inflammatory infiltration of the and 48 h for 17 patients (33.3%), and [48 h but \8 days
whole appendicular wall from the submucosa to the sub- for 10 patients (19.6%). With regard to medical history,
serosa and wide ulceration foci covered with a fibrino- there were three pregnant women (5.9%), two diabetic
leukocytic coating with numerous clusters of altered neu- patients (3.9%), and one patient (1.96%) who had been
trophilic polynuclear leukocytes. The diagnosis of chronic treated with antibiotic therapy during 5 days for abdominal
appendicitis (CA) was made when the histopathological pain before his arrival at the hospital.
examination of the appendix showed chronic-looking Two patients (3.9%) underwent repeated US examina-
inflammatory changes: absence of purulent changes, pres- tions (Table 1); in both cases, the first US examination was
ence of focal fibrosis of the submucosa and the muscularis normal, and the persistence of the pain led to a need to
mucosae with focal adipose involutions, rare polynuclear repeat the US examination either 3 or 7 days later, at which
neutrophils, and the presence of some polynuclear eosin- point there were direct signs of AA. In one case (1.96%),
ophils. In no cases were there histopathological signs of the patient was overweight and diabetic with a past medical
malignancy. The histopathological result was considered as history of myocardial infarction and bilateral carotid sur-
the ‘‘gold standard’’ to confirm or invalidate the preoper- gery, so he underwent CT scan with IV contrast media
ative diagnosis. directly, without receiving an US examination. Three
The patients were followed up in the surgical depart- patients (5.9%) underwent other radiological examinations
ment, with the length of hospitalization depending on the (refer to the ‘‘other’’ category in Table 1): one patient
state of health of the patient. One month after their dis- (1.96%) underwent an US examination that only showed
charge from hospital, all of the patients were examined by inflammation of the periappendiceal fat with an ileocecal
their surgeon in search of possible postoperative compli- effusion and the appendix could not be clearly identified.
cations, such as a ventral rupture of the scar, parietal Despite the unavailability of CT, the indication of appen-
suppuration, or parietal hematoma. dectomy was set. One patient (1.96%) underwent first an

Table 1 Gender, duration of


Radiological preoperative examinations
symptoms, and
histopathological results by US examination US examination and Repeated US IV contrasted Other
imaging diagnostic strategies only complementary IV examinations CT without US
contrasted CT

Men 20 4 1 1 –
Women 14 7 1 – 3
Duration of symptoms
B24 h 15 5 0 1 3
24–48 h 12 4 1 – –
[48 h 7 2 1 – –
US ultrasonography, IV Pathological results
intravenous, CT computed
tomography, IAA isolated acute Misdiagnosis 2 – – – –
appendicitis, CAA complicated IAA 9 1 1 – 1
acute appendicitis (abscess or CAA 21 9 1 1 2
peritonitis), CA chronic
CA 2 1 – – –
appendicitis

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US examination and then a CT scan with IV contrast media hematomas (morbidity = 7.8%, mortality = 0%). There
that could neither identify the appendix nor find any indi- were no incisional hernias or recurrent surgeries in the
rect signs of AA. This patient underwent a complementary series.
endovaginal US examination, which was normal. The
second interpretation of the CT found a partial portal
thrombosis. One day later, a third US examination was Discussion
used to make the diagnosis of AA. In one last case (1.96%),
the patient underwent an US examination and a CT scan Despite the fact that AA in adults is a common surgical
with IV contrast media, which were both nonconclusive; emergency [10], its diagnosis remains tricky [11, 12],
the complementary endovaginal US examination was used particularly when the patient presents with as clinical signs
to make the diagnosis of AA. isolated rebound tenderness in the right lower quadrant
After the histopathological analysis of the appendix of with no biological signs of inflammation. Few studies put
the 51 patients, the diagnosis of AA was confirmed for 49 forward similar cases [9], and some authors exclude the
of them (15.3% of 326 patients, 96.1% of 51 patients). Two diagnosis of acute appendicitis in the face of a similar
patients were misdiagnosed (3.9% of 51 patients): one clinical picture [13, 14]. This context is why we sought to
patient presented with Crohn’s disease associated with a quantify the proportion of acute appendicitis cases with
terminal ileitis, which was revealed by this atypical clinical normal laboratory findings and then to determine how the
presentation and another patient presented with lymphoid diagnosis was made. Our diagnostic strategy is based on
hyperplasia. Thus, there were two unnecessary appendec- several steps: after a clinical examination and blood sam-
tomies (3.9%). There were 49 inflammatory appendices pling, every patient presenting to the emergency room with
(96.1%), including 12 IAAs (23.5%), 34 CAAs (66.7 %), abdominal pain undergoes an US examination. This US
and 3 CAs (5.9%), which we chose to include in our study examination is performed at any time of the day or night by
among the AA because of the acute symptomatology. a staff or resident radiologist, specialized in digestive
Among the 51 patients, we recorded no normal appendices radiology or having attended a specialized training in
after the histopathological examination. Thus, among the digestive radiology during their degree training. Thus, if
51 patients, the imaging diagnosis fit the histopathological ultrasound is considered to be an operator-dependant
one in 96.1% of the cases (diagnostic value = 96.1%). The modality, we benefit from highly reliable radiological
histopathological examination showed that the patient who diagnoses [2]. This examination displays several advanta-
was operated on with a noncontributive US examination ges, including its noninvasive nature, absence of radiation
that could not be complemented by CT with IV contrast exposure, and ability to be rapidly performed. Moreover, it
media did in fact present with a CAA. is considered to be a sensitive and specific examination for
The mean hospital stay duration was 4 (range, 2–15) the diagnosis of acute appendicitis in adults [1, 15]. The CT
days. One month after discharge from the hospital, we scans with IV contrast media (Table 2) has the same
recorded two incision abscesses and two parietal advantages for the diagnosis of acute appendicitis in adults,

Table 2 Summary of the available literature


Predictive value of Helpful diagnostic value Doubtful diagnostic value

US examination Systematic US examination in suspected AA is US examination is less accurate than WBC count and
recommended for adults [1, 2] neutrophil count for the diagnosis of AA [26]
US is better for diagnosing positive findings, CT is more sensitive and specific than US in patients
whereas CT is better for excluding diagnosis of with an equivocal presentation of AA [29]
AA [4]
IV contrasted CT IV contrast media CT has a good diagnostic US is better for diagnosing positive findings, while CT
precision, especially in patients with equivocal is better for excluding diagnosis of AA [4]
presentation of AA [3, 6, 17]
IV contrast media CT is the initial test of choice for
the evaluation of the adult patient suspected of
having AA [30]
US combined to CT US eventually completed by an IV contrast media CT and even IV contrast media CT completed by an US
examination improve the diagnostic accuracy of AA [10, 31, 32]
Laboratory findings AA is unlikely in adult patients with normal Diagnostic accuracy of WBC count, CRP, and
leukocyte count and CRP value [13, 14, 33, 34] temperature is low [4, 19, 21, 23, 25]
AA acute appendicitis, US ultrasonography, IV intravenous, CT computed tomography, WBC white blood cell

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although it involves radiation exposure [16–18], which is diagnosis [4, 23]. This study clearly suggests that any adult
why we perform it when the radiologist cannot rule out patient presenting with isolated right lower quadrant pain
appendicitis from the results of the US. In our department, without fever or elevation of WBC counts and CRP levels
we do not practice diagnostic laparoscopy and we consider should undergo an US examination eventually comple-
this procedure to be a surgical approach to performing the mented by a CT scan with IV contrast media to rule out the
surgical treatment rather than a diagnostic modality. All of diagnosis of acute appendicitis. In fact, we normally use
these examinations are performed before the decision to this imaging strategy in our department. A prospective
hospitalize and operate on the patient is made, and their study evaluating the cost/benefit ratio of this imaging
results condition this decision. diagnostic strategy versus the CT scan with IV contrast
As far as the laboratory findings are concerned, we media only or no imaging examination could build upon
chose to include the results of the CRP level and WBC our work.
count because we use them routinely even if their use and
accuracy are controversial [11, 12, 14, 19] and if other
Conclusions
inflammatory markers, such as the neutrophil-lymphocyte
ratio, interleukin-6 [20], or interleukin-10 [21], and mea-
Among the patients with a preoperative diagnosis of acute
surement modalities, such as repeated laboratory examin-
appendicitis, 15.6% presented with an atypical overall
ations [11, 22], were proposed. Yet, one can question the
picture: isolated rebound tenderness in the right lower
choice of the cutoff values, especially for the WBC count
quadrant, apyrexia, and normal WBC counts and CRP
because we considered values \12.109/l as normal,
levels. This proportion is higher than those presented in
although other studies chose other cutoff values [23–25].
other surveys. In our population, such patients systemati-
Indeed, at the time the diagnoses and the decision to
cally underwent an US examination complemented by a
operate on the patients were made, our laboratory cutoff
CT scan with IV contrast if the result of the US exami-
point for hyperleukocytosis was 12.109/l. To be rigorous,
nation was equivocal. The imaging diagnosis of acute
we decided to keep this cutoff point. If we consider the
appendicitis fit the histopathological one in 96.1% with all
international standards and our current laboratory cutoff
inflammation stages included. Thus, the diagnosis of acute
point for hyperleukocytosis, which is 10.109/l, our rate of
appendicitis cannot be excluded in adult patients presenting
patients with a preoperative diagnosis of AA presenting
with such an overall picture, and for these patients radio-
with isolated RLQ pain is 11.3% (37 patients instead of
logical examinations, in particular ultrasonography, are
51), which is still higher than the results of the other
very helpful in making the diagnosis.
studies. Nevertheless, we stress the fact that the goal of this
study was not to evaluate the diagnostic accuracy of CRP
levels and WBC counts for the diagnosis of acute
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