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Acute Appendicitis: Review and Update

D. MIKE HARDIN, JR., M.D., Texas A&M University Health Science Center, Temple, Texas
Appendicitis is common, with a lifetime occurrence of 7 percent. Abdominal pain and anorexia are the predominant symptoms. The most important physical examination finding is right lower quadrant tenderness to palpation. A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and supporting the presence or absence of appendicitis, while appendiceal computed tomographic scans and ultrasonography can be helpful in equivocal cases. Delay in diagnosing appendicitis increases the risk of perforation and complications. Complication and mortality rates are much higher in children and the elderly. (Am Fam Physician 1999;60:2027-34.)

Appendicitis is the most common acute surgical condition of the abdomen. Approximately 7 percent of the
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population will have appendicitis in their lifetime, with the peak incidence occurring between the ages of 10 and
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30 years.

Despite technologic advances, the diagnosis of appendicitis is still based primarily on the patient's history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications. The mortality rate in nonperforated appendicitis is less than 1 percent, but it may be as high as 5
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percent or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.
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Pathogenesis

TABLE 1 Common Symptoms of Appendicitis


Common symptoms* Frequency (%)

Abdominal pain ~100 Anorexia ~100 Nausea 90 Vomiting 75 Pain migration 50 Classic symptom sequence (vague 50 periumbilical pain to anorexia/nausea/unsustained vomiting to migration of pain to right lower quadrant to low-grade fever)

The appendix is a long diverticulum that extends from the inferior tip of the cecum. Its lining is interspersed with
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lymphoid follicles. Most of the time, the appendix has an


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*--Onset of symptoms typically within past 24 to 36 hours. Information from references 3 through 5.

intraperitoneal location (either anterior or retrocecal) and, thus, may come in contact with the anterior parietal peritoneum when it is inflamed. Up to 30 percent of the time, the appendix may be "hidden" from the anterior peritoneum by being in a pelvic, retroileal or retrocolic (retroperitoneal retrocecal) position. The "hidden" position of the appendix notably changes the clinical
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manifestations of appendicitis. Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis. Obstruction has multiple causes, including lymphoid hyperplasia (related to viral illnesses, including upper respiratory infection, mononucleosis, gastroenteritis), fecaliths, parasites, foreign bodies, Crohn's disease, primary or metastatic cancer and carcinoid syndrome. Lymphoid hyperplasia is more common in children and young adults, accounting for the increased incidence of appendicitis in these age groups.
1,5

History and Physical Examination


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

abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis ( Table 1). A thorough review of the history of the abdominal pain and of the patient's recent genitourinary, gynecologic and pulmonary history should be obtained. Anorexia, nausea and vomiting are symptoms that are commonly associated with acute appendicitis. The classic history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50 percent of patients. Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis.
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TABLE 2 Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis
Negative likelihood ratio (LR-) 0 to 0.28 0.3 0.5 0 to 0.54

Symptom/sign Right lower quadrant (RLQ) pain Pain migration Pain before vomiting Anorexia, nausea and vomiting* Rigidity Psoas sign

Positive likelihood ratio (LR+) 8.0 3.2 2.8 Much lower LR+ than RLQ pain, pain migration and pain before vomiting 3.76 2.38

Symptom/sign RLQ pain No similar pain previously|| Pain migration Guarding

Rebound tenderness 0 to 0.86 Fever, rigidity and

psoas sign Rebound tenderness Fever Guarding and rectal tenderness* 1.1 to 6.3 1.9 Much lower LR+ than rigidity, psoas sign and rebound tenderness

NOTE: LR is the amount by which the odds of a disease change with new information, as follows: Likelihood ratio Degree of change in probability >10 or <0.1 5 to 10 or 0.1 to 0.2 2 to 5 or 0.2 to 0.5 1 to 2 or 0.5 to 1 Large (often conclusive) Moderate Small (but sometimes important) Small (rarely important)

*--These symptoms and signs have much lower LR+. --Ratios are presented in ranges for signs and symptoms that had widely varying results in studies. --Fever had only borderline LR+. --That is, the absence of RLQ pain significantly lowers the odds of having appendicitis. ||--That is, the history of experiencing a similar pain previously lowers the odds of having appendicitis. --These signs have higher LR-. Information from references 7, 8 and 19

In a recent meta-analysis, likelihood ratios were calculated for many of these symptoms (Table 2). A likelihood
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ratio is the amount by which the odds of a disease change with new information (e.g., physical examination findings, laboratory results). This change can be positive or negative. Symptoms such as anorexia, nausea and
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vomiting commonly occur in acute appendicitis; however, the presence of these symptoms does not necessarily increase the likelihood of appendicitis nor does their absence decrease the likelihood of the diagnosis. Moreover, other symptoms have more notable positive and negative likelihood ratios (Table 2).

TABLE 3 Common Signs of Appendicitis


Right lower quadrant pain on palpation (the single most important sign) Low-grade fever (38C [or 100.4F])--absence of fever or high fever can occur Peritoneal signs Localized tenderness to percussion Guarding Other confirmatory peritoneal signs (absence of these signs does not exclude appendicitis) Psoas sign--pain on extension of right thigh (retroperitoneal retrocecal appendix) Obturator sign--pain on internal rotation of right thigh (pelvic appendix) Rovsing's sign--pain in right lower quadrant with

A careful, systematic examination of the abdomen is essential. While right lower quadrant tenderness to palpation is the most important physical examination finding, other signs may help confirm the diagnosis (Table 3). The abdominal examination should begin with inspection followed by auscultation, gentle palpation (beginning at a site distant from the pain) and,

palpation of left lower quadrant Dunphy's sign--increased pain with coughing Flank tenderness in right lower quadrant (retroperitoneal retrocecal appendix) Patient maintains hip flexion with knees drawn up for comfort Information from references 3 through 5.

finally, abdominal percussion. The rebound tenderness that is associated with peritoneal irritation has been shown to be more accurately identified by percussion of the abdomen than by palpation with quick release.
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As previously noted, the location of the appendix varies. When the appendix is hidden from the anterior peritoneum, the usual symptoms and signs of acute appendicitis may not be present. Pain and tenderness can occur in a location other than the right lower quadrant. A retrocecal appendix in a retroperitoneal location may
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cause flank pain. In this case, stretching the iliopsoas muscle can elicit pain. The psoas sign is elicited in this manner: the patient lies on the left side while the examiner extends the patient's right thigh ( Figures 1a and 1b). In contrast, a patient with a pelvic appendix may show no abdominal signs, but the rectal examination may elicit tenderness in the cul-de-sac. In addition, an obturator sign (pain on passive internal rotation of the flexed right thigh) may be present in a patient with a pelvic appendix (Figures 2a and 2b).
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FIGURE 1A. The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk).

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

FIGURE 2B. Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.

FIGURE 1B. Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.

The differential diagnosis of appendicitis is broad, but the patient's history and the remainder of the physical examination may clarify the diagnosis (Table 4). Because many gynecologic conditions can mimic appendicitis, a pelvic examination should be performed on all women with abdominal pain. Given the breadth of the differential diagnosis, the pulmonary, genitourinary and rectal examinations are equally important. Studies have shown, however, that the rectal examination provides useful information only when the diagnosis is unclear and, thus, can be reserved for use in such cases.
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TABLE 4 Differential Diagnosis of Acute Appendicitis


Gastrointestinal Abdominal pain, cause unknown Cholecystitis Gynecologic Ectopic pregnancy Endometriosis Pulmonary Pleuritis Pneumonia (basilar)

Laboratory and Radiologic Evaluation


If the patient's history and the physical examination do not clarify the diagnosis, laboratory and radiologic evaluations may be helpful. A clear diagnosis of appendicitis obviates the need for further testing and should prompt immediate surgical referral. Laboratory Tests The white blood cell (WBC) count is elevated (greater than 10,000 per mm [100 3 10 per L]) in 80 percent of
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all cases of acute appendicitis. Unfortunately, the WBC


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is elevated in up to 70 percent of patients with other causes of right lower quadrant pain. Thus, an elevated
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WBC has a low predictive value. Serial WBC measurements (over 4 to 8 hours) in suspected cases may increase the specificity, as the WBC count often increases in acute appendicitis (except in cases of perforation, in which it may initially fall).
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Crohn's disease Diverticulitis Duodenal ulcer Gastroenteritis Intestinal obstruction Intussusception Meckel's diverticulitis Mesenteric lymphadenitis Necrotizing enterocolitis Neoplasm (carcinoid, carcinoma, lymphoma) Omental torsion Pancreatitis Perforated viscus Volvulus

Ovarian torsion Pelvic inflammatory disease Ruptured ovarian cyst (follicular, corpus luteum) Tubo-ovarian abscess Systemic Diabetic ketoacidosis Porphyria Sickle cell disease HenochSchnlein purpura

Pulmonary infarction Genitourinary Kidney stone Prostatitis Pyelonephritis Testicular torsion Urinary tract infection Wilms' tumor Other Parasitic infection Psoas abscess Rectus sheath hematoma

Reprinted with permission from Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653-71.

In addition, 95 percent of patients have neutrophilia and, in the elderly, an elevated band count greater than 6
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percent has been shown to have a high predictive value for appendicitis. In general, however, the WBC count and
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differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low specificities. A more recently suggested laboratory evaluation is determination of the C-reactive protein level. An elevated Creactive protein level (greater than 0.8 mg per dL) is common in appendicitis, but studies disagree on its sensitivity and specificity. An elevated C-reactive protein level in combination with an elevated WBC count and
4,5

neutrophilia are highly sensitive (97 to 100 percent). Therefore, if all three of these findings are absent, the chance of appendicitis is low.
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In patients with appendicitis, a urinalysis may demonstrate changes such as mild pyuria, proteinuria and hematuria, but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose
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appendicitis.

Radiologic Evaluation The options for radiologic evaluation of patients with suspected appendicitis have expanded in recent years, enhancing and sometimes replacing previously used radiologic studies. Plain radiographs, while often revealing abnormalities in acute appendicitis, lack specificity and are more helpful in diagnosing other causes of abdominal pain. Likewise, barium enema is now used infrequently because of the advances in abdominal imaging.
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Ultrasonography and computed tomographic (CT) scans are helpful


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FIGURE 3. Ultrasonogram showing appendix.

in evaluating patients with suspected appendicitis. Ultrasonography longitudinal section (arrows) of inflamed is appropriate in patients in which the diagnosis is equivocal by history and physical examination. It is especially well suited in evaluating right lower quadrant or pelvic pain in pediatric and female patients. A normal appendix (6 mm or less in diameter) must be identified to rule out appendicitis. An inflamed appendix usually measures greater than 6 mm in diameter (Figure 3), is noncompressible and tender with focal compression. Other right lower quadrant conditions such as inflammatory bowel disease, cecal diverticulitis, Meckel's diverticulum, endometriosis and pelvic inflammatory disease can cause false-positive ultrasonography results.
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TABLE 5 Comparison of Ultrasound and Appendiceal CT Evaluation of Suspected Appendicitis


Comparison graded ultrasound Sensitivity Specificity Use 85% 92% Evaluate patients with equivocal diagnosis of appendicitis Safe Relatively inexpensive Can rule out pelvic disease in females Appendiceal computed tomographic scan 90 to 100% 95 to 97% Evaluate patients with equivocal diagnosis of appendicitis More accurate Better identifies phlegmon and abscess Better identifies normal

Advantages

CT, specifically the technique of appendiceal CT, is more accurate than ultrasonography (Table 5). Appendiceal CT consists of a focused, helical, appendiceal CT after a Gastrografin-saline enema (with or without oral contrast) and can be performed and interpreted within one hour. Intravenous contrast is unnecessary. The accuracy of CT is
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due in part to its ability to identify a normal appendix better than ultrasonography. An inflamed appendix is greater than 6
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Better for children Disadvantages Operator dependent Technically inadequate studies due to gas Pain

appendix Cost Ionizing radiation Contrast

mm in diameter, but the CT also demonstrates periappendiceal inflammatory changes (Figures 4 and 5). If
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Information from references 11, 13, 20.

appendiceal CT is not available, standard abdominal/pelvic CT with contrast remains highly useful and may be more accurate than ultrasonography.
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Treatment
The standard for management of nonperforated appendicitis remains appendectomy. Because prompt treatment of appendicitis is important in preventing further morbidity and mortality, a margin of error in over-diagnosis is acceptable. Currently, the national rate of negative appendectomies is approximately 20 percent. Some studies
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have investigated nonoperative management with parenteral antibiotic treatment, but 40 percent of these patients eventually required appendectomy.
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Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or laparoscopy. Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age, while therapeutic laparoscopy may be preferred in certain subsets of patients (e.g., women, obese patients, athletes). While laparoscopic intervention has the advantages of decreased postoperative pain, earlier return to normal activity and better cosmetic results, its disadvantages include greater cost and longer operative time. Open
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appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted.

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

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

Complications
Appendiceal rupture accounts for a majority of the complications of The classic history of pain beginning in the periumbilical region and migrating to the appendicitis. Factors that increase the rate of perforation are delayed presentation to medical care, age extremes (young and
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right lower quadrant occurs in only 50 percent of patients.

old) and hidden location of appendix. A brief period of in-hospital


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observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve diagnostic accuracy.
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Diagnosis of a perforated appendix is usually easier (although immediately after rupture, the patient's symptoms may temporarily subside). The physical examination findings are more obvious if peritonitis generalizes, with a more generalized right lower quadrant tenderness progressing to complete abdominal tenderness. An ill-defined mass may be felt in the right lower quadrant. Fever is more common with rupture, and the WBC count may elevate to 20,000 to 30,000 per mm (200 to 300 3 10 per L) with a prominent left shift.
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A periappendiceal abscess may be treated immediately by surgery or by nonoperative management. Nonoperative


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management consists of parenteral antibiotics with observation or CT-guided drainage, followed by interval appendectomy six weeks to three months later.
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Special Considerations
The technique of appendiceal computed tomography is more accurate than ultrasonography in confirming the diagnosis of appendicitis.

While appendicitis is uncommon in young children, it poses special difficulties in this age group. Young children are unable to relate a history, often have abdominal pain from other causes and may have more nonspecific signs and symptoms. These factors contribute to a perforation rate as high as 50 percent in this group.
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In pregnancy, the location of the appendix begins to shift significantly by the fourth to fifth months of gestation. Common symptoms of pregnancy may mimic appendicitis, and the leukocytosis of pregnancy renders the WBC count less useful. While the maternal mortality rate is low, the overall fetal mortality rate is 2 to 8.5 percent, rising to as high as 35 percent in perforation with generalized peritonitis. As in nonpregnant patients, appendectomy is the standard for treatment.
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Elderly patients have the highest mortality rates. The usual signs and symptoms of appendicitis may be diminished, atypical or absent in the elderly, which leads to a higher rate of perforation. More frequent perforation combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a mortality rate of up to 5 percent or more.
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Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications. Because abdominal pain is a common presenting symptom in outpatient care, family physicians serve an important role in the diagnosis of appendicitis. Obvious cases of appendicitis require urgent referral, while equivocal cases warrant further evaluation and, many times, surgical consultation.
The author thanks Glen Cryer, Department of Publications, Scott and White Memorial Hospital, Temple, Tex., for help with the manuscript. Figures 3 through 5 were provided by Michael L. Nipper, M.D., Department of Radiology, Scott and White Memorial Hospital, Temple, Tex.

Appendicitis (Pediatric GI)

Figure 4 : Yersinia enterocolitis. Several enlarged lymph nodes (cursors) are seen on this sagittal sonogram of a child whose appendix appeared normal.

Imaging

Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower quadrant pain) from appendicitis (Fig. 4)

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


CT findings of normal appendix Visualized in 67-100%. AT posteromedial aspect of cecum. Diameter of up to 10 mm.

CT findings of Abnormal appendix Distended lumen (appendix >7 mm in diameter). Circumferential wall thickening. Target sign: homogeneously enhancing wall with mural stratification. Appendicolith: homogeneous/ringlike calcification (25%). Distal appendicitis: abnormal tip of appendix + normal proximal appendix and normal cecal apex.

Read the rest of this entry Filed under: Acute Appendicitis, Gastrointestinal Emergency , Acute Appendicitis, Arrowhead sign, CT Findings, normal appendix, Target sign

Acute appendicitis. Laparocopic diagnosis

Perforated duodenal ulcer.

Acute cholecystitis.

Figure: X-ray showing a strip of free air along the right paracolic gutter, delineating the lower border of liver (arrow).

While looking through the archives of ultrasound images I came across a couple of instances of common diagnoses made through tests that are not commonly done to diagnose them. This might become a series of posts, if I stick with the theme. Acute Appendicitis is, as everyone knows, a common diagnosis on ultrasonography of the Abdomen (TAS = Transabdominal sonography).

Rarely we do get to see a classical appendicolith on ultrasonography.

What is quite rare is this

Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS, also called EVS Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain.

While I only diagnosed Appendicitis through the transvaginal route, there are surgeons in India and the USA who have removed the inflammed Appendix through the vagina!! The Indian surgeons, who as per the PubMed abstract, were the first in the world to attempt this, are from my hometown Coimbatore.

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Location of the appendix in the digestive system

Appendicitis is a condition characterized by inflammation of the appendix. It is a medical emergency. All cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".

Symptoms
Signs and symptoms of acute appendicitis can be classified into two types, typical and atypical. The typical history includes pain starting centrally (periumbilical) before localizing to the right iliac fossa (the lower right side of the abdomen); this is due to the poor localizing (spatial) property of visceral nerves from the mid-gut, followed by the involvement of somatic nerves (parietal peritoneum) as the inflammation progresses. The pain is usually associated with loss of appetite and fever, although the latter isn't a necessary symptom. Nausea or vomiting may occur, as well as drowsiness and malaise. Atypical symptoms may include pain beginning and staying in the right iliac fossa, diarrhea and a more prolonged, smoldering course. If an inflamed appendix lies in contact with the bladder, there is frequency of urination. With post-ileal appendix, marked retching

may occur. Tenesmus or "downward urge" (the feeling that a bowel movement will relieve discomfort) is also experienced in some cases. Unlike acute appendicitis, chronic appendicitis symptoms can vary from patient to patientso much so that "There are no typical findings or routine diagnostic modalities to diagnose chronic relapsing appendicitis. It is a diagnosis of exclusion..."

Signs
These include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention. Other signs are:

Rovsing's sign
Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. This is the Rovsing's sign, also known as the Rovsing's symptom. It is used in the diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the right lower quadrant of the abdomen.

Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side and then extending the hip. Because extension elicits pain, the patient will lie with the right hip flexed for pain relief.

Obturator sign
If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and lateral rotation of the hip. This maneuver will cause pain in the hypogastrium.

Causes
On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen. Once this obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death. Among the causative agents, such as foreign bodies, trauma, intestinal worms, lymphadenitis, and calcified deposits known as appendicoliths, the occurrence of an obstructing fecalith has attracted attention. The prevalence of fecaliths in patients with appendicitis is significantly higher in developed than in developing countries, and an appendiceal fecalith is commonly associated with complicated appendicitis. Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls. The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time. From epidemiological data it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt for appendicitis. Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis . This is in accordance with the occurrence of a right sided fecal reservoir and the fact that dietary fiber reduces transit time.

Diagnosis
Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Atypical histories often require imaging with ultrasound and/or CT scanning. A pregnancy test is vital in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life

threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men) should be appreciated.

Ultrasound

Ultrasound image of an acute appendicitis.

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children. In some cases (15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult. Despite these limitations, in experienced hands sonographic imaging can often distinguish between appendicitis and other diseases with very similar symptoms such as inflammation of lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or fallopian tubes.

Computed tomography
In places where it is readily available, CT scan has become frequently used, especially in adults whose diagnosis is not obvious on history and physical. Concerns about radiation however exist which tends to limit its use in pregnant women and children. A properly

performed CT scan with modern equipment has a detection rate (sensitivity) of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in diameter on cross section), and appendiceal wall enhancement (IV dye). The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20% in the pre-CT era to only 3% according to data from the Massachusetts General Hospital. According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of 94%, specificity of 95%, a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81%, a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27). Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of appendiceal rupture among patients with acute appendicitis according to a cohort study. MMP-1 was higher in gangrenous (p<0.05) and perforated appendicitis (p<0.01) compared with controls. MMP-9 was most abundantly expressed in inflamed appendix and reached a tenfold higher expression in all groups with appendicitis compared with controls (p<0.001). A number of clinical and laboratory based scoring systems have been devised to assist diagnosis. The most widely used is Alvarado score.

Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis, while a score of 7 or more is strongly predictive of acute appendicitis. In patients with an equivocal score of 5-6, CT scan further reduces the rate of negative appendicectomy.

Differential diagnosis
In children:

Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, the absence of other symptoms can occur in children with UTI), new-onset Crohn's disease or ulcerative colitis, pancreatitis, and abdominal trauma from child abuse; distal intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in

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

children with leukemia; in girls: menarche, dysmenorrhea, severe menstrual cramps, Mittelschmerz, pelvic inflammatory disease, ectopic pregnancy In adults:

regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma; in men: testicular torsion, new-onset Crohn's disease or ulcerative colitis; in women: pelvic inflammatory disease, ectopic pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle) In elderly:

diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.

Management

Inflamed appendix removal by open surgery

Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be

used.

Pain management
Pain from appendicitis can be severe. Strong pain medications (i.e. narcotic pain medications) are recommended for pain management prior to surgery. Morphine is generally the standard of care in adults and children in the treatment of pain from appendicitis prior to surgery. In the past (and in some medical textbooks that are still published today), it has been commonly accepted that pain medication not be given until the surgeon has the chance to evaluate the patient, so as to not "corrupt" the findings of the physical examination. This line of practice, combined with the fact that surgeons may sometimes take hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to drive in from home, often leads to a situation that is ethically questionable at best. More recently, due to better understanding of the importance of pain control in patients, it has been shown that the physical examination is actually not that dramatically disturbed when pain medication is given prior to medical evaluation. Individual hospitals and clinics have adapted to this new approach of pain management of appendicitis by developing a compromise of allowing the surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain management is initiated. Many surgeons also advocate this new approach of providing pain management immediately rather than only after surgical evaluation.

Surgery
thumb|The stitches on a patient the day after having his appendix removed by surgery.The surgical procedure for the removal of the appendix is called an appendicectomy (also known as an appendectomy). Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to visualize the area of interest in the abdomen. If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy incision if required most often centers on the area of maximum tenderness, McBurney's point, in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly. In March 2008, an American woman had her appendix removed via her vagina, in a medical first.

According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure. Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio (OR) 0.45; confidence interval (CI) 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of laparoscopic procedures were significantly higher, the costs outside hospital were reduced. Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups. There is debate whether emergency appendicectomy (within 6 hours of admission) reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6 hours after admission). According to a retrospective case review study no significant differences in perforation rate among the two groups were noted (P=.397). Various complications (abscess formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to the next day does not significantly increase the risk of perforation or other complications. This finding is important not simply for the convenience of the surgeons and staff involved but for the fact that there have been other studies that have shown that surgeries taking place during the night, when people may be more tired and there are fewer staff available, have higher rates of surgical complications. These findings may fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are two distinct disease processes. Findings at the time of surgery suggest that perforation occurs at the onset of symptoms in atypical cases.(1) Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in complicated cases.

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

weeks if complications occur.

Prognosis
Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old) the recovery takes three weeks. The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e. outside of a proper hospital), when a timely medical evaluation was impossible. Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked about quite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump. During this period operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition. An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior, incomplete appendectomy.

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