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AppendicitisDifferentialDiagnoses

AppendicitisDifferentialDiagnoses
Author:SandyCraig,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Dec27,2015

DiagnosticConsiderations
Theoverallaccuracyfordiagnosingacuteappendicitisisapproximately80%,which
correspondstoameannegativeappendectomyrateof20%.Diagnosticaccuracy
variesbysex,witharangeof7892%inmalepatientsand5885%infemale
patients.
Theclassichistoryofanorexiaandperiumbilicalpainfollowedbynausea,right
lowerquadrant(RLQ)pain,andvomitingoccursinonly50%ofcases.Vomitingthat
precedespainissuggestiveofintestinalobstruction,andthediagnosisof
appendicitisshouldbereconsidered.
Thedifferentialdiagnosisofappendicitisisoftenaclinicalchallengebecause
appendicitiscanmimicseveralabdominalconditions(seeDifferentials). [14]Patients
withmanyotherdisorderspresentwithsymptomssimilartothoseofappendicitis,
suchasthefollowing:
Pelvicinflammatorydisease(PID)ortuboovarianabscess
Endometriosis
Ovariancystortorsion
Ureterolithiasisandrenalcolic
Degeneratinguterineleiomyomata
Diverticulitis
Crohndisease
Coloniccarcinoma
Rectussheathhematoma
Cholecystitis
Bacterialenteritis
Mesentericadenitisandischemia
Omentaltorsion
Biliarycolic
Renalcolic
Urinarytractinfection(UTI)
Gastroenteritis
Enterocolitis
Pancreatitis
Perforatedduodenalulcer
Otherproblemsthatshouldbeconsideredinapatientwithsuspectedappendicitis
includeappendicealstumpappendicitis,typhlitis,epiploicappendagitis,psoas
abscess,andyersiniosis.
Misdiagnosisinwomenofchildbearingage
Appendicitisismisdiagnosedin33%ofnonpregnantwomenofchildbearingage.
ThemostfrequentmisdiagnosesarePID,followedbygastroenteritisandurinary
tractinfection.IndistinguishingappendicealpainfromthatofPID,anorexiaand
onsetofpainmorethan14daysaftermensessuggestsappendicitis.PreviousPID,
vaginaldischarge,orurinarysymptomsindicatesPID.Onphysicalexamination,
tendernessoutsidetheRLQ,cervicalmotiontenderness,vaginaldischarge,and
positiveurinalysissupportthediagnosisofPID.
Althoughnegativeappendectomydoesnotappeartoadverselyaffectmaternalor
fetalhealth,diagnosticdelaywithperforationdoesincreasefetalandmaternal
morbidity.Therefore,aggressiveevaluationoftheappendixiswarrantedinpregnant
women.
Thelevelofurinarybetahumanchorionicgonadotropin(betahCG)isusefulin
differentiatingappendicitisfromearlyectopicpregnancy.However,withregardto
theWBCcount,physiologicleukocytosisduringpregnancymakesthisstudyless
usefulinthediagnosisthanatothertimes,andnoreliabledistinguishingWBC
parametersarecitedintheliterature.
Misdiagnosisinchildren
Appendicitisismisdiagnosedin2530%ofchildren,andtherateofinitial
misdiagnosisisinverselyrelatedtotheageofthepatient.Themostcommon
misdiagnosisisgastroenteritis,followedbyupperrespiratoryinfectionandlower
respiratoryinfection.
Childrenwithmisdiagnosedappendicitisaremorelikelythantheircounterpartsto
havevomitingbeforepainonset,diarrhea,constipation,dysuria,signsand
symptomsofupperrespiratoryinfection,andlethargyorirritability.Physicalfindings
lesslikelytobedocumentedinchildrenwithamisdiagnosisthaninothersinclude
bowelsoundsperitonealsignsrectalfindingsandear,nose,andthroatfindings.
Considerationsinelderlypatients

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Appendicitisinpatientsolderthan60yearsaccountsfor10%ofall
appendectomies.Theincidenceofmisdiagnosisisincreasedinelderlypatients.
Olderpatientstendtoseekmedicalattentionlaterinthecourseofillness
therefore,adurationofsymptomsinexcessof2448hoursshouldnotdissuadethe
clinicianfromthediagnosis.Inpatientswithcomorbidconditions,diagnosticdelayis
correlatedwithincreasedmorbidityandmortality.

DifferentialDiagnoses
AbdominalAbscess
BacterialGastroenteritis
CholecystitisandBiliaryColic
Constipation
CrohnDisease
CystitisinFemales
Diverticulitis
EctopicPregnancy
EmergentTreatmentofEndometriosis
EmergentTreatmentofGastroenteritis
InflammatoryBowelDisease
Intussusception
MesentericIschemiaImaging
MesentericLymphadenitis
Nephrolithiasis
OmentalTorsion
OvarianCysts
OvarianTorsion
PediatricMeckelDiverticulum
PelvicInflammatoryDisease
UrinaryTractInfectioninMales
WidowSpiderEnvenomation
Workup

ContributorInformationandDisclosures
Author
SandyCraig,MDResidencyProgramDirector,CarolinasMedicalCenterAssociateProfessor,Departmentof
EmergencyMedicine,UniversityofNorthCarolinaatChapelHillSchoolofMedicine
SandyCraig,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,SocietyforAcademic
EmergencyMedicine
Disclosure:Nothingtodisclose.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,Program
DirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserveUniversity
SchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyof
EmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
WilliamLober,MD,MSAssociateProfessor,HealthInformaticsandGlobalHealth,SchoolsofMedicine,
Nursing,andPublicHealth,UniversityofWashington
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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