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60/No. 7 (November 1, 1999)

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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 population will have appendicitis in their lifetime,2 with
the peak incidence occurring between the ages of 10 and 30 years.3
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.4
The mortality rate in nonperforated
appendicitis is less than 1 percent, but it
may be as high as 5 percent or more in
young and elderly patients, in whom
diagnosis may often be delayed, thus
making perforation more likely.1

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
50
(vague periumbilical pain to
anorexia/nausea/unsustained
vomiting to migration of pain
to right lower quadrant to lowgrade fever)

The appendix is a long diverticulum that

extends from the inferior tip of the cecum.5
Its lining is interspersed with lymphoid
follicles.3 Most of the time, the appendix
has an intraperitoneal location (either
anterior or retrocecal) and, thus, may come *--Onset of symptoms typically within past 24 to
in contact with the anterior parietal
36 hours.
Information from references 3 through 5.
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.6 The
"hidden" position of the appendix notably changes the clinical manifestations of
appendicitis.
Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute
appendicitis. Obstruction has multiple causes, including lymphoid hyperplasia (related to
viral illnesses, including upper respiratory infection, mononucleosis, gastroenteritis),
fecaliths, parasites, foreign bodies, 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.3 In multiple studies,3-5
specific characteristics of the abdominal pain and other associated symptoms have proved
to be reliable indicators of acute appendicitis (Table 1). A thorough review of the history
of the abdominal pain and of the 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.1 Duration of
symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis.1

TABLE 2
Significant Likelihood Ratios for Symptoms and Signs of Acute
Appendicitis
Positive likelihood ratio
(LR+)

Symptom/sign

Negative
likelihood
ratio (LR-)

Right lower
quadrant (RLQ)
pain
Pain migration

8.0

RLQ pain

0 to 0.28

3.2

0.3

Pain before
vomiting
Anorexia, nausea
and vomiting*

2.8

No similar pain
previously||
Pain migration

Symptom/sign

Rigidity
Psoas sign
Rebound
tenderness
Fever

Much lower LR+ than RLQ Guarding

pain, pain migration and
pain before vomiting
3.76
Rebound
tenderness
2.38
Fever, rigidity and
psoas sign
1.1 to 6.3

0.5
0 to 0.54
0 to 0.86

1.9

Guarding and rectal Much lower LR+ than

tenderness*
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

Large (often conclusive)

5 to 10 or 0.1 to 0.2 Moderate

2 to 5 or 0.2 to 0.5 Small (but sometimes important)
1 to 2 or 0.5 to 1

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,7 likelihood

ratios were calculated for many of these
symptoms (Table 2). A likelihood ratio is
the amount by which the odds of a
disease change with new information
(e.g., physical examination findings,
laboratory results).8 This change can be
positive or negative. Symptoms such as
anorexia, nausea and vomiting commonly
occur in acute appendicitis; however, the
presence of these symptoms does not
necessarily increase the likelihood of
appendicitis nor does their absence
decrease the likelihood of the diagnosis.
Moreover, other symptoms have more
notable positive and negative likelihood
ratios (Table 2).
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)

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 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.

and, finally, abdominal percussion. The rebound tenderness that is associated with
peritoneal irritation has been shown to be more accurately identified by percussion of the
abdomen than by palpation with quick release.1
As previously noted, the location of the appendix varies. When the appendix is hidden
from the anterior peritoneum, the usual symptoms and signs of acute appendicitis may
not be present. Pain and tenderness can occur in a location other than the right lower
quadrant.6 A retrocecal appendix in a retroperitoneal location may cause flank pain. In
this case, stretching the iliopsoas muscle can elicit pain. The psoas sign is elicited in this
manner: the patient lies on the left side while the examiner extends the 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 appendix3 (Figures 2a and 2b).

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.5

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
mm3 [100 3 109 per L]) in 80 percent
of all cases of acute appendicitis.9
Unfortunately, the WBC is elevated
in up to 70 percent of patients with
other causes of right lower quadrant
pain.10 Thus, an elevated WBC has a
low predictive value. Serial WBC
measurements (over 4 to 8 hours) in
suspected cases may increase the
specificity, as the WBC count often
increases in acute appendicitis
(except in cases of perforation, in
which it may initially fall).5

TABLE 4
Differential Diagnosis of Acute
Appendicitis
Gastrointestinal Gynecologic Pulmonary
Ectopic
Pleuritis
Pneumonia
Abdominal pain, pregnancy
cause unknown Endometriosis (basilar)
Pulmonary
Cholecystitis
infarction
Crohn's disease Ovarian
torsion
Genitourinary
Diverticulitis
Pelvic
Kidney stone
Duodenal ulcer
inflammatory
Prostatitis
Gastroenteritis
disease
Pyelonephritis
Intestinal
Ruptured
Testicular
obstruction
Intussusception ovarian cyst torsion
(follicular,
Urinary tract
Meckel's
corpus
infection
diverticulitis
luteum)
Wilms' tumor
Mesenteric
Tubo-ovarian
Other
lymphadenitis
abscess
Parasitic
Necrotizing
Systemic
infection
enterocolitis
Diabetic
Psoas
Neoplasm
ketoacidosis abscess
(carcinoid,
Porphyria
Rectus sheath
carcinoma,
Sickle cell
hematoma
lymphoma)
Omental torsion disease
HenochPancreatitis
Schnlein
Perforated
purpura
viscus
Volvulus
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 neutrophilia1 and, in the elderly, an elevated band count greater than 6 percent has
been shown to have a high predictive value for appendicitis.9 In general, however, the
WBC count and differential are only moderately helpful in confirming the diagnosis of
appendicitis because of their low specificities.
A more recently suggested laboratory evaluation is determination of the C-reactive
protein level. An elevated C-reactive protein level (greater than 0.8 mg per dL) is
common in appendicitis, but studies disagree on its sensitivity and specificity.4,5 An
elevated C-reactive protein level in combination with an elevated WBC count and
neutrophilia are highly sensitive (97 to 100 percent). Therefore, if all three of these
findings are absent, the chance of appendicitis is low.5
In patients with appendicitis, a urinalysis may demonstrate changes such as mild pyuria,
proteinuria and hematuria,1 but the test serves more to exclude urinary tract causes of
abdominal pain than to diagnose 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.
FIGURE 3. Ultrasonogram showing
Plain radiographs, while often revealing
longitudinal section (arrows) of inflamed
abnormalities in acute appendicitis, lack
appendix.
specificity and are more helpful in diagnosing
other causes of abdominal pain.
Likewise, barium enema is now used
infrequently because of the advances in TABLE 5
abdominal imaging.5

Ultrasonography and computed

tomographic (CT) scans are helpful in
evaluating patients with suspected
appendicitis.11 Ultrasonography is
appropriate in patients in which the
diagnosis is equivocal by history and
physical examination. It is especially
well suited in evaluating right lower
quadrant or pelvic pain in pediatric and
female patients. A normal appendix (6
mm or less in diameter) must be
identified to rule 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.12

Comparison of Ultrasound and

Appendiceal CT Evaluation of
Suspected Appendicitis

Appendiceal
Comparison computed
graded
tomographic
ultrasound scan
Sensitivity
Specificity
Use

Advantages

85%
92%
Evaluate
patients with
equivocal
diagnosis of
appendicitis
Safe
Relatively
inexpensive
Can rule out
pelvic
disease in
females
Better for
children

Disadvantages Operator
dependent
Technically
inadequate
studies due
to gas
Pain

90 to 100%
95 to 97%
Evaluate
patients with
equivocal
diagnosis of
appendicitis
More
accurate
Better
identifies
phlegmon
and abscess
Better
identifies
normal
appendix
Cost
Ionizing
radiation
Contrast

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 Gastrografinsaline enema (with or without oral
Information from references 11, 13, 20.
contrast) and can be performed and
interpreted within one hour.

Intravenous contrast is unnecessary.12 The accuracy of CT is due in part to its ability to

identify a normal appendix better than ultrasonography.13 An inflamed appendix is greater
than 6 mm in diameter, but the CT also demonstrates periappendiceal inflammatory
changes14 (Figures 4 and 5). If appendiceal CT is not available, standard abdominal/pelvic
CT with contrast remains highly useful and may be more accurate than ultrasonography.12

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.15 Some studies have
investigated nonoperative management with parenteral antibiotic treatment, but 40
percent of these patients eventually required appendectomy.3
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).16
While laparoscopic intervention has the advantages of decreased postoperative pain,
earlier return to normal activity and better cosmetic results, its disadvantages include
greater cost and longer operative time.4 Open appendectomy may remain the primary
approach to treatment until further cost and benefit analyses are conducted.

FIGURE 4. Computed tomographic scan showing

cross-section of inflamed appendix (A) with
appendicolith (a).

Complications

FIGURE 5. Computed tomographic scan

showing enlarged and inflamed appendix (A)
extending from the cecum (C).

Appendiceal rupture accounts for a majority of the

complications of appendicitis. Factors that increase
the rate of perforation are delayed presentation to
medical care,17 age extremes (young and old)18 and
hidden location of appendix.6 A brief period of inhospital observation (less than six hours) in
equivocal cases does not increase the perforation
rate and may improve diagnostic accuracy.18

The classic history of pain

beginning in the periumbilical
region and migrating to the
right lower quadrant occurs in
only 50 percent of patients.

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 mm3 (200 to 300 3 109 per L) with a prominent left
shift.3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative
management.4 Nonoperative management consists of parenteral antibiotics with
observation or CT-guided drainage, followed by interval appendectomy six weeks to
three months later.1

Special Considerations
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.1

The technique of appendiceal

computed tomography is more
accurate than ultrasonography
in confirming the diagnosis of
appendicitis.

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.3
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.1

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.

The Author
D. MIKE HARDIN, JR., M.D.,
is an assistant professor in the Department of Family Medicine at Scott & White Clinic
and Memorial Hospital, Bellmead, Tex., affiliated with Texas A&M University Health
Science Center in Temple. Dr. Hardin graduated from the University of Texas Medical
School at Houston and completed a residency in family practice at the McLennan County
Medical Education and Research Foundation, Waco, Tex.
Address correspondence to D. Mike Hardin, Jr., M.D., 556 North Loop 340, Bellmead, TX 76705.
Reprints are not available from the author.

REFERENCES
1.

Liu CD, McFadden DW. Acute abdomen and appendix. In: Greenfield LJ, et al., eds. Surgery:
scientific principles and practice. 2d ed. Philadelphia: Lippincott-Raven, 1997:1246-61.
2. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and
appendectomy in the United States. Am J Epidemiol 1990;132:910-25.
3. Schwartz SI. Appendix. In: Schwartz SI, ed. Principles of surgery. 6th ed. New York: McGraw
Hill, 1994:1307-18.
4. Wilcox RT, Traverso LW. Have the evaluation and treatment of acute appendicitis changed with
new technology? Surg Clin North Am 1997;77:1355-70.
5. Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653-71.
6. Guidry SP, Poole GV. The anatomy of appendicitis. Am Surg 1994;60:68-71.
7. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA
1996;276:1589-94.
8. Quantitative aspects of clinical decision making. In: SAM-CD. Windows version CD-ROM. New
York: Scientific American, 1999.
9. Elangovan S. Clinical and laboratory findings in acute appendicitis in the elderly. J Am Board Fam
Pract 1996;9:75-8.
10. Calder JD, Gajraj H. Recent advances in the diagnosis and treatment of acute appendicitis. Br J
Hosp Med 1995;54:129-33.
11. Rao PM, Feltmote CM, Rhea JT, Schulick AH, Novelline RA. Helical computed tomography in
differentiating appendicitis and acute gynecologic conditions. Obstet Gynecol 1999;93:417-21.
12. Gupta H, Dupuy DE. Advances in imaging of the acute abdomen. Surg Clin North Am 1997;77:
1245-63.

13. Rao PM, Rhea JT, Novelline RA, McCabe CJ, Lawrason JN, Berger DL, et al. Helical CT
technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT
examination. Radiology 1997;202:139-44.
14. Paulman AA, Huebner DM, Forrest TS. Sonography in the diagnosis of acute appendicitis. Am
Fam Physician 1991;44:465-8.
15. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ, et al. Effect of computed
tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med
1998;338: 141-6.
16. Geis WP, Miller CE, et al. Laparoscopic appendectomy for acute appendicitis: rationale and
technical aspects. Contemp Surg 1992;40:13-9.
17. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults: a prospective
study. Ann Surg 1995;221:278-81.
18. Ricci MA, Trevisani MF, Beck WC. Acute appendicitis: a five year review. Am Surg 1991;57:3015.
19. Jaeschke R, Guyatt GH, Sackett DL. Users' guides to the medical literature. III. How to use an
article about a diagnostic test. B. What are the results and will they help me in caring for my
patients? The Evidence-Based Medicine Working Group. JAMA 1994;271:703-7.
20. Orr RK, Porter D, Hartman D. Ultrasonography to evaluate adults for appendicitis: decision
making based on meta-analysis and probabilistic reasoning. Acad Emerg Med 1995;2:644-50.
Copyright 1999 by the American Academy of Family Physicians.
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