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Introduction
Background
Appendicitis is a common and urgent surgical illness with protean manifestations, generous
overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic
delay. No single sign, symptom, or diagnostic test accurately confirms the diagnosis of
appendiceal inflammation in all cases.
The surgeon's goals are to evaluate a relatively small population of patients referred for
suspected appendicitis and to minimize the negative appendectomy rate without increasing the
incidence of perforation. The emergency department clinician must evaluate the larger group of
patients who present to the ED with abdominal pain of all etiologies with the goal of approaching
100% sensitivity for the diagnosis in a time-, cost-, and consultation-efficient manner.
Pathophysiology
Obstruction of the appendiceal lumen is the primary cause of appendicitis. An anatomic blind
pouch, obstruction of the appendiceal lumen leads to distension of the appendix due to
accumulated intraluminal fluid. Ineffective lymphatic and venous drainage allows bacterial
invasion of the appendiceal wall and, in advanced cases, perforation and spillage of pus into the
peritoneal cavity.
Frequency
United States
Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000 people
per year. Some familial predisposition exists.
International
Incidence of appendicitis is lower in cultures with a higher intake of dietary fiber. Dietary fiber is
thought to decrease the viscosity of feces, decrease bowel transit time, and discourage formation
of fecaliths, which predispose individuals to obstructions of the appendiceal lumen.
Mortality/Morbidity
• The overall mortality rate of 0.2-0.8% is attributable to complications of the disease
rather than to surgical intervention.
• Mortality rate rises above 20% in patients older than 70 years, primarily because of
diagnostic and therapeutic delay.
• Perforation rate is higher among patients younger than 18 years and patients older than 50
years, possibly because of delays in diagnosis. Appendiceal perforation is associated with
a sharp increase in morbidity and mortality rates.
Sex
The incidence of appendicitis is approximately 1.4 times greater in men than in women. The
incidence of primary appendectomy is approximately equal in both sexes.
Age
• Incidence of appendicitis gradually rises from birth, peaks in the late teen years, and
gradually declines in the geriatric years. The median age at appendectomy is 22 years.
• Although rare, neonatal and even prenatal appendicitis have been reported.
• The emergency department clinician must maintain a high index of suspicion in all age
groups.
Clinical
History
• Variations in the position of the appendix, age of the patient, and degree of inflammation
make the clinical presentation of appendicitis notoriously inconsistent.
• It is important to remember that the position of the appendix is variable. Of 100 patients
undergoing 3-D multidetector CT, the base of the appendix was located at McBurney's
point in only 4% of patients. In 36% of patients, the base was within 3 cm of McBurney's
point; in 28%, it was 3-5 cm from McBurney's point; and, in 36% of patients, the base of
the appendix was more than 5 cm from McBurney's point.
• In addition, patients with many other disorders present with symptoms similar to those of
appendicitis. Examples include the following:
o Pelvic inflammatory disease (PID) or tubo-ovarian abscess
o Endometriosis
o Ovarian cyst or torsion
o Ureterolithiasis and renal colic
o Degenerating uterine leiomyomata
o Diverticulitis
o Crohn disease
o Colonic carcinoma
o Rectus sheath hematoma
o Cholecystitis
o Bacterial enteritis
o Mesenteric adenitis
o Omental torsion
• The classic history of anorexia and periumbilical pain followed by nausea, right lower
quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
• Migration of pain from the periumbilical area to the RLQ is the most discriminating
feature of the patient's history. This finding has a sensitivity and specificity of
approximately 80%.
• When vomiting occurs, it nearly always follows the onset of pain. Vomiting that precedes
pain is suggestive of intestinal obstruction, and the diagnosis of appendicitis should be
reconsidered.
• Nausea is present in 61-92% of patients; anorexia is present in 74-78% of patients.
Neither finding is statistically different from findings in ED patients with other etiologies
of abdominal pain.
• Diarrhea or constipation is noted in as many as 18% of patients and should not be used to
discard the possibility of appendicitis.
• Duration of symptoms is less than 48 hours in approximately 80% of adults but tends to
be longer in elderly persons and in those with perforation. Approximately 2% of patients
report duration of pain in excess of 2 weeks.
• A history of similar pain is reported in as many as 23% of cases. A history of similar
pain, in and of itself, should not be used to rule out the possibility of appendicitis.
• An inflamed appendix near the urinary bladder or ureter can cause irritative voiding
symptoms and hematuria or pyuria. Cystitis in male patients is rare in the absence of
instrumentation. Consider the possibility of an inflamed pelvic appendix in male patients
with apparent cystitis.
• Also consider the possibility of appendicitis in pediatric or adult patients who present
with acute urinary retention.
Physical
• Male infants and children occasionally present with an inflamed hemiscrotum due to
migration of an inflamed appendix or pus through a patent processus vaginalis. This is
often initially misdiagnosed as acute testicular torsion.
• RLQ tenderness is present in 96% of patients, but this is a nonspecific finding. Rarely,
left lower quadrant (LLQ) tenderness has been the major manifestation in patients with
situs inversus or in patients with a lengthy appendix that extends into the LLQ.
• The most specific physical findings are rebound tenderness, pain on percussion, rigidity,
and guarding.
• The Rovsing sign (RLQ pain with palpation of the LLQ) suggests peritoneal irritation in
the right lower quadrant precipitated by palpation at a remote location.
• The obturator sign (RLQ pain with internal or external rotation of the flexed right hip)
suggests that the inflamed appendix is located deep in the right hemipelvis.
• The psoas sign (RLQ pain with extension of the right hip) suggests that an inflamed
appendix is located along the course of the right psoas muscle.
• These signs are present in a minority of patients with acute appendicitis. Their absence
never should be used to rule out appendiceal inflammation.
• Dunphy's sign (sharp pain in the RLQ elicited by a voluntary cough) may be helpful in
making the clinical diagnosis of localized peritonitis. Similarly, RLQ pain in response to
percussion of a remote quadrant of the abdomen, or to firm percussion of the patient's
heel, suggests peritoneal inflammation. The Markle sign, pain elicited in a certain area of
the abdomen when the standing patient drops from standing on toes to the heels with a
jarring landing, is stated in DeGowin's Diagnostic Examination to be very sensitive for
localizing true peritonitis.1
• There is no evidence in the medical literature that the digital rectal examination (DRE)
provides useful information in the evaluation of patients with suspected appendicitis;
however, failure to perform a rectal examination is frequently cited in successful
malpractice claims. In 2008, Sedlak et al studied 577 patients who underwent DRE as
part of an evaluation for suspected appendicitis and found no value as a means of
distinguishing patients with and without appendicitis.2
Causes
Differential Diagnoses
Abdominal Abscess Mesenteric
Lymphadenitis
Meckel Diverticulum
Mesenteric Ischemia
Workup
Laboratory Studies
Studies consistently show that 80-85% of adults with appendicitis have a WBC count greater
than 10,500 cells/mm3. Neutrophilia greater than 75% occurs in 78% of patients. Fewer than 4%
of patients with appendicitis have a WBC count less than 10,500 cells/mm3 and neutrophilia less
than 75%.
Dueholm et al, in 1989, further delineated the relationship between WBC count and the
likelihood of appendicitis by calculating likelihood ratios for defined intervals of the WBC
count.3
[ CLOSE WINDOW ]
Table
WBC (X Likelihood Ratio
10,000) (95% CI*)
19-22 ∞
19-22 ∞
CBC tests are inexpensive, rapid, and widely available; however, the findings are nonspecific.
The literature is inconsistent with regard to WBC counts in children and elderly patients with
appendicitis.
In a 1989 study of 70 patients, Thimsen et al noted that a normal CRP level after 12 hours of
symptoms was 100% predictive of benign, self-limited illness.4
Multiple studies have examined the sensitivity of CRP alone for the diagnosis of appendicitis in
patients selected to undergo appendectomy.
Investigators have also studied the ability of combinations of WBC and CRP to reliably rule out
the diagnosis of appendicitis.
Some studies have examined the sensitivity of combined WBC and CRP in the subpopulation of
patients older than 60 years.
Several studies have examined the accuracy of CRP and WBC in the subpopulation of pediatric
patients with suspected appendicitis.
• Gronroos, in 2001, studied 100 children with pathology-proven appendicitis
and found that both WBC and CRP were normal in 7 of the 100 patients.15
• Mohammed, in 2004, prospectively studied 216 children admitted for
suspected appendicitis and found triple screen sensitivity and negative
predictive value of 86% and 81%, respectively.16
• Stefanutti et al, in 2007, prospectively studied more than 100 children
undergoing surgery for suspected appendicitis and found that either WBC or
CRP was elevated in 98% of those with pathology-proven appendicitis (CI,
95.3-100%).17
CRP is nonspecific and does not distinguish between various types of infection or inflammation.
Urinalysis
One study of 500 patients with acute appendicitis revealed that approximately one third reported
urinary symptoms, most commonly dysuria or right flank pain. One in 7 patients had pyuria
greater than 10 WBC per high power field, and 1 in 6 patients had greater than 3 RBC per high
power field. Thus, the diagnosis of appendicitis should not be dismissed due to the presence of
urologic symptoms or abnormal urinalysis.18
Imaging Studies
• Computed tomography
o Abdominal CT has become the most important imaging study in the
evaluation of patients with atypical presentations of appendicitis.
Studies have found a decrease in negative laparotomy rate and
appendiceal perforation rate when pelvic CT was used in selected
patients with suspected appendicitis.19,20,21,22
o
CT scan reveals an enlarged appendix with thickened walls, which do not fill
with colonic contrast agent, lying adjacent to the right psoas muscle.
[ CLOSE WINDOW ]
CT scan reveals an enlarged appendix with thickened walls, which do not fill
with colonic contrast agent, lying adjacent to the right psoas muscle.
[ CLOSE WINDOW ]
o
Transverse graded compression transabdominal sonogram of an acutely
inflamed appendix. Note the targetlike appearance due to thickened wall and
surrounding loculated fluid collection.
[ CLOSE WINDOW ]
Transverse graded compression transabdominal sonogram of an acutely
inflamed appendix. Note the targetlike appearance due to thickened wall and
surrounding loculated fluid collection.
[ CLOSE WINDOW ]
Kidneys-ureters-bladder (KUB) radiograph shows an appendicolith in the
right lower quadrant. An appendicolith is seen in fewer than 10% of patients
with appendicitis, but, when present, it is essentially pathognomonic.
[ CLOSE WINDOW ]
Other Tests
Several investigators have created diagnostic scoring systems in which a finite number of clinical
variables is elicited from the patient and each is given a numerical value. The sum of these
values is used to predict the likelihood of acute appendicitis.
The best known of these is the MANTRELS score, which tabulates migration of pain, anorexia,
nausea and/or vomiting, tenderness in the RLQ, rebound tenderness, elevated temperature,
leukocytosis, and shift to the left (Table 2).
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Table
Characteristic Scor
e
M = Migration of pain to 1
the RLQ
A = Anorexia 1
T = Tenderness in RLQ 2
R = Rebound pain 1
E = Elevated temperature 1
L = Leukocytosis 2
Total 10
Scor
Characteristic
e
M = Migration of pain to 1
the RLQ
A = Anorexia 1
T = Tenderness in RLQ 2
R = Rebound pain 1
E = Elevated temperature 1
L = Leukocytosis 2
Total 10
Source.—Alvarado, 1986.48
Clinical scoring systems are attractive because of their simplicity; however, none has been
shown prospectively to improve on the clinician's judgment in the subset of patients evaluated in
the ED for abdominal pain suggestive of appendicitis. The MANTRELS score, in fact, was based
on a population of patients hospitalized for suspected appendicitis, which differs markedly from
the population seen in the ED.
Schneider et al, in 2007, studied 588 patients aged 3-21 years and found that a MANTRELS
score of 7 or greater had a positive predictive value of 65% and a negative predictive value of
85%. They concluded that the MANTRELS score was not sufficiently accurate to be used as the
sole method for determining the need for appendectomy in the pediatric population.50
Computer-aided diagnosis
A retrospective database of clinical features of patients with appendicitis and other causes of
abdominal pain is entered into a computer. It is then used in prospectively assessing the risk of
appendicitis.
Computer-aided diagnosis can achieve a sensitivity greater than 90% while reducing rates of
perforation and negative laparotomy by as much as 50%.
The principle disadvantages are that each institution must generate its own database to reflect
characteristics of its local population. Specialized equipment and significant initiation time are
required.
Treatment
Emergency Department Care
Consultations
Medication
The goals of therapy are to eradicate the infection and to prevent complications.
Antibiotics
These agents are effective in decreasing the rate of postoperative wound infection and in
improving outcome in patients with appendiceal abscess or septicemia. The Surgical Infection
Society recommends starting prophylactic antibiotics before surgery, using appropriate spectrum
agents for less than 24 hours for nonperforated appendicitis and for less than 5 days for
perforated appendicitis. Regimens are of approximately equal efficacy, so consideration should
be given to features such as medication allergy, pregnancy category (if applicable), toxicity, and
cost.
Metronidazole (Flagyl)
Used in combination with aminoglycoside (eg, gentamicin); broad gram-negative and anaerobic
coverage. Appears to be absorbed into cells; intermediate metabolized compounds bind DNA
and inhibit protein synthesis, causing cell death.
Adult
Pediatric
15-30 mg/kg/d IV divided bid/tid for 7 d, or 40 mg/kg PO once; not to exceed 2 g/d
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and peripheral neuropathy
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with agent against
gram-positive organisms and one against anaerobes. Not DOC. Consider if penicillins or other
less toxic drugs contraindicated, when clinically indicated, and in mixed infections caused by
susceptible staphylococci and gram-negative organisms. Numerous regimens; adjust dose for
CrCl and changes in volume of distribution. May be given IV/IM.
Adult
2 mg/kg IV loading dose before surgery; 3-5 mg/kg/d divided tid/qid thereafter
Pediatric
Cefotetan (Cefotan)
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Documented hypersensitivity
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dose by half if CrCl 10-30 mL/min and by three quarters if <10 mL/min; bacterial or
fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Cefoxitin (Mefoxin)
Second-generation cephalosporin indicated as single agent for management of infections caused
by susceptible gram-positive cocci and gram-negative rods. Half-life is 0.8 h.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Documented hypersensitivity
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or
repeated treatment; caution in patients with previously diagnosed colitis
Meropenem (Merrem)
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Used as a
single agent, effective against most gram-positive and gram-negative bacteria.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
1 g IV q8h
Pediatric
40 mg/kg IV q8h
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Documented hypersensitivity
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Drug combination of beta-lactamase inhibitor with piperacillin. Activity against some gram-
positive organisms, gram-negative organisms, and anaerobic bacteria. Used as a single agent,
inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active
multiplication.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
3.375 g IV q6h
Pediatric
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver
function abnormalities by measuring AST and ALT during therapy; exercise caution in patients
diagnosed with hepatic insufficiencies; perform urinalysis, and BUN and creatinine
determinations during therapy and adjust dose if values become elevated; monitor blood levels to
avoid possible neurotoxic reactions
Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall
synthesis during active replication, causing bactericidal activity against susceptible organisms.
Used as a single agent.
Activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal
species), and anaerobic bacteria.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
• Dosing
• Interactions
• Contraindications
• Precautions
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and
has additive effects on ampicillin rash; may decrease effects of oral contraceptives
• Dosing
• Interactions
• Contraindications
• Precautions
Documented hypersensitivity
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Analgesics
These agents can be used to relieve acute undifferentiated abdominal pain in patients presenting
to the ED.
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of
reversibility with naloxone. Various IV doses are used; commonly titrated to desired effect.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may
start at 0.05 mg/kg/dose
Follow-up
Further Inpatient Care
• Wound infection
• Dehiscence
• Bowel obstruction
• Abdominal/pelvic abscess
• Stump appendicitis - Although rare, approximately 36 reported cases of appendicitis in
the surgical stump after prior appendectomy exist.54
• Death (rare)
Prognosis
Patient Education
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and
Intestine Center. Also, see eMedicine's patient education articles, Appendicitis and
Abdominal Pain in Adults.
Miscellaneous
Medicolegal Pitfalls
• For approximately 10% of adults with appendicitis, the condition is not diagnosed
correctly on their first visit to the health care provider.
• Failure to diagnose appendicitis is the leading cause of successful malpractice claims and
the fifth most expensive source of claims against emergency physicians.
Special Concerns
• Pregnant women
o The incidence of appendicitis is unchanged in pregnancy, but the clinical
presentation is more variable than at other times.
o During pregnancy, the appendix migrates in a counterclockwise direction toward
the right kidney, rising above the iliac crest at about 4.5 months' gestation.
o RLQ pain and tenderness dominate in the first trimester, but in the latter half of
pregnancy, right upper quadrant (RUQ) or right flank pain must be considered a
possible sign of appendiceal inflammation.
o Nausea, vomiting, and anorexia are common in uncomplicated first trimester
pregnancies, but their reappearance later in gestation should be viewed with
suspicion.
o Physiologic leukocytosis during pregnancy makes the WBC count less useful in
the diagnosis than at other times, and no reliable distinguishing WBC parameters
are cited in the literature.
o One study of 22 pregnant women in the first and second trimesters showed that
graded compression ultrasonography had a sensitivity of 66% and specificity of
95%.55
o Diagnostic laparoscopy has also been suggested for pregnant patients in the first
trimester with suspected appendicitis.
o Although negative appendectomy does not appear to adversely affect maternal or
fetal health, diagnostic delay with perforation does increase fetal and maternal
morbidity. Therefore, aggressive evaluation of the appendix is warranted in this
group.
• Nonpregnant women of childbearing age
o Appendicitis is misdiagnosed in 33% of nonpregnant women of childbearing age.
The most frequent misdiagnoses are PID, followed by gastroenteritis and urinary
tract infection.
o In distinguishing appendiceal pain from that of PID, anorexia and onset of pain
more than 14 days after menses suggests appendicitis. Previous PID, vaginal
discharge, or urinary symptoms indicates PID.
o On physical examination, tenderness outside the RLQ, cervical motion
tenderness, vaginal discharge, and positive urinalysis support the diagnosis of
PID.
• Children
o Appendicitis is misdiagnosed in 25-30% of children, and the rate of initial
misdiagnosis is inversely related to the age of the patient.
o The most common misdiagnosis is gastroenteritis, followed by upper respiratory
infection and lower respiratory infection.
o Children with misdiagnosed appendicitis are more likely than their counterparts to
have vomiting before pain onset, diarrhea, constipation, dysuria, signs and
symptoms of upper respiratory infection, and lethargy or irritability.
o Physical findings less likely to be documented in children with a misdiagnosis
than in others include bowel sounds; peritoneal signs; rectal findings; and ear,
nose, and throat findings.
• Elderly patients
o Appendicitis in patients older than 60 years accounts for 10% of all
appendectomies.
o The incidence of misdiagnosis is increased in elderly patients.
o In patients with comorbid conditions, diagnostic delay is correlated with increased
morbidity and mortality.
o Older patients tend to seek medical attention later in the course of illness;
therefore, a duration of symptoms in excess of 24-48 hours should not dissuade
the clinician from the diagnosis.
• Multimedia
Media file 1: CT scan reveals an enlarged appendix with
thickened walls, which do not fill with colonic contrast agent,
lying adjacent to the right psoas muscle.
(Enlarge Image)
• [ CLOSE WINDOW ]
•
• CT scan reveals an enlarged appendix with thickened walls, which do not fill with
colonic contrast agent, lying adjacent to the right psoas muscle.
(Enlarge Image)
• [ CLOSE WINDOW ]
•
• Sagittal graded compression transabdominal sonogram shows an acutely inflamed
appendix. The tubular structure is noncompressible, lacks peristalsis, and measures
greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.
Media file 3: Transverse graded compression transabdominal sonogram
of an acutely inflamed appendix. Note the targetlike appearance due to
thickened wall and surrounding loculated fluid collection.
(Enlarge Image)
• [ CLOSE WINDOW ]
•
• Transverse graded compression transabdominal sonogram of an acutely inflamed
appendix. Note the targetlike appearance due to thickened wall and surrounding
loculated fluid collection.
(Enlarge Image)
• [ CLOSE WINDOW ]
•
• Kidneys-ureters-bladder (KUB) radiograph shows an appendicolith in the right
lower quadrant. An appendicolith is seen in fewer than 10% of patients with
appendicitis, but, when present, it is essentially pathognomonic.
Media file 5: Technetium-99m radionuclide scan of the abdomen
shows focal uptake of labeled WBCs in the right lower quadrant
consistent with acute appendicitis.
(Enlarge Image)