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Introduction The appendix is a wormlike extension of the cecum and, for this reason, has been called thevermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm).The appendix appears during the fifth month of gestation, and several lymphoid follicles arescattered in its mucosa. Such follicles increase in number when individuals are aged 8-20 years.
(See image below and Image 1.)

Normal appendix; barium enema radiographic examination. A complete contrast-filledappendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.

Normal appendix; barium enema radiographic examination. A complete contrast-filledappendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.
Appendicitis is inflammation of the inner lining of the vermiform appendix that spreads to itsother parts. Appendicitis may occur for several reasons, such as an infection of the appendix, butthe most important step is the obstruction of the appendiceal lumen Appendicitis is one of the more common surgical emergencies, and it is one of the most commoncauses of abdominal pain. In the last few years, though, the incidence and mortality rate of appendicitis has markedly decreased

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and IntestineCenter . Also, see eMedicine's patient education articlesAppendicitisandAbdominal Pain in Adults. History of the Procedure The first report of an appendectomy came from Amyan, asurgeon of theEnglish army. Amyanperformed an appendectomy in 1735 without anesthesia toremove a perforated appendix.R eginald H.Fitz, an anatomopathologist at Harvard who advocated early surgical intervention,first described appendicitis in 1886. Because he was not a surgeon, his advice was ignored for a time.

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Then, at the end of the 19th century, the English surgeon H. Hancock successfully performed thefirst appendectomy in a patient with acute appendicitis. Some years after this, the American C.McBurney published a series of reports that constituted the basis of the subsequent diagnosticand therapeutic management of acute appendicitis. Appendectomy, either open noncomplicatedappendicitis. Problem Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinicalemergency. In fact, appendicitis is one of the more common causes of acute abdominal pain. Leftuntreated, appendicitis has the potential for severe complications, including perforation or sepsis,and may even cause death. The diagnosis of appendicitis is clinical and essentially is based on history and clinicalexamination findings. The classic form of appendicitis may be promptly diagnosed and treated.When appendicitis appears with atypical presentations, it remains a clinical challenge. In suchcases, laboratory and imaging investigation may be useful in establishing a correct diagnosis of appendicitis. (See images below and Images 2, 3, 4.) or laparoscopic, currently remains the treatment of

Computed tomography scan reveals an enlarged appendix with thickened walls, which donot fill with colonic contrast agent, lying adjacent to the right psoas muscle.

Computed tomography scan reveals an enlarged appendix with thickened walls, which donot fill with colonic contrast agent, lying adjacent to the right psoas muscle.

Computed tomography (CT) study of appendicitis. Intravenous (IV) contrast wasadministered to the patient, who had gram-negative sepsis but no abdominal pain onexamination.Left , an inconclusive CT scan after administration of oral contrast but noIV contrast.Right , arepeat CT scan study following administration of IV contrastdemonstrates the thickened, enhanced appendiceal wall and periappendiceal changes. Theretrocecal location of the appendix may have attenuated abdominal symptoms.

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Computed tomography (CT) study of appendicitis.Intravenous (IV) contrast was administered to the patient, who had gram-negative sepsis but no abdominal pain onexamination.Left , an inconclusive CT scan after administration of oral contrast but noIV contrast.Right , a repeat CT scan study following administration of IV contrastdemonstrates the thickened, enhanced appendiceal wall and periappendiceal changes. Theretrocecal location of the appendix may have attenuated abdominal symptoms.

Suppurative appendicitis; transverse view, color Doppler ultrasound image.Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strongindicator of acute appendicitis.

Suppurative appendicitis; transverse view, color Doppler ultrasound image.Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strongindicator of acute appendicitis.

Statistics report that 1 of 5 cases of appendicitis is misdiagnosed; however, a normal appendix isfound in 15-40% of patients who have an emergency appendectomy. Although many antibiotics to control infections are available, appendicitis remains a surgicaldisease. In fact, appendectomy is the only rational therapy for acute appendicitis. It avoidsclinical deterioration and may avoid chronic or recurrent appendicitis. Although difficult, prompt preventcomplications. recognition and immediate treatment of appendicitis

Frequency The incidence of acute appendicitis is around 7% of the population in the United States and in European countries. In Asian and African countries, the incidence of acute appendicitis isprobably lower because of the dietary habits of the inhabitants of these geographic areas.

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In the last few years, a decrease in frequency of appendicitis in Western countries has beenreported, which may be related to changes in dietary fiber intake. In fact, the higher incidence of appendicitis is believed to be related to poor fiber intake in such countries.Persons of any age may be affected, with highest incidence occurring during the second and thirddecades of life .R are cases of neonatal and prenatal appendicitis have been reported.Appendicitis occurs more frequently in males than in females, with a male-to-female ratio of 1.7:1. Etiology Appendicitis is caused by obstruction of the appendiceal lumen. The causes of the obstructioninclude lymphoid hyperplasia secondary to irritable bowel disease (IBD) or infections (morecommon during childhood and in young adults), fecal stasis and fecaliths (more common inelderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms. Lymphoid hyperplasia of the appendix may be related to Crohn disease, mononucleosis,amebiasis, measles, and GI and respiratory infections.Fecaliths are solid bodies within theappendix that form after precipitation of calcium salts and undigested fiber in a matrix of dehydrated fecal material. Pathophysiology Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes. Independent of the etiology, obstruction is believed to cause an increase in pressurewithin the lumen. Such an increase is related to continuous secretion of fluids and mucus fromthe mucosa and the stagnation of this material. At the same time, intestinal bacteria within theappendix multiply, leading to the recruitment of white cells and the formation of pus andsubsequent higher intraluminal pressure. (See image below andImage 5.)

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled whiteblood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled whiteblood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.

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If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of theappendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wallischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of theappendiceal wall. Various specific bacteria, viruses, fungi, and parasites can be responsible agents of infection thataffect the appendix, including.Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species,Histoplasma species, Schistosomaspecies, pinworms, and Strongyloidesstercoralis. Within a few hours, this localized condition may worsen because of thrombosis of theappendicular artery and veins, leading to perforation and gangrene of the appendix. As thisprocess continues, a periappendicular abscess or peritonitismay occur.

Presentation The most common symptom of appendicitis is abdominal pain. Typically, symptoms begin asperiumbilical or epigastric pain migrating to the right lower quadrant (R LQ) of the abdomen Later, a worsening progressive pain along with vomiting, nausea, and anorexia are described bythe patient. Usually, a fever is not present at this stage. In addition to recording the history of the abdominal pain, obtain a complete summary of therecent personal history surrounding gastroenterologic, genitourinary, and pneumologicconditions. Also, consider gynecologic history in female patients. The differential diagnosis of appendicitis is often a clinical challenge because appendicitis canmimic several abdominal conditions. The differential diagnosis of appendicitis must includecholecystitis and biliary colic, gastroenteritis, enterocolitis, diverticulitis, pancreatitis, perforatedduodenal ulcer, renal colic, and urinary tract infection (UTI). In pediatric patients, consider mesenteric lymphadenitis and intussusception. In women of childbearing age who are notpregnant, the differential diagnosis of appendicitis must also include ovarian cyst torsion,mittelschmerz, ectopic pregnancy, and pelvic inflammatory disease. Small bowel obstruction,Crohn disease, Meckel diverticulitis, tumors, Henoch-Schnlein purpura, and rectus sheathhematoma are more rare conditions that mimic appendicitis. Usually, patients are lying down, flexing their hips, and drawing their knees up to reducemovements and to avoid worsening the pain. A careful physical examination, not limited to the abdomen, must be performed in any patientwith suspected appendicitis. GI, genitourinary, and pulmonary systems must be studied. Performa rectal examination in any patient with an unclear clinical picture, and perform a pelvicexamination in all women with abdominal pain. Tenderness on palpation in the R LQ over the McBurney point is the most important sign in thesepatients. Additional signs, such as increasing pain with cough (ie, Dunphy sign), reboundtenderness related to peritoneal irritation elicited by deep palpation with quick release (ie,Blumberg sign), and guarding, may or may not be present. Patients with appendicitis may not have the reported classic clinical picture 37-45% of the time,especially when the appendix is located in an unusual place (see Relevant Anatomy). In suchcases, imaging studies may be important but not always available. Patients with appendicitisusually have accessory signs that may be helpful for diagnosis.For example, the obturator sign ispresent when the internal rotation of the thigh elicits pain (ie, pelvic appendicitis), and the psoassign is present when the extension of the right thigh elicits pain (ie, retroperitoneal or retrocecalappendicitis).

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In regard to variations in clinical presentation, Niwa et al reported an interesting case of recurrentpain in a young woman referred for appendicitis and treated with antibiotics.After 12 months,the woman underwent a laparotomy, demonstrating appendiceal diverticulitis associated with arare pelvic pseudocyst, probably due to diverticular perforation of the pseudocyst. Indications Consider an appendectomy for patients with a history of persistent abdominal pain, fever, andclinical signs of localized or diffuse peritonitis, especially if leukocytosis is present. If the clinical picture is unclear, a short period (4-6 h) of watchful waiting and a computedtomography (CT) scan may improve diagnostic accuracy and help to hasten diagnosis. However,if a patient is discharged from the medical center without a definite diagnosis at the end of theobservation period, instruct the patient to return for continued or recurrent symptoms, and thepatient may benefit from a follow-up examination in 24 hours. Relevant Anatomy The appendix is a wormlike extension of the cecum, and the average length of the appendix is 810 cm (ranging from 2-20 cm). The appendix appears during the fifth month of gestation, and itswall has an inner mucosal layer, 2 muscular layers, and a serosa. Several lymphoid follicles arescattered in its mucosa. The number of follicles increases when individuals are aged 8-20 years. The inner muscular layer is circular, and the outer layer is longitudinal and derives from thetaenia coli. Taenia coli converge on the posteromedial area of the cecum. This site is theappendiceal base. The appendix runs into a serosal sheet of the peritoneum called themesoappendix.Within the mesoappendix courses the appendicular artery, which is derived fromthe ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found. The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. Thecourse of the appendix and the position of its tip may vary widely, accounting for the nonspecificsigns and symptoms of appendicitis. In fact, many individuals may have an appendix located inthe retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver. Contraindications Patients with appendicitis always need urgent referral and prompt treatment. Nocontraindications to appendectomy are known for patients with suspected appendicitis, except inthe case of a patient with a long history of symptoms and signs of a large phlegmon. If aperiappendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture,some clinicians may choose a conservative approach with broad-spectrum antibiotics andpercutaneous drainage followed by appendectomy later. Certain contraindications exist for laparoscopic appendectomy. These contraindications areextensive adhesions, radiation or immunosuppressive therapy, severe portal hypertension, andcoagulopathies. Laparoscopic appendectomy is contraindicated in the first trimester of pregnancy. Rarely, an appendiceal mucocele may occur. It is a collection of mucus within the appendiceallumen. Occasionally, patients may present with a low-grade carcinoma of the appendix or the

cecum. In such cases, the surgeon must avoid perforation during dissection because it may causeseeding of the peritoneum with viable cells, leading to pseudomyxoma peritonei.(Enlarge Image)

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Media file 1: Normal appendix; barium enema radiographicexamination. A complete contrastfilled appendix is observed(arrows), which effectively excludes the diagnosis of appendicitis Normal appendix; barium enema radiographic examination. A complete contrast-filledappendix is observed (arrows), which effectively excludes the diagnosis of appendicitis

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(Enlarge Image) Media file 2: Computed tomography scan reveals an enlargedappendix with thickened walls, which do not fill with coloniccontrast agent, lying adjacent to the right psoas muscle.

Computed tomography scan reveals an enlarged appendix with thickened walls, which donot fill with colonic contrast agent, lying adjacent to the right psoas muscle.

(Enlarge Image) Media file 3: Computed tomography (CT) study of appendicitis.Intravenous (IV) contrast was administered to the patient, whohad gram-negative sepsis but no abdominal pain on examination.Left , an inconclusive CT scan after administration of oral contrastbut no IVcontrast.Right , a repeat CT scan study followingadministration of IV contrast demonstrates the thickened,enhanced appendiceal wall and periappendiceal changes. Theretrocecal location of the appendix may have attenuatedabdominal symptoms

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Computed tomography (CT) study of appendicitis.Intravenous (IV) contrast wasadministered to the patient, who had gram-negative sepsis but no abdominal pain onexamination.Left , an inconclusive CT scan after administration of oral contrast but no IV contrast.Right , a repeat CT scan study following administration of IV contrastdemonstrates the thickened, enhanced appendiceal wall and periappendiceal changes. Theretrocecal location of the appendix may have attenuated abdominal symptoms.

(Enlarge Image) Media file 4: Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed inthe wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis

Suppurative appendicitis; transverse view, color Doppler ultrasound image.Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strongindicator of acute appendicitis.

Media file 5: Technetium-99m radionuclide scan of the abdomenshows focal uptake of labeled white blood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.

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Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled whiteblood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.

(Enlarge Image) Media file 6: Sagittal graded compression transabdominal ultrasonogramshows an acutely inflamed appendix. The tubular structure isnoncompressible, lacks peristalsis, and measures greater than 6 mm indiameter. A thin rim of periappendiceal fluid is present.

Sagittal graded compression transabdominal ultrasonogram shows an acutely inflamedappendix. The tubular structure is noncompressible, lacks peristalsis, and measuresgreater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.

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Media file 7: Transverse graded compression transabdominalultrasonogram of an acutely inflamed appendix. Note the targetlikeappearance due to thickened wall and surrounding loculated fluidcollection.