Original Paper

Received: August 19, 2012

Accepted after revision: February 19, 2013
Published online: July 6, 2013

Dig Surg 2013;30:198206

DOI: 10.1159/000350043

Manifestations of Acute Appendicitis:

A Prospective Study on Acute Abdominal
Pain
H. Laurell a L.-E. Hansson b U. Gunnarsson c
Departments of Surgery at a Mora Hospital, Mora, b Sahlgrenska University Hospital, Gothenburg, and
c
Karolinska Institute, Stockholm, Sweden

Key Words
Appendicitis Acute abdominal pain Symptoms

Abstract
Background/Aims: The aim of this prospective study was to
identify the clinical symptoms and signs most important for
the prediction of appendicitis among patients with acute abdominal pain. Methods: Clinical findings in 2,478 patients
admitted to the emergency department of Mora Hospital
from February 1997 to June 2000, with acute abdominal pain
of up to 7 days duration, were registered in a database. The
medical records were reviewed after 1 year. Results: A total
of 432 patients were suspected of having appendicitis and
in 221 this diagnosis was confirmed. Some 53 patients, with
another preliminary diagnosis, were eventually found to suffer from appendicitis, making a total of 274 patients with appendicitis. Appendectomy was performed in 316 patients
and was negative in 14%. Clinical diagnosis of appendicitis
had a sensitivity of 0.81, a specificity of 0.90, a positive predictive value of 0.51, a positive likelihood ratio of 8.1, and a
diagnostic accuracy of 0.89. The highest odds ratios were
found for isolated tenderness in the right iliac fossa (3.29),
rebound tenderness (3.00), right-sided rectal tenderness
(2.53), migration of pain to the right iliac fossa (2.18), and local guarding (2.11). Conclusion: Clinical findings indicating
localised inflammation in the right iliac fossa were reliable in

2013 S. Karger AG, Basel

02534886/13/03030198$38.00/0
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predicting acute appendicitis. The patients history of pain

combined with a careful clinical examination still plays an
important role in detecting appendicitis among patients
with acute abdominal pain.
Copyright 2013 S. Karger AG, Basel

Introduction

Acute appendicitis is one of the most common differential diagnoses in a surgical emergency department. Epidemiological studies have shown frequencies of appendicitis of about 10% among unselected patients with acute
abdominal pain [13]. Nevertheless, this diagnosis is still
a challenge on account of the great variation in its manifestations. To improve the diagnostic accuracy, scoring
systems and computer-aided diagnostic programs have
been tested, often with fairly good results, but they have
not been used commonly in clinical routine practice.
Even though the use of computed tomography (CT) and
ultrasonography as a diagnostic tool has increased over
the last few years [4], the diagnosis of appendicitis is still
often based on the patients history, clinical examination,
and laboratory tests alone [5]. Many of the symptoms that
have traditionally been associated with appendicitis,
namely nausea, loss of appetite, and right-sided rectal
tenderness, have been shown to have only low or no diDr. Helena Laurell
Department of Surgery, Mora Hospital
SE792 85 Mora (Sweden)
E-Mail helena.laurell@ltdalarna.se

agnostic value [6]. Most studies on appendicitis have been

based on patients diagnosed with appendicitis or with
suspected appendicitis. The present study, however, is
based on all patients admitted to the emergency department with acute abdominal pain. The aim of this study
was to assess the value, in the diagnosis of appendicitis, of
symptoms and signs that are commonly recorded in patients with acute abdominal pain.

28 patients with appendicitis who should have been included in

our database register. These records were also checked at the follow-up to establish the final diagnosis and were included only in
the calculation of the incidence rate. The diagnostic criteria for appendicitis were microscopic findings of inflammation at the histopathological examination or the surgeons macroscopic judgement that the appendix showed inflammation. The histopathological criterion for appendicitis was the presence of transmural
infiltration by granulocytes. Microscopic examination was performed on 112 surgically removed appendices, and the surgeons
assessment regarding inflammation was the same as that of the
pathologists in 101 (90%) cases [7].

Patients and Methods

Mora Hospital, in the central part of Sweden, is a rural district
hospital with a catchment population of about 87,000. This population is demographically stable, and almost 100% of the emergency care to the population is provided by Mora Hospital. This
hospital also provides care for a substantial number of tourists. The
hospital offers full 24-hour emergency service with surgery, X-ray,
intensive care, and on-call consultants also in gynaecology, anaesthesiology, and internal medicine.
Patients admitted to the hospital with acute abdominal pain,
during the period from February 1, 1997, to June 1, 2000, were
registered prospectively in a local database. Study approval was
obtained from the regional ethical review board in Uppsala. On
admission, the attending physician gave oral as well as written information about the research project before asking the patient for
participation in the study. After having given consent, the patient
was asked, among other questions, about the duration of pain, previous episodes of pain, any intake of medication for the pain or
cortisone treatment, and the occurrence of gastrointestinal symptoms. The attending physician also recorded findings at the clinical
examination and results of laboratory investigations. The location
of the pain, at onset and at the time of examination, was marked
on a drawing on the study protocol. The physician was then asked
to give the most likely diagnosis, which was later compared with
the diagnosis at discharge and at follow-up (performed by reviewing the medical records after at least 1 year). The physicians attending at the emergency department were predominantly pre-registrar and registrar house officers. A total of 3,109 patients attending
the emergency department were registered, and the medical records were reviewed at least 1 year (mean 2.7 years) after admission
to establish a final diagnosis. Inclusion criteria for the present
study were age above 1 year and abdominal pain of up to 7 days
duration which was not caused by trauma. Ten of the patients did
not fulfil these inclusion criteria and were excluded. Tourists who
received surgical treatment or had a diagnosis verified by radiology or endoscopy were included as they were considered to have
an accurate diagnosis (n = 78), whereas other tourists were excluded (n = 248) because of difficulties in obtaining medical records
from a large number of hospitals. In patients who were admitted
more than once to the emergency department, and consequently
had two study protocols or more, we only analysed the protocol for
the time when they had surgery or the protocol registered at the
first visit. On these grounds, 373 protocols were excluded, leaving
a total of 2,478 patients eligible for statistical analyses in this study.
At the emergency department, all patients admitted are registered
according to type of symptoms and signs, and when scrutinising
this register for patients with abdominal pain, we found another

Manifestations of Acute Appendicitis

Statistical Methods
Statistica software (Statsoft, Tulsa, Okla., USA) was used for
statistical calculations. The distribution fit of the data was initially
checked, and most parameters appeared to be normally distributed, with many patients in each group, whereas for others, there
were groups of variable size that did not fit into that distribution
model. The non-parametric Mann-Whitney U test was generally
used to calculate the significance of differences in continuous variables, whereas the 2 test was used in cases of dichotomous response parameters and to test differences in proportions between
groups. The calculated sensitivity, specificity, positive predictive
value (PPV), negative predictive value (NPV), positive likelihood
ratio (LR+), and negative likelihood ratio (LR) of clinical findings
were used as measures of the value of the parameters in question
for predicting a diagnosis of acute appendicitis. The value was
calculated to measure the congruence between the preliminary
and discharge diagnosis. The LR+ for the preliminary diagnosis
was used as an alternative measure of diagnostic accuracy irrespective of the prevalence of that diagnosis in this population. The sensitivity of a symptom represents the probability that a patient who
is suffering from appendicitis will have that certain symptom,
whereas the PPV is the probability that the patient is suffering from
appendicitis if a symptom or sign is present. An LR+ tells us by
how much a positive symptom or sign increases the likelihood of
disease in a person who is examined. An excellent diagnostic test
has an LR+ of about 10, a fair LR+ is at least 2, and if the LR+ is <1,
it indicates that the diagnostic test is useless. The statistic provides a measure that varies from +1, indicating perfect congruence,
to 0, indicating no greater congruence than can be expected by
chance. To identify the most important diagnostic markers for appendicitis, each diagnostic variable was tested first in a univariate
logistic regression analysis, where the results were expressed as
odds ratios (ORs) with 95% confidence intervals (CIs), and then in
a multivariate analysis with adjustments for age and gender.

Results

Differential Diagnostics and Diagnostic Outcome

Out of 2,478 patients admitted with acute abdominal
pain, 432 patients were suspected to have acute appendicitis. Of these, 221 patients were submitted to surgery and
appendicitis was found. In 53 patients who eventually
were found to have appendicitis, another preliminary
Dig Surg 2013;30:198206
DOI: 10.1159/000350043

199

Table 1. Differences in the history of pain-related gastrointestinal complaints between patients with appendicitis and other patients with

acute abdominal pain

Subjects
Symptoms
Anorexia
Nausea
Vomiting
Diarrhoea
Constipation

App
n (%)

AAP
n (%)

274

2,204

193 (70)
206 (75)
133 (48)
49 (18)
22 (8)

1,129 (51)
1,221 (55)
686 (31)
307 (14)
349 (16)

Sens
App

Spec
App

Acc
App

PPV
App

NPV
App

LR+
App

LR
App

0.70
0.75
0.48
0.18
0.08

0.49
0.45
0.69
0.86
0.84

0.51
0.48
0.67
0.78
0.76

0.15
0.14
0.16
0.14
0.06

0.93
0.94
0.92
0.89
0.88

1.37
1.36
1.55
1.29
0.50

0.61
0.56
0.75
0.95
1.09

App = Appendicitis; AAP = acute abdominal pain (this group includes all patients except those with appendicitis); Sens = sensitivity; Spec = specificity; Acc = accuracy.

diagnosis was suggested at the emergency department.

Consequently, 274 patients had the diagnosis of appendicitis confirmed; 271 had their appendix surgically removed and 3 patients had an appendiceal abscess diagnosed by CT or ultrasonography and were treated with
antibiotics only. None of the patients with an abscess had
an appendectomy within the follow-up period (at least 1
year). One hundred and sixty-five patients (60%) had advanced appendicitis (gangrenous or perforated), and the
perforation rate was 25% (n = 68). Of 432 patients with
suspected appendicitis, 423 (98%) were admitted to the
surgical ward, 2 were referred to the gynaecological department (1 had diverticulitis and 1 had torsion of the
right ovary), and 7 patients were sent home but agreed to
return to the emergency department the next morning
(none of these patients ended up having appendicitis).
Some 160 patients with a preliminary diagnosis of appendicitis were not operated on for the reason that the pain
had disappeared (111 patients) or that another diagnosis
was confirmed (49 patients). At follow-up, 211 of the 432
patients with appendicitis as a preliminary diagnosis had
a different final diagnosis; 122 patients had non-specific
abdominal pain (NSAP), 24 gynaecological complaints,
13 diverticulitis (2 with perforation), 10 mesenteric
lymphadenitis, 8 urinary infection, 7 biliary stone disease,
5 gastroenteritis, 4 ureteric stone, 3 constipation, 3 upper
respiratory tract infection, 2 intestinal obstruction, 2 abdominal malignancies, 2 torsion of colonic epiploicae, 1
aortic dissection, 1 perforated gastric ulcer, 1 dyspepsia,
1 Meckels diverticulitis, 1 Crohns disease, and 1 pneumonia. Fifty-three of these 211 patients underwent surgery. Among 316 appendectomies the result was negative
in 45 cases (14%). Of the 432 patients with suspected ap200

Dig Surg 2013;30:198206

DOI: 10.1159/000350043

pendicitis, preoperative CT scan was performed in 6 cases only and ultrasound in 36 cases.
The preoperative clinical diagnosis of appendicitis had
a sensitivity of 0.81, specificity of 0.90, PPV of 0.51, NPV
of 0.97, LR+ of 8.1, diagnostic accuracy of 0.89, and
value of 0.78.
There were another 28 patients who received surgery
and were diagnosed as having appendicitis during the
40-month study period from 1997 to 2000, but not registered in the database. A calculation based on these 28 cases and 269 appendectomies performed on study patients
living within the catchment area among a population of
87,000 gave an incidence rate of patients treated surgically for appendicitis of 102 per year and 100,000 inhabitants.
Gender and Age Differences
There were predominantly males who suffered from
appendicitis (155/274; 57%), while females (1,246/2,204;
57%) dominated among patients with acute abdominal
pain without appendicitis (p < 0.001). Patients with appendicitis were generally younger than those in the nonappendicitis group, with mean ages of 32 and 47 years,
respectively (p < 0.001). Twenty-five percent (68/274) in
the appendicitis group were aged younger than 16 years,
as compared to 17% (371/2,204) children among patients
with other reasons for acute abdominal pain.
Clinical Symptoms
Upper gastrointestinal complaints, such as loss of appetite (anorexia), nausea, and vomiting, were more common in the appendicitis group (p < 0.001; table1) compared to other patients with acute abdominal pain. There
Laurell /Hansson /Gunnarsson

Table 2. Differences in characteristics of abdominal pain between patients with appendicitis and other patients with acute abdominal

pain

Subjects
Symptoms
Mean pain duration, ha
Duration of pain >48 ha
Rapid onset of pain
Gradual onset of pain
Improvement of pain
No change in pain intensity
Aggravation of pain
Pain-free intervals
Fluctuating pain
Continuous pain
Burning pain
Colic pain
Dull pain
Aggravation of pain when moving
Aggravation of pain when coughing
Alleviation of pain when not moving
Migration of pain to right IF
Mean VAS
Previous episode of similar pain

App
n (%)

AAP
n (%)

274

2,204

27 (24 30)b
60 (22)
75 (27)
184 (67)
26 (9)
61 (22)
176 (64)
32 (12)
81 (30)
184 (67)
27 (10)
48 (18)
161 (59)
170 (62)
120 (44)
164 (60)
43 (16)
2.9 (2.5 3)b
42 (15)

36 (34 38)b
711 (33)
729 (33)
1,287 (58)
497 (23)
727 (33)
845 (38)
648 (29)
1,056 (48)
1,016 (46)
245 (11)
699 (32)
931 (42)
646 (29)
337 (15)
652 (30)
62 (3)
2.9 (2.8 3)b
819 (37)

Sens
App

Spec
App

Acc
App

PPV
App

NPV
App

LR+
App

LR
App

0.22
0.27
0.67
0.09
0.22
0.64
0.12
0.30
0.67
0.10
0.17
0.59
0.62
0.44
0.60
0.16

0.68
0.67
0.42
0.77
0.67
0.62
0.71
0.52
0.54
0.89
0.68
0.58
0.71
0.85
0.70
0.97

0.63
0.63
0.44
0.70
0.62
0.62
0.64
0.50
0.55
0.80
0.63
0.58
0.70
0.80
0.69
0.88

0.08
0.09
0.12
0.05
0.08
0.17
0.05
0.07
0.15
0.10
0.06
0.15
0.21
0.26
0.20
0.41

0.87
0.88
0.91
0.87
0.87
0.93
0.87
0.86
0.93
0.89
0.87
0.92
0.94
0.92
0.93
0.90

0.69
0.82
1.16
0.39
0.67
1.68
0.41
0.62
1.46
0.91
0.53
1.40
2.14
2.93
2.00
5.33

1.15
1.09
0.79
1.18
1.16
0.58
1.24
1.35
0.61
1.01
1.22
0.71
0.54
0.66
0.57
0.87

0.15

0.63

0.58

0.05

0.86

0.41

1.35

App = Appendicitis; AAP = acute abdominal pain (this group includes all patients except those with appendicitis); Sens = sensitivity; Spec = specificity; Acc = accuracy; IF = iliac fossa; VAS = visual analogue scale (patients estimation of severity of pain graded from
0 to 10). a Before seeking medical advice, from onset of pain to admission at the emergency department. b Numbers with ranges in parentheses indicating 95% confidence limits of the mean.

was no difference in duration of pain between the two

groups (p = 0.950), but a pain duration of >48 h was less
common in patients with appendicitis than in other patients with acute abdominal pain (p < 0.001; table2). In
appendicitis patients, the pain often had a gradual onset,
and improvement of the pain was rare. Furthermore,
continuous pain and dull pain were common, whereas
pain-free intervals, fluctuating pain, and colic pain were
not. The sensation of burning pain was not commonly
described in either group. Migration of pain to the right
iliac fossa was noted in 43 (16%) patients, and previous
episodes of similar pain in 42 (15%) of the appendicitis
patients. Pain migration to the right iliac fossa was very
uncommon among patients not diagnosed with appendicitis (62/2,204; 3%; p < 0.001), whereas previous episodes
of pain were more common in this group (819/2,204;
37%; p < 0.001; table2). Sixteen percent (44/274) of the
patients with appendicitis and 17% (377/2,204) of those
with acute abdominal pain without appendicitis had tak-

en some kind of analgesic (most commonly paracetamol)

for the pain before admission to the hospital. Only 1 patient with appendicitis (phlegmonous) and 30 patients
(1.4%) in the abdominal pain group (2,204) had received
medication with cortisone during (at least) the last 2
weeks.

Manifestations of Acute Appendicitis

Dig Surg 2013;30:198206

DOI: 10.1159/000350043

Clinical Findings
Clinical signs of peritonitis such as aggravation of pain
when moving or coughing and alleviation when not moving were more common (p < 0.001) in appendicitis patients. There was no difference in the severity of the pain,
as estimated by the visual analogue scale, between the two
groups (table2). Isolated tenderness in the right iliac fossa and rebound tenderness were more frequent (p < 0.001;
table 3) among the appendicitis patients compared to
other patients with abdominal pain, but no patient with
appendicitis had tenderness located only in the left iliac
fossa. Right-sided rectal tenderness was more common
201

Table 3. Differences in clinical findings at the physical examination on admission between patients with appendicitis and other patients

with acute abdominal pain

Subjects
Symptoms
Tenderness in right IF only
Tenderness in left IF only
General abdominal tenderness
Rebound tenderness
Local guarding
General rigidity
Right-sided rectal tenderness

App
n (%)

AAP
n (%)

274

2,204

194 (71)
0
36 (13)
201 (73)
107 (39)
15 (5)
74 (27)

403 (18)
220 (10)
422 (19)
516 (23)
277 (13)
39 (2)
120 (5)

Sens
App

Spec
App

Acc
App

PPV
App

NPV
App

LR+
App

LR
App

0.70

0.82

0.80

0.32

0.96

3.89

0.37

0.13
0.73
0.39
0.05
0.27

0.81
0.77
0.87
0.98
0.95

0.73
0.76
0.82
0.88
0.87

0.08
0.28
0.28
0.28
0.38

0.88
0.96
0.92
0.89
0.91

0.68
3.17
3.00
2.50
5.40

1.07
0.35
0.70
0.97
0.77

App = Appendicitis; AAP = acute abdominal pain (this group includes all patients except those with appendicitis); Sens = sensitivity; Spec = specificity; Acc = accuracy; IF = iliac fossa.

Table 4. Clinical symptoms and signs in different age groups

Age group

Symptoms
Anorexia
Nausea
Gradual onset of pain
Aggravation of pain
Continuous pain
Aggravation of pain when moving
Migration of pain
Isolated tenderness in right IF
Rebound tenderness
General rigidity
Local guarding
Right-sided rectal tenderness

1 19 years (n = 506)

20 49 years (n = 866)

>50 years (n = 1,106)

Sens

Spec

LR+

Sens

Spec

LR+

Sens

Spec

LR+

0.73
0.78
0.73
0.66
0.70
0.67
0.14
0.64
0.80
0.05
0.30
0.32

0.49
0.51
0.38
0.65
0.64
0.61
0.90
0.72
0.72
0.99
0.92
0.89

1.43
1.59
1.18
1.89
1.94
1.72
1.40
2.28
2.16
5.00
3.75
2.91

0.70
0.73
0.61
0.68
0.69
0.60
0.24
0.74
0.71
0.04
0.43
0.22

0.49
0.44
0.41
0.60
0.53
0.68
0.96
0.81
0.76
0.99
0.90
0.94

1.37
1.30
1.03
1.70
1.47
1.88
6.00
3.89
2.96
5.00
4.30
3.67

0.68
0.75
0.71
0.54
0.70
0.60
0.16
0.86
0.66
0.09
0.46
0.29

0.48
0.43
0.43
0.64
0.50
0.76
0.97
0.86
0.79
0.97
0.84
0.97

1.31
1.32
1.25
1.50
1.40
2.50
5.33
6.14
3.14
3.00
2.88
9.67

Sens = Sensitivity; Spec = specificity; IF = iliac fossa.

in the appendicitis group (p < 0.001; table 3). Patients

younger than 20 years showed lower values of LR+ for
signs on abdominal examination, with the exception of
the muscle response parameters (local guarding and general rigidity), than patients over 50 years of age (table4).
When testing the same symptoms and signs (table4) according to gender, there were no differences in LR+, except for right-sided rectal tenderness, which had a higher
LR+ in males (6.50) than in females (4.67). There were no
differences when comparing different degree of inflam202

Dig Surg 2013;30:198206

DOI: 10.1159/000350043

mation, except a higher LR+ for general rigidity in perforated (7.50) compared to phlegmonous (1.50) and gangrenous appendicitis (1.00). The mean body temperature
was 37.6 C in patients with phlegmonous, 37.8 C in patients with gangrenous, and 38.0 C in patients with perforated appendicitis.

Diagnostic Markers for Appendicitis

Diagnostic variables with a strong or fairly strong relation (LR+ >1; tables13) to acute appendicitis were loss of
Laurell /Hansson /Gunnarsson

Table 5. Multivariate analysis of diagnostic value of symptoms and signs for diagnosis of appendicitis

Factors

Upper gastrointestinal symptoms

Anorexia
Nausea
Pain characteristics
Gradual onset of pain
Aggravation of pain
Continuous pain
Signs of localised inflammation
Aggravation of pain on movement
Migration of pain to right iliac fossa
Findings at abdominal examination
Isolated tenderness in right iliac fossa
Rebound tenderness
General rigidity
Local guarding
Right-sided rectal tenderness

Univariate analyses

Multivariate analyses

OR

95% CI

OR

95% CI

1.51
1.56

1.31 1.73
1.35 1.80

1.37
1.41

1.16 1.63
1.19 1.67

1.20
1.70
1.54

1.06 1.38
1.49 1.94
1.35 1.77

1.02
1.59
1.45

0.86 1.21
1.34 1.89
1.22 1.72

1.99
2.18

1.74 2.26
1.82 2.62

1.70
2.02

1.35 2.16
1.61 2.56

3.29
3.00
1.79
2.11
2.53

2.86 3.79
2.60 3.46
1.32 2.43
1.84 2.42
2.16 2.98

2.96
2.45
1.92
1.81
2.19

2.50 3.51
2.07 2.91
1.30 2.83
1.49 2.20
1.80 2.66

In the multivariate analyses, the factors were adjusted for age and gender. Each group in the table was processed in separate models, except for the last group, which was split into three groups: isolated tenderness in right
iliac fossa and rebound tenderness; general rigidity; local guarding and right-sided rectal tenderness.

appetite (anorexia), nausea, vomiting, diarrhoea, gradual

onset of pain, aggravation of pain, continuous pain, dull
pain, aggravation of pain when moving and coughing, alleviation of pain when not moving, migration of pain to
the right iliac fossa, isolated tenderness in the right iliac
fossa, rebound tenderness, local guarding, general rigidity,
and right-sided rectal tenderness. Diagnostic variables
with LR+ <1 were constipation, pain duration of >48 h,
rapid onset of pain, improvement or no change in intensity of pain, pain-free intervals, fluctuation of pain, burning and colic pain, previous episodes of pain, and general
abdominal tenderness. When the more important variables were adjusted for age and gender in the multivariate
analysis, the ORs were similar to those obtained in the univariate analysis (table5). The highest OR (univariate) was
found for isolated tenderness in the right iliac fossa (3.29),
followed by rebound tenderness (3.00), right-sided rectal
tenderness (2.53), migration of pain to the right iliac fossa
(2.18), local guarding (2.11), aggravation of pain on movement (1.99), and general rigidity (1.79). In the multivariate
analysis, these variables still had the highest ORs. Combination of the three most frequently noted clinical findings
with high LR+, namely isolated tenderness in the right iliac fossa, rebound tenderness, and aggravation of pain
when moving, gave an LR+ of 9.5 (table6).
Manifestations of Acute Appendicitis

Discussion

The main finding in this study was that classical clinical symptoms and signs indicating localised inflammation, such as isolated pain in the right iliac fossa, rebound
tenderness, aggravation of pain when moving, pain migration to the right iliac fossa, local guarding, and rightsided rectal tenderness, proved to be reliable in predicting
acute appendicitis. In the present study, the clinical diagnosis appendicitis had a sensitivity, specificity, diagnostic accuracy, and LR+ comparable to a previous Finnish
study [8] with a sensitivity of 0.93, specificity of 0.86, diagnostic accuracy of 0.87, and LR+ of 6.64 for the preoperative clinical diagnosis. Using computer-aided diagnosis, these figures rose marginally to 0.88, 0.88, 0.88 and
7.33, respectively. CT studies [4, 9] on appendicitis have
produced sensitivity values of 0.91 and 0.94. In a study on
surgical ultrasonography, the surgical residents raised
the sensitivity of the clinical diagnosis from 0.51 to 0.83
by performing ultrasonography in cases of suspected appendicitis [10]. However, looking for the appendix is
probably far too time-consuming for a physician at the
emergency department. Scoring systems, such as the Alvarado score [11], have shown potential benefits in some
earlier studies [12, 13], but on the other hand, diagnostic
Dig Surg 2013;30:198206
DOI: 10.1159/000350043

203

Table 6. Clinical symptoms and signs of diagnostic importance for appendicitis in combination with the two most common clinical
findings: isolated tenderness in the right iliac fossa and rebound tenderness

Subjects
Symptoms
1, 2
1, 2, aggravation of pain when moving
1, 2, rectal tenderness
1, 2, migration of pain
1, 2, local guarding
1, 2, anorexia
1, 2, nausea
1, 2, gradual onset of pain
1, 2, aggravation of pain
1, 2, continuous pain
1, 2, leukocyte count >15

App
n (%)

AAP
n (%)

274

2,204

149 (54)
103 (38)
48 (18)
34 (12)
68 (25)
116 (42)
109 (40)
110 (40)
104 (38)
99 (36)
56 (20)

155 (7)
92 (4)
41 (2)
28 (1)
36 (2)
86 (4)
79 (4)
28 (4)
72 (3)
87 (4)
30 (1)

p value

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Sens
App

Spec
App

Acc
App

PPV
App

LR+
App

0.54
0.38
0.18
0.12
0.25
0.42
0.40
0.40
0.38
0.36
0.20

0.93
0.96
0.98
0.99
0.98
0.96
0.96
0.96
0.97
0.96
0.99

0.89
0.89
0.89
0.89
0.90
0.91
0.90
0.90
0.90
0.89
0.90

0.49
0.53
0.54
0.55
0.65
0.57
0.58
0.54
0.59
0.53
0.65

7.7
9.5
9.0
12.0
12.5
10.5
10.0
10.0
12.7
9.0
20.0

App = Appendicitis; AAP = acute abdominal pain (this group includes all patients except those with appendicitis); Sens = sensitivity; Spec = specificity; Acc = accuracy; 1 = isolated tenderness in the right iliac fossa; 2 = rebound tenderness.

scores are not commonly used as clinical routine [14, 15].

The majority of the most common differential diagnoses
to appendicitis, i.e. NSAP, diverticulitis, mesenteric
lymphadenitis, urinary infection, and gastroenteritis, do
not usually require surgery, and in many cases, observation and repeated clinical examination of the abdomen
are preferable [16]. The most important clinical symptoms in the univariate (single-factor) analysis were occurrence of pain in the right iliac fossa and rebound tenderness. Migration of pain to the right iliac fossa showed very
low sensitivity, but a high LR+ of 5.33. Pain migration was
seldom noted in other patients with acute abdominal
pain. There were some differences in the quality of pain,
and patients with appendicitis more often had a gradual
onset of pain, aggravation of pain, and continuous pain.
All these symptoms are consistent with signs of an inflammatory process. Pain duration of >48 h and previous
episodes of pain were not common in patients with appendicitis. Upper gastrointestinal symptoms were indicative of appendicitis, but did not show as high an LR+ as
the clinical findings at the abdominal examination. More
than 40% of the patients with appendicitis in our study
complained of anorexia and nausea. In some previous
studies, anorexia and nausea were found to have no diagnostic value [6], and in addition, right-sided rectal tenderness has been regarded as a useless diagnostic test for
appendicitis [17, 18], with even an inverse relationship to
appendicitis [6], and should only be used for differential
204

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DOI: 10.1159/000350043

diagnoses. This is in contrast to our finding that rightsided rectal tenderness showed great power in predicting
appendicitis, with an LR+ of 5.4. The most important diagnostic markers for appendicitis in the present study
population (table 5) had similar ORs when tested in a
multivariate model. This indicates that they were reliable
also after adjustments for age and gender, as age below 40
years and male gender dominated among patients with
appendicitis. A fully competent diagnostic test reaching
an LR+ of about 10 will probably never be achieved on
clinically based diagnoses alone. However, a combination
of the three most frequently noted clinical findings with
high LR+, i.e. isolated tenderness in the right iliac fossa,
rebound tenderness, and aggravation of pain by movement, gave an LR+ of 9.5 (table6). These three particular
findings are considered as signs of localised inflammation and peritonitis in the abdominal cavity. As many as
38% of our patients with appendicitis showed these three
symptoms on examination at the emergency department
compared to 4% among the other patients with acute abdominal pain. The finding that LR+ for several symptoms
and signs (isolated tenderness in the right iliac fossa,
migration of pain to the right iliac fossa, and right-sided
rectal tenderness) on abdominal examination was much
lower in patients younger than 20 years (table4) was considered to imply that an appendicitis diagnosis is more
difficult to make among children and adolescents. However, symptoms indicating a peritoneal reaction to localLaurell /Hansson /Gunnarsson

ised inflammation, shown as rebound tenderness, local

guarding or general rigidity, provided higher LR+ for patients <50 years than >50 years of age. Other variables
indicating inflammation, such as fever, leukocyte counts,
and C-reactive protein, also contain important information and should always be included in the clinical diagnostic procedure of suspected appendicitis [6]. There was
a tendency of having a higher body temperature when
measured on admission at the emergency department for
patients who had a more inflamed appendix when surgically removed. When combining a leukocyte count of >15
with the clinical signs isolated tenderness in the right iliac
fossa and rebound tenderness, the LR+ for appendicitis
increased to 20.0 (table6).
During the last decade, the use of CT and ultrasonography in unclear cases of abdominal pain has increased
significantly [4]. A large study of 971 adult patients undergoing appendectomy has demonstrated a significant
decrease in the negative appendectomy rate from 23 to
1.7% [19]. In the present study, radiological imaging was
only used in occult or complicated cases of suspected appendicitis. This may explain the fairly high negative appendectomy rate of 14%. The potential of CT as a diagnostic tool in acute abdominal pain is still limited [20] as
the logistic part is often time-consuming [21], especially
when an oral contrast agent is needed, and it has not been
found to shorten the in-hospital time [9]. A negative CT
or ultrasonography is not sufficient to exclude appendicitis, and for children with suspected appendicitis, CT
scans should be avoided if possible, to limit the exposure
of ionizing radiation [22]. Currently, data on the use of
magnetic resonance imaging are encouraging, although
general recommendations for children are still lacking
[23].
With this in mind, the physician must not forget the
importance, proven in the present study, of careful evaluation concerning the patients history of pain and clinical

examination in cases of suspected appendicitis. Good advice is to document the results of repeated evaluations in
the patients medical record and save the CT scan for the
more equivocal cases of acute abdominal pain.
One limitation of the present study is that the diagnosis was not confirmed by review of pathology specimen in
each appendectomy. In clinical routine, the surgeon judges the appendix macroscopically and sends only appendices with suspected malignancy. However, for 1 year
(1997), every removed appendix was examined with histopathology and the result was compared with the surgeons macroscopic judgement with a congruence of 90%
[7]. In 9 cases of laparoscopic procedures, the appendix
was left in situ when another diagnosis was found perioperatively and the appendix was judged not to be inflamed.
According to the results of the present study, we believe that the best way of discriminating patients with appendicitis at the emergency department is to look for
signs of localised inflammation in the right iliac fossa,
such as isolated pain in the right iliac fossa, rebound tenderness, right-sided rectal tenderness, pain migration to
the right iliac fossa, local guarding, and aggravation of
pain when moving, and not to forget to evaluate the findings with repeated clinical examinations in unclear cases
of suspected appendicitis with mild symptoms, as the majority of differential diagnoses to appendicitis are self-resolving or do not require surgical treatment. In conclusion, the assessment in cases with these typical findings of
suspected appendicitis can still be based on clinical judgements.

Acknowledgement
This study was financially supported by Dalarna County Council, the Bengt Ihre Foundation, and the Department of Surgery in
Mora.

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