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AcuteAppendicitis:ReviewandUpdateAmericanFamilyPhysician

AcuteAppendicitis:ReviewandUpdate
D.MIKEHARDIN,JR.,M.D.,TexasA&MUniversityHealthScienceCenter,Temple,Texas
AmFamPhysician.1999Nov160(7):20272034.
Appendicitisiscommon,withalifetimeoccurrenceof7percent.Abdominalpainandanorexiaarethepredominantsymptoms.Themostimportant
physicalexaminationfindingisrightlowerquadranttendernesstopalpation.Acompletebloodcountandurinalysisaresometimeshelpfulin
determiningthediagnosisandsupportingthepresenceorabsenceofappendicitis,whileappendicealcomputedtomographicscansand
ultrasonographycanbehelpfulinequivocalcases.Delayindiagnosingappendicitisincreasestheriskofperforationandcomplications.Complication
andmortalityratesaremuchhigherinchildrenandtheelderly.
Appendicitisisthemostcommonacutesurgicalconditionoftheabdomen.1Approximately7percentofthepopulationwillhaveappendicitisintheirlifetime,2with
thepeakincidenceoccurringbetweentheagesof10and30years.3
Despitetechnologicadvances,thediagnosisofappendicitisisstillbasedprimarilyonthepatient'shistoryandthephysicalexamination.Promptdiagnosisand
surgicalreferralmayreducetheriskofperforationandpreventcomplications.4Themortalityrateinnonperforatedappendicitisislessthan1percent,butitmaybe
ashighas5percentormoreinyoungandelderlypatients,inwhomdiagnosismayoftenbedelayed,thusmakingperforationmorelikely.1

Pathogenesis
Theappendixisalongdiverticulumthatextendsfromtheinferiortipofthececum.5Itsliningisinterspersedwithlymphoidfollicles.3Mostofthetime,theappendix
hasanintraperitoneallocation(eitheranteriororretrocecal)and,thus,maycomeincontactwiththeanteriorparietalperitoneumwhenitisinflamed.Upto30
percentofthetime,theappendixmaybehiddenfromtheanteriorperitoneumbybeinginapelvic,retroilealorretrocolic(retroperitonealretrocecal)position.6
Thehiddenpositionoftheappendixnotablychangestheclinicalmanifestationsofappendicitis.
Obstructionofthenarrowappendiceallumeninitiatestheclinicalillnessofacuteappendicitis.Obstructionhasmultiplecauses,includinglymphoidhyperplasia
(relatedtoviralillnesses,includingupperrespiratoryinfection,mononucleosis,gastroenteritis),fecaliths,parasites,foreignbodies,Crohn'sdisease,primaryor
metastaticcancerandcarcinoidsyndrome.Lymphoidhyperplasiaismorecommoninchildrenandyoungadults,accountingfortheincreasedincidenceof
appendicitisintheseagegroups.1,5

HistoryandPhysicalExamination
Abdominalpainisthemostcommonsymptomofappendicitis.3Inmultiplestudies,35specificcharacteristicsoftheabdominalpainandotherassociatedsymptoms
haveprovedtobereliableindicatorsofacuteappendicitis(Table1).Athoroughreviewofthehistoryoftheabdominalpainandofthepatient'srecent
genitourinary,gynecologicandpulmonaryhistoryshouldbeobtained.
View/PrintTable

TAL1
CommonSymptomsofAppendicitis
COMMONSYMPTOMS*

FREQUENCY(%)

Abdominalpain

~100

Anorexia

~100

Nausea

90

Vomiting

75

Painmigration

50

Classicsymptomsequence(vagueperiumbilicalpaintoanorexia/nausea/unsustainedvomitingtomigrationofpaintorightlowerquadranttolowgradefever)

50

*Onsetofsymptomstypicallywithinpast24to36hours.
Informationfromreferences3through5.

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Anorexia,nauseaandvomitingaresymptomsthatarecommonlyassociatedwithacuteappendicitis.Theclassichistoryofpainbeginningintheperiumbilicalregion
andmigratingtotherightlowerquadrantoccursinonly50percentofpatients.1Durationofsymptomsexceeding24to36hoursisuncommoninnonperforated
appendicitis.1
Inarecentmetaanalysis,7likelihoodratioswerecalculatedformanyofthesesymptoms(Table2).Alikelihoodratioistheamountbywhichtheoddsofadisease
changewithnewinformation(e.g.,physicalexaminationfindings,laboratoryresults).8Thischangecanbepositiveornegative.Symptomssuchasanorexia,
nauseaandvomitingcommonlyoccurinacuteappendicitishowever,thepresenceofthesesymptomsdoesnotnecessarilyincreasethelikelihoodofappendicitis
nordoestheirabsencedecreasethelikelihoodofthediagnosis.Moreover,othersymptomshavemorenotablepositiveandnegativelikelihoodratios(Table2).
View/PrintTable

TAL2
SignificantLikelihoodRatiosforSymptomsandSignsofAcuteAppendicitis
SYMPTOM/SIGN

POSITIVELIKELIHOODRATIO(LR+)

Rightlowerquadrant(RLQ)pain

8.0

Painmigration

3.2

Painbeforevomiting

2.8

Anorexia,nauseaandvomiting*

MuchlowerLR+thanRLQpain,painmigrationandpainbeforevomiting

Psoassign

2.38

Reboundtenderness

1.1to6.3

Fever

1.9

Guardingandrectaltenderness*

MuchlowerLR+thanrigidity,psoassignandreboundtenderness

SYMPTOM/SIGN

NEGATIVELIKELIHOODRATIO(LR)

RLQpain

0to0.28

Nosimilarpainpreviously

0.3

Painmigration

0.5

Guarding

0to0.54

Reboundtenderness

0to0.86

Fever,rigidityandpsoassign

NOTE:LRistheamountbywhichtheoddsofadiseasechangewithnewinformation,asfollows:

Likelihoodratio

Degreeofchangeinprobability

Acareful,systematicexaminationoftheabdomenisessential.Whilerightlowerquadranttendernesstopalpationisthemostimportantphysicalexamination
finding,othersignsmayhelpconfirmthediagnosis(Table3).Theabdominalexaminationshouldbeginwithinspectionfollowedbyauscultation,gentlepalpation
(beginningatasitedistantfromthepain)and,finally,abdominalpercussion.Thereboundtendernessthatisassociatedwithperitonealirritationhasbeenshownto
bemoreaccuratelyidentifiedbypercussionoftheabdomenthanbypalpationwithquickrelease.1
View/PrintTable

TAL3
CommonSignsofAppendicitis

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Rightlowerquadrantpainonpalpation(thesinglemostimportantsign)
Lowgradefever(38C[or100.4F])absenceoffeverorhighfevercanoccur
Peritonealsigns
Localizedtendernesstopercussion
Guarding
Otherconfirmatoryperitonealsigns(absenceofthesesignsdoesnotexcludeappendicitis)
Psoassignpainonextensionofrightthigh(retroperitonealretrocecalappendix)
Obturatorsignpainoninternalrotationofrightthigh(pelvicappendix)
Rovsing'ssignpaininrightlowerquadrantwithpalpationofleftlowerquadrant
Dunphy'ssignincreasedpainwithcoughing
Flanktendernessinrightlowerquadrant(retroperitonealretrocecalappendix)
Patientmaintainshipflexionwithkneesdrawnupforcomfort

Informationfromreferences3through5.

Aspreviouslynoted,thelocationoftheappendixvaries.Whentheappendixishiddenfromtheanteriorperitoneum,theusualsymptomsandsignsofacute
appendicitismaynotbepresent.Painandtendernesscanoccurinalocationotherthantherightlowerquadrant.6Aretrocecalappendixinaretroperitoneal
locationmaycauseflankpain.Inthiscase,stretchingtheiliopsoasmusclecanelicitpain.Thepsoassigniselicitedinthismanner:thepatientliesontheleftside
whiletheexaminerextendsthepatient'srightthigh(Figures1aand1b).Incontrast,apatientwithapelvicappendixmayshownoabdominalsigns,buttherectal
examinationmayelicittendernessintheculdesac.Inaddition,anobturatorsign(painonpassiveinternalrotationoftheflexedrightthigh)maybepresentina
patientwithapelvicappendix3(Figures2aand2b).
View/PrintFigure

FIGURE1A.
Thepsoassign.Painonpassiveextensionoftherightthigh.Patientliesonleftside.Examinerextendspatient'srightthighwhileapplyingcounterresistancetotherighthip(asterisk).

View/PrintFigure

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FIGURE1B.
Anatomicbasisforthepsoassign:inflamedappendixisinaretroperitoneallocationincontactwiththepsoasmuscle,whichisstretchedbythismaneuver.

View/PrintFigure

FIGURE2A.
Theobturatorsign.Painonpassiveinternalrotationoftheflexedthigh.Examinermoveslowerleglaterallywhileapplyingresistancetothelateralsideoftheknee(asterisk)resulting
ininternalrotationofthefemur.

View/PrintFigure

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FIGURE2B.
Anatomicbasisfortheobturatorsign:inflamedappendixinthepelvisisincontactwiththeobturatorinternusmuscle,whichisstretchedbythismaneuver.

Thedifferentialdiagnosisofappendicitisisbroad,butthepatient'shistoryandtheremainderofthephysicalexaminationmayclarifythediagnosis(Table4).
Becausemanygynecologicconditionscanmimicappendicitis,apelvicexaminationshouldbeperformedonallwomenwithabdominalpain.Giventhebreadthof
thedifferentialdiagnosis,thepulmonary,genitourinaryandrectalexaminationsareequallyimportant.Studieshaveshown,however,thattherectalexamination
providesusefulinformationonlywhenthediagnosisisunclearand,thus,canbereservedforuseinsuchcases.5
View/PrintTable

TAL4
DifferentialDiagnosisofAcuteAppendicitis
Gastrointestinal
Abdominalpain,causeunknown
Cholecystitis
Crohn'sdisease
Diverticulitis
Duodenalulcer
Gastroenteritis
Intestinalobstruction
Intussusception
Meckel'sdiverticulitis
Mesentericlymphadenitis
Necrotizingenterocolitis
Neoplasm(carcinoid,carcinoma,lymphoma)
Omentaltorsion
Pancreatitis
Perforatedviscus
Volvulus

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Gynecologic
Ectopicpregnancy
Endometriosis

LaboratoryandRadiologicEvaluation
Ifthepatient'shistoryandthephysicalexaminationdonotclarifythediagnosis,laboratoryandradiologicevaluationsmaybehelpful.Acleardiagnosisof
appendicitisobviatestheneedforfurthertestingandshouldpromptimmediatesurgicalreferral.

LABORATORYTESTS
Thewhitebloodcell(WBC)countiselevated(greaterthan10,000permm3[100109perL])in80percentofallcasesofacuteappendicitis.9Unfortunately,the
WBCiselevatedinupto70percentofpatientswithothercausesofrightlowerquadrantpain.10Thus,anelevatedWBChasalowpredictivevalue.SerialWBC
measurements(over4to8hours)insuspectedcasesmayincreasethespecificity,astheWBCcountoftenincreasesinacuteappendicitis(exceptincasesof
perforation,inwhichitmayinitiallyfall).5
Inaddition,95percentofpatientshaveneutrophilia1and,intheelderly,anelevatedbandcountgreaterthan6percenthasbeenshowntohaveahighpredictive
valueforappendicitis.9Ingeneral,however,theWBCcountanddifferentialareonlymoderatelyhelpfulinconfirmingthediagnosisofappendicitisbecauseoftheir
lowspecificities.
AmorerecentlysuggestedlaboratoryevaluationisdeterminationoftheCreactiveproteinlevel.AnelevatedCreactiveproteinlevel(greaterthan0.8mgperdL)is
commoninappendicitis,butstudiesdisagreeonitssensitivityandspecificity.4,5AnelevatedCreactiveproteinlevelincombinationwithanelevatedWBCcountand
neutrophiliaarehighlysensitive(97to100percent).Therefore,ifallthreeofthesefindingsareabsent,thechanceofappendicitisislow.5
Inpatientswithappendicitis,aurinalysismaydemonstratechangessuchasmildpyuria,proteinuriaandhematuria,1butthetestservesmoretoexcludeurinary
tractcausesofabdominalpainthantodiagnoseappendicitis.

RADIOLOGICEVALUATION
Theoptionsforradiologicevaluationofpatientswithsuspectedappendicitishaveexpandedinrecentyears,enhancingandsometimesreplacingpreviouslyused
radiologicstudies.
Plainradiographs,whileoftenrevealingabnormalitiesinacuteappendicitis,lackspecificityandaremorehelpfulindiagnosingothercausesofabdominalpain.
Likewise,bariumenemaisnowusedinfrequentlybecauseoftheadvancesinabdominalimaging.5
Ultrasonographyandcomputedtomographic(CT)scansarehelpfulinevaluatingpatientswithsuspectedappendicitis.11Ultrasonographyisappropriateinpatients
inwhichthediagnosisisequivocalbyhistoryandphysicalexamination.Itisespeciallywellsuitedinevaluatingrightlowerquadrantorpelvicpaininpediatricand
femalepatients.Anormalappendix(6mmorlessindiameter)mustbeidentifiedtoruleoutappendicitis.Aninflamedappendixusuallymeasuresgreaterthan6
mmindiameter(Figure3),isnoncompressibleandtenderwithfocalcompression.Otherrightlowerquadrantconditionssuchasinflammatoryboweldisease,cecal
diverticulitis,Meckel'sdiverticulum,endometriosisandpelvicinflammatorydiseasecancausefalsepositiveultrasonographyresults.12
View/PrintFigure

FIGURE3.
Ultrasonogramshowinglongitudinalsection(arrows)ofinflamedappendix.

CT,specificallythetechniqueofappendicealCT,ismoreaccuratethanultrasonography(Table5).AppendicealCTconsistsofafocused,helical,appendicealCT
afteraGastrografinsalineenema(withorwithoutoralcontrast)andcanbeperformedandinterpretedwithinonehour.Intravenouscontrastisunnecessary.12The
accuracyofCTisdueinparttoitsabilitytoidentifyanormalappendixbetterthanultrasonography.13Aninflamedappendixisgreaterthan6mmindiameter,but
theCTalsodemonstratesperiappendicealinflammatorychanges14(Figures4and5).IfappendicealCTisnotavailable,standardabdominal/pelvicCTwith
contrastremainshighlyusefulandmaybemoreaccuratethanultrasonography.12

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View/PrintTable

TAL5
ComparisonofUltrasoundandAppendicealCTEvaluationofSuspectedAppendicitis
COMPARISONGRADEDULTRASOUND

APPENDICEALCOMPUTEDTOMOGRAPHICSCAN

Sensitivity

85%

90to100%

Specificity

92%

95to97%

Use

Evaluatepatientswithequivocaldiagnosisofappendicitis

Evaluatepatientswithequivocaldiagnosisofappendicitis

Advantages

Safe

Moreaccurate

Relativelyinexpensive

Betteridentifiesphlegmonandabscess

Canruleoutpelvicdiseaseinfemales

Betteridentifiesnormalappendix

Betterforchildren
Disadvantages

Operatordependent

Cost

Technicallyinadequatestudiesduetogas

Ionizingradiation

Pain

Contrast

Informationfromreferences11,13,20.

View/PrintFigure

FIGURE4.
Computedtomographicscanshowingcrosssectionofinflamedappendix(A)withappendicolith(a).

View/PrintFigure

FIGURE5.
Computedtomographicscanshowingenlargedandinflamedappendix(A)extendingfromthececum(C).

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Treatment
Thestandardformanagementofnonperforatedappendicitisremainsappendectomy.Becauseprompttreatmentofappendicitisisimportantinpreventingfurther
morbidityandmortality,amarginoferrorinoverdiagnosisisacceptable.Currently,thenationalrateofnegativeappendectomiesisapproximately20percent.15
Somestudieshaveinvestigatednonoperativemanagementwithparenteralantibiotictreatment,but40percentofthesepatientseventuallyrequired
appendectomy.3
Appendectomymaybeperformedbylaparotomy(usuallythroughalimitedrightlowerquadrantincision)orlaparoscopy.Diagnosticlaparoscopymaybehelpfulin
equivocalcasesorinwomenofchildbearingage,whiletherapeuticlaparoscopymaybepreferredincertainsubsetsofpatients(e.g.,women,obesepatients,
athletes).16
Whilelaparoscopicinterventionhastheadvantagesofdecreasedpostoperativepain,earlierreturntonormalactivityandbettercosmeticresults,itsdisadvantages
includegreatercostandlongeroperativetime.4Openappendectomymayremaintheprimaryapproachtotreatmentuntilfurthercostandbenefitanalysesare
conducted.

Complications
Appendicealruptureaccountsforamajorityofthecomplicationsofappendicitis.Factorsthatincreasetherateofperforationaredelayedpresentationtomedical
care,17ageextremes(youngandold)18andhiddenlocationofappendix.6Abriefperiodofinhospitalobservation(lessthansixhours)inequivocalcasesdoesnot
increasetheperforationrateandmayimprovediagnosticaccuracy.18
Diagnosisofaperforatedappendixisusuallyeasier(althoughimmediatelyafterrupture,thepatient'ssymptomsmaytemporarilysubside).Thephysical
examinationfindingsaremoreobviousifperitonitisgeneralizes,withamoregeneralizedrightlowerquadranttendernessprogressingtocompleteabdominal
tenderness.Anilldefinedmassmaybefeltintherightlowerquadrant.Feverismorecommonwithrupture,andtheWBCcountmayelevateto20,000to30,000
permm3(200to300109perL)withaprominentleftshift.3
Aperiappendicealabscessmaybetreatedimmediatelybysurgeryorbynonoperativemanagement.4Nonoperativemanagementconsistsofparenteralantibiotics
withobservationorCTguideddrainage,followedbyintervalappendectomysixweekstothreemonthslater.1

SpecialConsiderations
Whileappendicitisisuncommoninyoungchildren,itposesspecialdifficultiesinthisagegroup.Youngchildrenareunabletorelateahistory,oftenhaveabdominal
painfromothercausesandmayhavemorenonspecificsignsandsymptoms.Thesefactorscontributetoaperforationrateashighas50percentinthisgroup.1
Inpregnancy,thelocationoftheappendixbeginstoshiftsignificantlybythefourthtofifthmonthsofgestation.Commonsymptomsofpregnancymaymimic
appendicitis,andtheleukocytosisofpregnancyrenderstheWBCcountlessuseful.Whilethematernalmortalityrateislow,theoverallfetalmortalityrateis2to8.5
percent,risingtoashighas35percentinperforationwithgeneralizedperitonitis.Asinnonpregnantpatients,appendectomyisthestandardfortreatment.3
Elderlypatientshavethehighestmortalityrates.Theusualsignsandsymptomsofappendicitismaybediminished,atypicalorabsentintheelderly,whichleadsto
ahigherrateofperforation.Morefrequentperforationcombinedwithahigherincidenceofothermedicalproblemsandlessreservetofightinfectioncontributetoa
mortalityrateofupto5percentormore.1

FinalComment
Promptdiagnosisofappendicitisensurestimelytreatmentandpreventscomplications.Becauseabdominalpainisacommonpresentingsymptominoutpatient
care,familyphysiciansserveanimportantroleinthediagnosisofappendicitis.Obviouscasesofappendicitisrequireurgentreferral,whileequivocalcaseswarrant
furtherevaluationand,manytimes,surgicalconsultation.

TheAuthor showallauthorinfo
D.MIKEHARDIN,JR.,M.D.,isanassistantprofessorintheDepartmentofFamilyMedicineatScott&WhiteClinicandMemorialHospital,Bellmead,Tex.,affiliated
withTexasA&MUniversityHealthScienceCenterinTemple.Dr.HardingraduatedfromtheUniversityofTexasMedicalSchoolatHoustonandcompleteda
residencyinfamilypracticeattheMcLennanCountyMedicalEducationandResearchFoundation,Waco,Tex....

Figures3through5wereprovidedbyMichaelL.Nipper,M.D.,DepartmentofRadiology,ScottandWhiteMemorialHospital,Temple,Tex.

REFERENCES showallreferences
1.LiuCD,McFaddenDW.Acuteabdomenandappendix.In:GreenfieldLJ,etal.,eds.Surgery:scientificprinciplesandpractice.2ded.Philadelphia:Lippincott

Raven,1997:124661....

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