9/12/2014 Appendicitis

News & Perspective

Drugs & Diseases
CME & Education
Log Out My Account
A Mega
Discussion

Appendicitis
Author: Sandy Craig, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...

Updated: Jul 21, 2014

Practice Essentials
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other
parts. Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and is
one of the more common causes of acute abdominal pain. See the image below.

Transverse graded compression transabdominal sonogram of an acutely inflamed appendix. Note the targetlike appearance due
to thickened wall and surrounding loculated fluid collection.

See Appendicitis: Avoiding Pitfalls in Diagnosis, a Critical Images slideshow, to help make an accurate diagnosis.

Essential update: New screening algorithm for pediatric appendicitis may reduce CT use

A new algorithm for screening pediatric patients (18 y) with suspected appendicitis appears to reduce the use of
computed tomography (CT) scanning without affecting diagnostic accuracy.[1, 2] This tool also has implications for
reducing the levels of radiation exposure and the cost of using this imaging modality. The algorithm includes
pediatric surgery consultation without imaging studies in patients with an unequivocal history; for those with an
equivocal history, physical examination, and ultrasonographic findings, the algorithm includes consultation and
physical examination before obtaining CT studies.[2]

Investigators analyzed data from 331 pediatric patients with suspected appendicitis 2 years before (41%; n = 136)
and 3 years after (59%; n = 195) implementation of the new algorithm and found a significant decrease in the use of
CT scanning from 39% to 18%, respectively.[1, 2] Moreover, although the negative appendectomy rate rose from 9%
pre-implementation of the algorithm to 11% post-implementation, this increase was not significant and there was no
association between negative appendectomy and CT scan utilization.[1, 2]

Signs and symptoms

The clinical presentation of appendicitis is notoriously inconsistent. The classic history of anorexia and periumbilical

http://emedicine.medscape.com/article/773895-overview 1/11
9/12/2014 Appendicitis

pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases. Features
include the following:

Abdominal pain: Most common symptom

Nausea: 61-92% of patients
Anorexia: 74-78% of patients
Vomiting: Nearly always follows the onset of pain; vomiting that precedes pain suggests intestinal obstruction
Diarrhea or constipation: As many as 18% of patients

Features of the abdominal pain are as follows:

Typically begins as periumbilical or epigastric pain, then migrates to the RLQ[3]

Patients usually lie down, flex their hips, and draw their knees up to reduce movements and to avoid
worsening their pain
The 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.

Physical examination findings include the following:

Rebound tenderness, pain on percussion, rigidity, and guarding: Most specific finding
RLQ tenderness: Present in 96% of patients, but nonspecific
Left lower quadrant (LLQ) tenderness: May be the major manifestation in patients with situs inversus or in
patients with a lengthy appendix that extends into the LLQ
Male infants and children occasionally present with an inflamed hemiscrotum
In pregnant women, RLQ pain and tenderness dominate in the first trimester, but in the latter half of
pregnancy, right upper quadrant (RUQ) or right flank pain may occur

The following accessory signs may be present in a minority of patients:

Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal irritation
Obturator sign (RLQ pain with internal and external rotation of the flexed right hip): Suggests the inflamed
appendix is located deep in the right hemipelvis
Psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip against resistance):
Suggests that an inflamed appendix is located along the course of the right psoas muscle
Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough): Suggests localized peritonitis
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
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): Has a sensitivity of 74%[4]

See Clinical Presentation for more detail.

Diagnosis

The following laboratory tests do not have findings specific for appendicitis, but they may be helpful to confirm
diagnosis in patients with an atypical presentation:

CBC
C-reactive protein (CRP)
Liver and pancreatic function tests
Urinalysis (for differentiating appendicitis from urinary tract conditions)
Urinary beta-hCG (for differentiating appendicitis from early ectopic pregnancy in women of childbearing age)
Urinary 5-hydroxyindoleacetic acid (5-HIAA)

CBC

WBC >10,500 cells/L: 80-85% of adults with appendicitis

Neutrophilia >75-78% of patients
Less than 4% of patients with appendicitis have a WBC count less than 10,500 cells/L and neutrophilia less
than 75%

In infants and elderly patients, a WBC count is especially unreliable because these patients may not mount a normal
http://emedicine.medscape.com/article/773895-overview 2/11
9/12/2014 Appendicitis

response to infection. In pregnant women, the physiologic leukocytosis renders the CBC count useless for the
diagnosis of appendicitis.

C-reactive protein

CRP levels >1 mg/dL are common in patients with appendicitis

Very high levels of CRP in patients with appendicitis indicate gangrenous evolution of the disease, especially
if it is associated with leukocytosis and neutrophilia
In adults who have had symptoms for longer than 24 hours, a normal CRP level has a negative predictive
value of 97-100% for appendicitis[5, 6, 7]

Urinary 5-HIAA

HIAA levels increase significantly in acute appendicitis and decrease when the inflammation shifts to necrosis of the
appendix.[8] Therefore, such decrease could be an early warning sign of perforation of the appendix.

CT scanning

CT scanning with oral contrast medium or rectal Gastrografin enema has become the most important imaging
study in the evaluation of patients with atypical presentations of appendicitis
Low-dose abdominal CT may be preferable for diagnosing children and young adults in whom exposure to CT
radiation is of particular concern[9]

Ultrasonography

Ultrasonography may offer a safer alternative as a primary diagnostic tool for appendicitis, with CT scanning
used in those cases in which ultrasonograms are negative or inconclusive
In pediatric patients, American College of Emergency Physicians (ACEP) clinical policy recommends
ultrasonography for confirmation, but not exclusion, of acute appendicitis; to definitively exclude acute
appendicitis, the ACEP recommends CT[10, 11]
A healthy appendix usually cannot be viewed with ultrasonography; when appendicitis occurs, the
ultrasonogram typically demonstrates a noncompressible tubular structure of 7-9 mm in diameter
Vaginal ultrasonography alone or in combination with transabdominal scan may be useful to determine the
diagnosis in women of childbearing age[12]

Other imaging studies

Kidneys-ureters-bladder radiographs: Insensitive, nonspecific, and not cost-effective

Barium enema study: Has essentially no role in the diagnosis of acute appendicitis
Radionuclide scanning: Localized uptake of tracer in the RLQ suggests appendiceal inflammation
MRI: Useful in pregnant patients if graded compression ultrasonography is nondiagnostic

See Workup for more detail.

Management

Emergency department care is as follows:

Establish IV access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration
or septicemia
Keep patients with suspected appendicitis NPO
Administer parenteral analgesic and antiemetic as needed for patient comfort; no study has shown that
analgesics adversely affect the accuracy of physical examination[13]

Appendectomy remains the only curative treatment of appendicitis, but management of patients with an appendiceal
mass can usually be divided into the following 3 treatment categories:

Phlegmon or a small abscess: After IV antibiotic therapy, an interval appendectomy can be performed 4-6
weeks later
Larger well-defined abscess: After percutaneous drainage with IV antibiotics is performed, the patient can be
discharged with the catheter in place; interval appendectomy can be performed after the fistula is closed
Multicompartmental abscess: These patients require early surgical drainage
http://emedicine.medscape.com/article/773895-overview 3/11
9/12/2014 Appendicitis

Antibiotics

Antibiotic prophylaxis should be administered before every appendectomy

Preoperative antibiotics should be administered in conjunction with the surgical consultant
Broad-spectrum gram-negative and anaerobic coverage is indicated
Cefotetan and cefoxitin seem to be the best choices of antibiotics
In penicillin-allergic patients, carbapenems are a good option
Pregnant patients should receive pregnancy category A or B antibiotics
Antibiotic treatment may be stopped when the patient becomes afebrile and the WBC count normalizes

See Treatment and Medication for more detail.

Image library

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.

Background
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other
parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with
other clinical syndromes, and significant morbidity, which increases with diagnostic delay (see Clinical Presentation).
In fact, despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and
is one of the more common causes of acute abdominal pain.

No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all
cases, and the classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ)
pain, and vomiting occurs in only 50% of cases (see Clinical Presentation).

Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the
obstruction of the appendiceal lumen (see Pathogenesis and Etiology). Left untreated, appendicitis has the potential
for severe complications, including perforation or sepsis, and may even cause death (see Prognosis and
Complications). However, the differential diagnosis of appendicitis is often a clinical challenge because appendicitis
can mimic several abdominal conditions (see Diagnostic Considerations and Differentials).[14]

Appendectomy remains the only curative treatment of appendicitis (see Treatment and Management). 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 (ED)
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.

Go to Pediatric Appendicitis for more information on this topic.

Anatomy
The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix.
The average length of the appendix is 8-10 cm (ranging from 2-20 cm). The appendix appears during the fifth month

http://emedicine.medscape.com/article/773895-overview 4/11
9/12/2014 Appendicitis

of gestation, and several lymphoid follicles are scattered in its mucosa. Such follicles increase in number when
individuals are aged 8-20 years. A normal appendix is seen below.

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

The appendix is contained within the visceral peritoneum that forms the serosa, and its exterior layer is longitudinal
and derived from the taenia coli; the deeper, interior muscle layer is circular. Beneath these layers lies the
submucosal layer, which contains lymphoepithelial tissue. The mucosa consists of columnar epithelium with few
glandular elements and neuroendocrine argentaffin cells.

Taenia coli converge on the posteromedial area of the cecum, which is the site of the appendiceal base. The
appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which courses the
appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery
(deriving from the posterior cecal artery) may be found.

Appendiceal vasculature

The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The appendicular artery is
contained within the mesenteric fold that arises from a peritoneal extension from the terminal ileum to the medial
aspect of the cecum and appendix; it is a terminal branch of the ileocolic artery and runs adjacent to the
appendicular wall. Venous drainage is via the ileocolic veins and the right colic vein into the portal vein; lymphatic
drainage occurs via the ileocolic nodes along the course of the superior mesenteric artery to the celiac nodes and
cisterna chyli.

Appendiceal location

The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal ileum, either in a dorsomedial location
(most common) from the cecal fundus, directly beside the ileal orifice, or as a funnel-shaped opening (2-3% of
patients). The appendix has a retroperitoneal location in 65% of patients and may descend into the iliac fossa in
31%. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the
terminal ileum, cecum, ascending colon, or liver. Thus, the course of the appendix, the position of its tip, and the
difference in appendiceal position considerably changes clinical findings, accounting for the nonspecific signs and
symptoms of appendicitis.

Congenital appendiceal disorders

Appendiceal congenital disorders are extremely rare but occasionally reported (eg, agenesis, duplication,
triplication).

Pathophysiology
Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes (see Etiology).
Independent of the etiology, obstruction is believed to cause an increase in pressure within the lumen. Such an
increase is related to continuous secretion of fluids and mucus from the mucosa and the stagnation of this material.
At the same time, intestinal bacteria within the appendix multiply, leading to the recruitment of white blood cells (see
the image below) and the formation of pus and subsequent higher intraluminal pressure.

http://emedicine.medscape.com/article/773895-overview 5/11
9/12/2014 Appendicitis

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled WBCs in the right lower quadrant consistent
with acute appendicitis.

If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal veins, leading
to venous outflow obstruction. As a consequence, appendiceal wall ischemia begins, resulting in a loss of epithelial
integrity and allowing bacterial invasion of the appendiceal wall.

Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and veins,
leading to perforation and gangrene of the appendix. As this process continues, a periappendicular abscess or
peritonitis may occur.

Etiology
Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of luminal obstruction
include lymphoid hyperplasia secondary to inflammatory bowel disease (IBD) or infections (more common during
childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in
Eastern countries), or, more rarely, foreign bodies and neoplasms.

Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal material
located within the appendix. Lymphoid hyperplasia is associated with various inflammatory and infectious disorders
including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis.

Obstruction of the appendiceal lumen has less commonly been associated with bacteria (Yersinia species,
adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species), parasites (eg,
Schistosomes species, pinworms, Strongyloides stercoralis), foreign material (eg, shotgun pellet, intrauterine device,
tongue stud, activated charcoal), tuberculosis, and tumors.

Epidemiology
Appendicitis is one of the more common surgical emergencies, and it is one of the most common causes of
abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million
patient-days of admission. The incidence of acute appendicitis has been declining steadily since the late 1940s, and
the current annual incidence is 10 cases per 100,000 population. Appendicitis occurs in 7% of the US population,
with an incidence of 1.1 cases per 1000 people per year. Some familial predisposition exists.

In Asian and African countries, the incidence of acute appendicitis is probably lower because of the dietary habits of
the inhabitants of these geographic areas. The 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.

In the last few years, a decrease in frequency of appendicitis in Western countries has been reported, 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.

There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, 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.

http://emedicine.medscape.com/article/773895-overview 6/11
9/12/2014 Appendicitis

The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the
geriatric years. The mean age when appendicitis occurs in the pediatric population is 6-10 years. Lymphoid
hyperplasia is observed more often among infants and adults and is responsible for the increased incidence of
appendicitis in these age groups. Younger children have a higher rate of perforation, with reported rates of 50-85%.
The median age at appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have been
reported. Clinicians must maintain a high index of suspicion in all age groups.

Go to Pediatric Appendicitis for more information on this topic.

Prognosis
Acute appendicitis is the most common reason for emergency abdominal surgery. Appendectomy carries a
complication rate of 4-15%, as well as associated costs and the discomfort of hospitalization and surgery. Therefore,
the goal of the surgeon is to make an accurate diagnosis as early as possible. Delayed diagnosis and treatment
account for much of the mortality and morbidity associated with appendicitis.

The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to surgical
intervention. The mortality rate in children ranges from 0.1% to 1%; in patients older than 70 years, the rate rises
above 20%, primarily because of diagnostic and therapeutic delay.

Appendiceal perforation is associated with increased morbidity and mortality compared with nonperforating
appendicitis. The mortality risk of acute but not gangrenous appendicitis is less than 0.1%, but the risk rises to 0.6%
in gangrenous appendicitis. The rate of perforation varies from 16% to 40%, with a higher frequency occurring in
younger age groups (40-57%) and in patients older than 50 years (55-70%), in whom misdiagnosis and delayed
diagnosis are common. Complications occur in 1-5% of patients with appendicitis, and postoperative wound
infections account for almost one third of the associated morbidity.

Patient Education
For patient education information, see eMedicineHealth's Esophagus, Stomach, and Intestine Center, as well as
Appendicitis and Abdominal Pain in Adults.

Contributor Information and Disclosures

Author
Sandy Craig, MD Residency Program Director, Carolinas Medical Center; Associate Professor, Department of
Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine

Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic
Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program
Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University
School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Emergency Medicine, American College of Chest Physicians, American College of
Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society,
Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for
Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors
Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency
Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine,
Martin Luther King Jr/Drew Medical Center

http://emedicine.medscape.com/article/773895-overview 7/11
9/12/2014 Appendicitis

Disclosure: Nothing to disclose.

William Lober, MD, MS Associate Professor, Health Informatics and Global Health, Schools of Medicine,
Nursing, and Public Health, University of Washington

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
1. Polites SF, Mohamed MI, Habermann EB, et al. A simple algorithm reduces computed tomography use in
the diagnosis of appendicitis in children. Surgery. Jun 19 2014;[Medline].

2. Douglas D. Algorithm cuts pediatric CT use in suspected appendicitis. Reuters Health Information [serial
online]. July 10, 2014;Accessed July 14, 2014. Available at http://www.medscape.com/viewarticle/828027.

3. Yeh B. Evidence-based emergency medicine/rational clinical examination abstract. Does this adult patient
have appendicitis?. Ann Emerg Med. Sep 2008;52(3):301-3. [Medline].

4. Markle GB 4th. Heel-drop jarring test for appendicitis. Arch Surg. Feb 1985;120(2):243. [Medline].

5. Thimsen DA, Tong GK, Gruenberg JC. Prospective evaluation of C-reactive protein in patients suspected to
have acute appendicitis. Am Surg. Jul 1989;55(7):466-8. [Medline].

6. de Carvalho BR, Diogo-Filho A, Fernandes C, Barra CB. [Leukocyte count, C reactive protein, alpha-1 acid
glycoprotein and erythrocyte sedimentation rate in acute appendicitis]. Arq Gastroenterol. Jan-Mar
2003;40(1):25-30. [Medline].

7. Albu E, Miller BM, Choi Y, et al. Diagnostic value of C-reactive protein in acute appendicitis. Dis Colon
Rectum. Jan 1994;37(1):49-51. [Medline].

8. Bolandparvaz S, Vasei M, Owji AA, Ata-Ee N, Amin A, Daneshbod Y, et al. Urinary 5-hydroxy indole acetic
acid as a test for early diagnosis of acute appendicitis. Clin Biochem. Nov 2004;37(11):985-9. [Medline].

9. Kim K, Kim YH, Kim SY, Kim S, Lee YJ, Kim KP, et al. Low-dose abdominal CT for evaluating suspected
appendicitis. N Engl J Med. Apr 26 2012;366(17):1596-605. [Medline].

10. Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW. Clinical policy: Critical issues in
the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg
Med. Jan 2010;55(1):71-116. [Medline].

11. National Guideline Clearinghouse (NGC). Guideline summary: Clinical policy: critical issues in the
evaluation and management of emergency department patients with suspected appendicitis. National
Guideline Clearinghouse (NGC), Rockville (MD). Available at http://guideline.gov/content.aspx?id=15598.
Accessed November 18, 2013.

12. Barloon TJ, Brown BP, Abu-Yousef MM, Warnock N, Berbaum KS. Sonography of acute appendicitis in
pregnancy. Abdom Imaging. Mar-Apr 1995;20(2):149-51. [Medline].

13. Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane
Database Syst Rev. Jan 19 2011;1:CD005660. [Medline].

14. Karamanakos SN, Sdralis E, Panagiotopoulos S, Kehagias I. Laparoscopy in the emergency setting: a
retrospective review of 540 patients with acute abdominal pain. Surg Laparosc Endosc Percutan Tech. Apr
2010;20(2):119-24. [Medline].

15. Niwa H, Hiramatsu T. A rare presentation of appendiceal diverticulitis associated with pelvic pseudocyst.
World J Gastroenterol. Feb 28 2008;14(8):1293-5. [Medline]. [Full Text].

16. Place RC. Acute urinary retention in a 9-year-old child: an atypical presentation of acute appendicitis. J
http://emedicine.medscape.com/article/773895-overview 8/11
9/12/2014 Appendicitis

Emerg Med. Aug 2006;31(2):173-5. [Medline].

17. Oto A, Ernst RD, Mileski WJ, Nishino TK, Le O, Wolfe GC, et al. Localization of appendix with MDCT and
influence of findings on choice of appendectomy incision. AJR Am J Roentgenol. Oct 2006;187(4):987-90.
[Medline].

18. Sedlak M, Wagner OJ, Wild B, Papagrigoriades S, Exadaktylos AK. Is there still a role for rectal examination
in suspected appendicitis in adults?. Am J Emerg Med. Mar 2008;26(3):359-60. [Medline].

19. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. May
1986;15(5):557-64. [Medline].

20. [Best Evidence] Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a
prospective pediatric cohort. Ann Emerg Med. Jun 2007;49(6):778-84, 784.e1. [Medline].

21. Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric
cohort. Ann Emerg Med. Jun 2007;49(6):778-84, 784.e1. [Medline].

22. Migraine S, Atri M, Bret PM, Lough JO, Hinchey JE. Spontaneously resolving acute appendicitis: clinical
and sonographic documentation. Radiology. Oct 1997;205(1):55-8. [Medline].

23. Cobben LP, de Van Otterloo AM, Puylaert JB. Spontaneously resolving appendicitis: frequency and natural
history in 60 patients. Radiology. May 2000;215(2):349-52. [Medline].

24. Dueholm S, Bagi P, Bud M. Laboratory aid in the diagnosis of acute appendicitis. A blinded, prospective trial
concerning diagnostic value of leukocyte count, neutrophil differential count, and C-reactive protein. Dis
Colon Rectum. Oct 1989;32(10):855-9. [Medline].

25. Gurleyik E, Gurleyik G, Unalmiser S. Accuracy of serum C-reactive protein measurements in diagnosis of
acute appendicitis compared with surgeon's clinical impression. Dis Colon Rectum. Dec 1995;38(12):1270-
4. [Medline].

26. Shakhatreh HS. The accuracy of C-reactive protein in the diagnosis of acute appendicitis compared with
that of clinical diagnosis. Med Arh. 2000;54(2):109-10. [Medline].

27. Asfar S, Safar H, Khoursheed M, Dashti H, al-Bader A. Would measurement of C-reactive protein reduce
the rate of negative exploration for acute appendicitis?. J R Coll Surg Edinb. Feb 2000;45(1):21-4.
[Medline].

28. Erkasap S, Ates E, Ustuner Z, Sahin A, Yilmaz S, Yasar B, et al. Diagnostic value of interleukin-6 and C-
reactive protein in acute appendicitis. Swiss Surg. 2000;6(4):169-72. [Medline].

29. Gronroos JM, Gronroos P. Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis. Br
J Surg. Apr 1999;86(4):501-4. [Medline].

30. Ortega-Deballon P, Ruiz de Adana-Belbel JC, Hernandez-Matias A, Garcia-Septiem J, Moreno-Azcoita M.

Usefulness of laboratory data in the management of right iliac fossa pain in adults. Dis Colon Rectum. Jul
2008;51(7):1093-9. [Medline].

31. Gronroos JM. Is there a role for leukocyte and CRP measurements in the diagnosis of acute appendicitis in
the elderly?. Maturitas. Mar 15 1999;31(3):255-8. [Medline].

32. Yang HR, Wang YC, Chung PK, et al. Role of leukocyte count, neutrophil percentage, and C-reactive
protein in the diagnosis of acute appendicitis in the elderly. Am Surg. Apr 2005;71(4):344-7. [Medline].

33. Gronroos JM. Do normal leucocyte count and C-reactive protein value exclude acute appendicitis in
children?. Acta Paediatr. Jun 2001;90(6):649-51. [Medline].

34. Stefanutti G, Ghirardo V, Gamba P. Inflammatory markers for acute appendicitis in children: are they
helpful?. J Pediatr Surg. May 2007;42(5):773-6. [Medline].

35. Mohammed AA, Daghman NA, Aboud SM, Oshibi HO. The diagnostic value of C-reactive protein, white
blood cell count and neutrophil percentage in childhood appendicitis. Saudi Med J. Sep 2004;25(9):1212-5.
[Medline].

http://emedicine.medscape.com/article/773895-overview 9/11
9/12/2014 Appendicitis

36. Yang HR, Wang YC, Chung PK, Chen WK, Jeng LB, Chen RJ. Laboratory tests in patients with acute
appendicitis. ANZ J Surg. Jan-Feb 2006;76(1-2):71-4. [Medline].

37. Tundidor Bermudez AM, Amado Dieguez JA, Montes de Oca Mastrapa JL. [Urological manifestations of
acute appendicitis]. Arch Esp Urol. Apr 2005;58(3):207-12. [Medline].

38. Rao PM, Rhea JT, Rattner DW, et al. Introduction of appendiceal CT: impact on negative appendectomy
and appendiceal perforation rates. Ann Surg. Mar 1999;229(3):344-9. [Medline].

39. McGory ML, Zingmond DS, Nanayakkara D, Maggard MA, Ko CY. Negative appendectomy rate: influence
of CT scans. Am Surg. Oct 2005;71(10):803-8. [Medline].

40. Harswick C, Uyenishi AA, Kordick MF, Chan SB. Clinical guidelines, computed tomography scan, and
negative appendectomies: a case series. Am J Emerg Med. Jan 2006;24(1):68-72. [Medline].

41. Frei SP, Bond WF, Bazuro RK, Richardson DM, Sierzega GM, Reed JF. Appendicitis outcomes with
increasing computed tomographic scanning. Am J Emerg Med. Jan 2008;26(1):39-44. [Medline].

42. Pickhardt PJ, Lawrence EM, Pooler BD, Bruce RJ. Diagnostic performance of multidetector computed
tomography for suspected acute appendicitis. Ann Intern Med. Jun 21 2011;154(12):789-96. [Medline].

43. Kepner AM, Bacasnot JV, Stahlman BA. Intravenous contrast alone vs intravenous and oral contrast
computed tomography for the diagnosis of appendicitis in adult ED patients. Am J Emerg Med. May 23
2012;[Medline].

44. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med.
Nov 29 2007;357(22):2277-84. [Medline].

45. Zilbert NR, Stamell EF, Ezon I, Schlager A, Ginsburg HB, Nadler EP. Management and outcomes for
children with acute appendicitis differ by hospital type: areas for improvement at public hospitals. Clin
Pediatr (Phila). Jun 2009;48(5):499-504. [Medline].

46. [Best Evidence] Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, et al. US or CT
for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology. Oct 2006;241(1):83-94.
[Medline].

47. Boggs W. Ultrasound/MRI Strategy Diagnoses Appendicitis in Kids Without Radiation. Medscape Medical
News. Available at http://www.medscape.com/viewarticle/821332. Accessed March 12, 2014.

48. Aspelund G, Fingeret A, Gross E, Kessler D, Keung C, Thirumoorthi A, et al. Ultrasonography/MRI Versus
CT for Diagnosing Appendicitis. Pediatrics. Mar 3 2014;[Medline].

49. Cobben LP, Groot I, Haans L, Blickman JG, Puylaert J. MRI for clinically suspected appendicitis during
pregnancy. AJR Am J Roentgenol. Sep 2004;183(3):671-5. [Medline].

50. Thieme ME, Leeuwenburgh MM, Valdehueza ZD, Bouman DE, de Bruin IG, Schreurs WH, et al. Diagnostic
accuracy and patient acceptance of MRI in children with suspected appendicitis. Eur Radiol. Oct 19 2013;
[Medline].

51. Eriksson S, Granstrm L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute
appendicitis. Br J Surg. Feb 1995;82(2):166-9. [Medline].

52. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll
Surg. Mar 2006;202(3):401-6. [Medline].

53. Abou-Nukta F, Bakhos C, Arroyo K, Koo Y, Martin J, Reinhold R, et al. Effects of delaying appendectomy
for acute appendicitis for 12 to 24 hours. Arch Surg. May 2006;141(5):504-6; discussion 506-7. [Medline].

54. [Guideline] Korndorffer JR Jr, Fellinger E, Reed W. SAGES guideline for laparoscopic appendectomy. Surg
Endosc. Apr 2010;24(4):757-61. [Medline]. [Full Text].

55. Wilasrusmee C, Sukrat B, McEvoy M, Attia J, Thakkinstian A. Systematic review and meta-analysis of
safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg.
Nov 2012;99(11):1470-8. [Medline].

http://emedicine.medscape.com/article/773895-overview 10/11
9/12/2014 Appendicitis

56. Liang MK, Lo HG, Marks JL. Stump appendicitis: a comprehensive review of literature. Am Surg. Feb
2006;72(2):162-6. [Medline].

57. Barclay L. Ultrasound, CT Comparable to Detect Appendicitis in Children. Medscape Medical News.
Available at http://www.medscape.com/viewarticle/817370. Accessed December 9, 2013.

58. Le J, Kurian J, Cohen HW, Weinberg G, Scheinfeld MH. Do clinical outcomes suffer during transition to an
ultrasound-first paradigm for the evaluation of acute appendicitis in children?. AJR Am J Roentgenol. Dec
2013;201(6):1348-52. [Medline].

Medscape Reference 2011 WebMD, LLC

http://emedicine.medscape.com/article/773895-overview 11/11