Appendicitis, Acute

Last Updated: June 9, 2004

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Synonyms and related keywords: acute inflammation of the appendix, abdominal
pain
AUTHOR INFORATION Section ! o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous
(ictures )ibliograph*
Author+ Sandy #rai$, %, Associate (rogram irector, Ad,unct
Assistant (rofessor, epartment of Emergenc* $edicine, -ni.ersit* of
/orth Carolina at Chapel 0ill, Carolinas $edical Center
1and* Craig, $, is a member of the follo&ing medical societies+ Alpha
2mega Alpha, and 1ociet* for Academic Emergenc* $edicine
Editor3s4+ &illiam Lo'er, %, Instructor, epartment of $edical
Education, i.ision of )iomedical and 0ealth Informatics, -ni.ersit* of
!ashington 1chool of $edicine5 Francisco Tala(era, )*arm%, )*%,
1enior (harmac* Editor, (harmac*, e$edicine5 +u$ene Hardin, %,
Chair, epartment of Emergenc* $edicine, $artin 6uther 7ing
Jr8Charles R re& $edical Center5 $edical irector, 0ubert 0
0umphre* Comprehensi.e 0ealth Center5 ,o*n Halamka, %, Chief
Information 2fficer, Care9roup 0ealthcare 1*stem, Assistant (rofessor
of $edicine, epartment of Emergenc* $edicine, )eth Israel
eaconess $edical Center5 Assistant (rofessor of $edicine, 0ar.ard
$edical 1chool5 and ,onat*an Adler, %, Instructor, epartment of
Emergenc* $edicine, $assachusetts 9eneral 0ospital, 0ar.ard
$edical 1chool
INTRO%U#TION Section - o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous
(ictures )ibliograph*
.ack$round: Appendicitis is a common and urgent surgical illness &ith
protean manifestations, generous o.erlap &ith other clinical s*ndromes,
and significant morbidit*, &hich increases &ith diagnostic dela*: /o single
sign, s*mptom, or diagnostic test accuratel* ma"es the diagnosis of
appendiceal inflammation in all cases: #he surgeon;s goals are to
e.aluate a relati.el* small population of patients referred for suspected
appendicitis and to minimi<e the negati.e appendectom* rate &ithout
increasing the incidence of perforation: #he emergenc* ph*sician must
e.aluate the larger group of patients &ho present to the E &ith
abdominal pain of all etiologies &ith the goal of approaching =00>
sensiti.it* for the diagnosis in a time', cost', and consultation'efficient
manner:
)at*op*ysiolo$y: 2bstruction of the appendiceal lumen is the primar*
/uick Find
Author Information
Introduction
Clinical
ifferentials
!or"up
#reatment
$edication
%ollo&'up
$iscellaneous
(ictures
)ibliograph*
Clic" for related
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Related Articles
Cholec*stitis and
)iliar* Colic
Constipation
i.erticular isease
Endometriosis
9astroenteritis
Inflammator* )o&el
isease
$esenteric
Ischemia
2.arian C*sts
2.arian #orsion
(ediatrics,
Intussusception
(el.ic Inflammator*
isease
1pider
En.enomations,
!ido&
cause of appendicitis: 2bstruction of the lumen leads to distension of the
appendix due to accumulated intraluminal fluid: Ineffecti.e l*mphatic and
.enous drainage allo&s bacterial in.asion of the appendiceal &all and, in
ad.anced cases, perforation and spillage of pus into the peritoneal ca.it*:
Fre0uency:
In t*e US: Appendicitis occurs in ?> of the -1 population, &ith an
incidence of =:=8=000 people per *ear: 1ome familial predisposition
exists:
Internationally: Incidence of appendicitis is lo&er in cultures &ith a
higher inta"e of dietar* fiber: ietar* fiber is thought to decrease
the .iscosit* of feces, decrease bo&el transit time, and discourage
formation of fecaliths, &hich predispose indi.iduals to obstructions
of the appendiceal lumen:
ortality1or'idity:
2.erall mortalit* rate of 0:2'0:@> is attributable to complications of
the disease rather than to surgical inter.ention:
$ortalit* rate rises abo.e 20> in patients older than ?0 *ears,
primaril* because of diagnostic and therapeutic dela*:
(erforation rates are higher in patients *ounger than =@ *ears and
in patients older than A0 *ears, possibl* because of dela*s in
diagnosis: Appendiceal perforation is associated &ith an increase
in morbidit* and mortalit* rates:
Se2: Incidence of appendicitis is approximatel* =:4 times greater in men
than in &omen: #he incidence of primar* appendectom* is approximatel*
eBual in both sexes:
A$e:
Incidence of appendicitis graduall* rises from birth, pea"s in the
late teen *ears, and graduall* declines in the geriatric *ears:
Although rare, cases of neonatal and e.en prenatal appendicitis
ha.e been reported:
#he emergenc* ph*sician must maintain a high index of suspicion
in all age groups:
#ontinuin$
+ducation
C$E a.ailable for
this topic: Clic"
here to ta"e this
C$E:
)atient +ducation
Esophagus,
1tomach, and
Intestine Center
Appendicitis
2.er.ie&
Appendicitis
Causes
Appendicitis
1*mptoms
Appendicitis
#reatment
Abdominal (ain in
Adults 2.er.ie&
#LINI#AL Section 3 o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous
(ictures )ibliograph*
History:
Cariations in the position of the appendix, age of the patient, and
degree of inflammation ma"e the clinical presentation of
appendicitis notoriousl* inconsistent: In addition, man* other
disorders present &ith s*mptoms similar to those of appendicitis:
#hese include pel.ic inflammator* disease 3(I4, tubo'o.arian
abscess, endometriosis, o.arian c*st or torsion, degenerating
uterine leiom*omata, di.erticulitis, Crohn disease, colonic
carcinoma, rectus sheath hematoma, cholec*stitis, bacterial
enteritis, mesenteric adenitis, and omental torsion:
#he classic histor* of anorexia and periumbilical pain follo&ed b*
nausea, right lo&er Buadrant 3R6D4 pain, and .omiting occurs in
onl* A0> of cases:
$igration of pain from the periumbilical area to the R6D is the most
discriminating historical feature, &ith sensiti.it* and specificit* of
approximatel* @0>:
!hen .omiting occurs, it nearl* al&a*s follo&s the onset of pain:
Comiting that precedes pain is suggesti.e of intestinal obstruction,
and the diagnosis of appendicitis should be reconsidered:
/ausea is present in E='92> of cases5 anorexia is present in ?4'
?@> of cases: /either finding is statisticall* different from findings
in E patients &ith other etiologies of abdominal pain:
iarrhea or constipation is noted in as man* as =@> of patients
and should not be used to discard the possibilit* of appendicitis:
uration of s*mptoms is less than 4@ hours in approximatel* @0>
of adults but tends to be longer in the elderl* and in those &ith
perforation: Approximatel* 2> of patients report duration of pain in
excess of 2 &ee"s:
0istor* of prior similar pain is reported in as man* as 2F> of
cases: 0istor* of similar pain should not, in and of itself, be used to
discard the possibilit* of appendicitis:
An inflamed appendix located in proximit* to the urinar* bladder or
ureter can gi.e rise to irritati.e .oiding s*mptoms and hematuria or
p*uria: Remember that c*stitis in males is rare in the absence of
instrumentation: Consider the possibilit* of an inflamed pel.ic
appendix in males &ith apparent c*stitis:
)*ysical:
R6D tenderness is present in 9E> of patients but is a .er*
nonspecific finding:
#he most specific ph*sical findings are rebound tenderness, pain
on percussion, rigidit*, and guarding:
Ro.sing sign 3ie, R6D pain &ith palpation of the 66D4, obturator
sign 3ie, R6D pain &ith internal rotation of the flexed right hip4, and
psoas sign 3ie, R6D pain &ith h*perextension of the right hip4 are
present in a minorit* of patients &ith acute appendicitis: #heir
absence ne.er should be used to rule out appendiceal
inflammation:
A positi.e cough sign 3ie, sharp pain in the R6D elicited b* a
.oluntar* cough4 ma* be helpful in ma"ing the clinical diagnosis of
locali<ed peritonitis: 1imilarl*, R6D pain in response to percussion
of a remote Buadrant of the abdomen, or to firm percussion of the
patient;s heel, suggests peritoneal inflammation:
6iterature is inconsistent as to &hether rectal examination is helpful
in ma"ing the diagnosis5 ho&e.er, failure to perform a rectal
examination is cited freBuentl* in successful malpractice claims:
#auses:
Appendicitis is usuall* precipitated b* obstruction of the
appendiceal lumen: Causes of luminal obstruction include fecaliths,
l*mphoid follicle h*perplasia, foreign bodies 3eg, shotgun pellet,
intrauterine de.ice4, and tumors:
o %ecaliths form &hen calcium salts and fecal debris become
la*ered around a nidus of inspissated fecal material located
&ithin the appendix:
o 6*mphoid h*perplasia is associated &ith a .ariet* of
inflammator* and infectious disorders including Crohn
disease, gastroenteritis, amebiasis, respirator* infections,
measles, and mononucleosis:
%IFF+R+NTIALS Section 4 o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous
(ictures )ibliograph*
Cholec*stitis and )iliar* Colic
Constipation
i.erticular isease
Endometriosis
9astroenteritis
Inflammator* )o&el isease
$esenteric Ischemia
2.arian C*sts
2.arian #orsion
(ediatrics, Intussusception
(el.ic Inflammator* isease
1pider En.enomations, !ido&
Ot*er )ro'lems to 'e #onsidered:
#*philitis
Epiploic appendagitis
$esenteric adenitis
&OR5U) Section 6 o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph*
La' Studies:
Complete blood count
o 1tudies consistentl* sho& that @0'@A> of adults &ith appendicitis ha.e a !)C
count greater than =0,000: /eutrophilia greater than ?A> occurs in ?@> of
patients: %e&er than 4> of patients &ith appendicitis ha.e a !)C count less than
=0,000 and neutrophilia less than ?A>:
o C)C is inexpensi.e, rapid, and &idel* a.ailable5 ho&e.er, it is nonspecific and
misses 4> of cases: It costs approximatel* GA0:
o 6iterature is inconsistent &ith regard to !)C count parameters in children and
elderl* patients &ith appendicitis:
C'reacti.e protein test
o C'reacti.e protein 3CR(4 is an acute'phase reactant s*nthesi<ed b* the li.er in
response to bacterial infection: 1erum le.els begin to rise &ithin E'=2 hours of
acute tissue inflammation: A rapid assa* is &idel* a.ailable:
o 1e.eral prospecti.e studies ha.e concluded that in adult patients &ho ha.e had
s*mptoms for longer than 24 hours, a normal CR( has a negati.e predicti.e .alue
of approximatel* =00> for the presence of appendicitis: 1pecificit* has ranged from
A0'@?> in se.eral series: #&o other studies in adults found that a combination of a
!)C count of less than =0,A00, neutrophilia less than ?A>, and a normal CR( had
=00> negati.e predicti.e .alue for the diagnosis of acute appendicitis: In =9@9,
#himsen et al noted that a normal CR( after =2 hours of s*mptoms &as =00>
predicti.e of benign, self'limited illness:
o CR( does not distinguish bet&een .arious t*pes of bacterial infection:
o Cost is approximatel* GEE:
Ima$in$ Studies:
Computed tomograph*
o Abdominal C# has become the most important imaging stud* in the e.aluation of
patients &ith at*pical presentations of appendicitis: 1e.eral studies ha.e sho&n a
decrease in negati.e laparotom* rate and appendiceal perforation rate &hen
abdominal C# is used in selected patients &ith suspected appendicitis: Ad.antages
of C# scanning include superior sensiti.it* and accurac* compared &ith other
imaging techniBues, read* a.ailabilit*, nonin.asi.eness, and potential to re.eal
alternati.e diagnoses: isad.antages include radiation exposure, potential for
anaph*lactoid reaction if intra.enous 3IC4 contrast is used, length* acBuisition time
if oral contrast is used, and patient discomfort if rectal contrast is used: A .ariet* of
C# techniBues ha.e been studied:
o Initial studies e.aluated seBuential 3nonhelical4 C# scanning in the diagnosis of
appendicitis: $alone, in =99F, e.aluated unenhanced, seBuential C# scanning in
2== patients and reported a sensiti.it* of @?> and specificit* of 9?>: Addition of IC
and oral contrast increases sensiti.it* to 9E'9@>, but it increases cost to
approximatel* G900: 1eBuential C# &ith oral and IC contrast is highl* accurate but
time consuming and expensi.e5 it is best used for eBui.ocal presentations &hen
helical C# is not a.ailable:
o In =99?, 6ane e.aluated helical C# scanning &ithout contrast and found a
sensiti.it* of 90> and specificit* of 9?>: $ore recent studies 36ane, =9995 Ege,
20024 of noncontrast helical C# in adult patients &ith suspected appendicitis found
the sensiti.it* to be 9E> and the specificit* to be 9@'99>:
o Rao, in =99?, found that focused 3lo&er abdomen and upper pel.is4 helical C#
scanning &ith F> 9astrografin contrast instilled into the colon 3&ithout IC contrast4
has a superior sensiti.it* of 9@> and specificit* of 9@>: %ocused helical scanning
&ith a.oidance of IC contrast eliminates the ris" of anaph*lactoid contrast reaction
and reduces the cost to approximatel* G2F0: AcBuisition time is less than =A
minutes: Radiation exposure is less than that of a standard obstruction series:
Alternati.e diagnoses are re.ealed in up to E2> of patients and include
di.erticulitis, nephrolithiasis, adnexal patholog*, R6D tumor, small bo&el hernias,
and ischemia:
o Current literature suggests that limited helical C# &ith rectal contrast is a highl*
accurate, time'efficient, cost'effecti.e &a* to e.aluate adult patients &ith eBui.ocal
presentations for appendicitis: #&o studies of focused helical C# in children
suggest sensiti.it* of 9A'9?> in that population: Continued impro.ements in helical
C# technolog* and interpretation ma* allo& noncontrast helical C# to be the
imaging test of choice in the future:
-ltrasonograph*
o In =9@E, (u*laert described a graded compression techniBue for e.aluation of the
appendix using transabdominal ultrasonograph*: A A'$0< transducer is used,
appl*ing gentle but firm pressure in the R6D to displace inter.ening bo&el gas and
to decrease the distance bet&een the transducer and the appendix, thereb*
impro.ing image Bualit*: An outer diameter of greater than E mm,
noncompressibilit*, lac" of peristalsis, or presence of a periappendiceal fluid
collection characteri<es an inflamed appendix: #he normal appendix is not
.isuali<ed in most cases: A posterolateral approach is suggested to e.aluate the
retrocecal area: 1cattered case reports endorse trans.aginal ultrasonograph* for
&omen &ith lo& pel.ic tenderness if the appendix is not .isuali<ed on
transabdominal sonograph*:
o /umerous studies ha.e documented a sensiti.it* of @A'90> and a specificit* of 92'
9E>: %i.e studies using graded compression ultrasonograph* in children reported
sensiti.ities of @A'9A> and specificities ranging from 4?'9E>: #he cost is
approximatel* G22A:
o Ad.antages include nonin.asi.eness, short acBuisition time, lac" of radiation
exposure, and potential for diagnosis of other causes of abdominal pain,
particularl* in the subset of females of childbearing age: $an* authorities feel that
ultrasonograph* should be the initial imaging test in pregnant &omen and in
pediatric patients because radiation exposure is particularl* undesirable in those
groups:
o #he principal disad.antage is that ultrasonographic examination is operator
dependent: )ecause non.isuali<ation is interpreted as a noninflamed appendix,
technical expertise and commitment to a thorough examination are essential in
obtaining maximum sensiti.it*:
o If graded compression ultrasonograph* of the right lo&er Buadrant is positi.e for
appendicitis, appendectom* should be performed: If negati.e, this finding is not
sufficientl* sensiti.e to rule out the possibilit* of appendicitis: Consideration should
be gi.en to further obser.ation and focused helical C# &ith rectal contrast:
Abdominal radiograph*
o 7idne*s'ureters'bladder 37-)4 .ie& used t*picall*:
o Cisuali<ation of an appendicolith in a patient &ith s*mptoms consistent &ith
appendicitis is highl* suggesti.e of appendicitis, but this occurs in fe&er than =0>
of cases:
o #he consensus in the literature is that plain radiograph* is insensiti.e, nonspecific,
and not cost'effecti.e:
)arium enema
o A single contrast stud* can be performed on an unprepared bo&el: /onfilling or
incomplete filling of the appendix coupled &ith pressure effect or spasm in the
cecum suggests appendicitis: #he cost is approximatel* G420:
o $ultiple studies ha.e found that the sensiti.it* of a barium enema is in the range of
@0'=00>: 0o&e.er, as man* as =E> of examinations in adults 3and 22'F9> of
examinations in children4 &ere technicall* unsuitable for interpretation and &ere
excluded from data anal*sis:
o Ad.antages of barium enema are its &ide a.ailabilit*, use of simple eBuipment, and
potential for diagnosis of other diseases 3eg, Crohn disease, colon cancer,
ischemic colitis4 that ma* mimic appendicitis:
o isad.antages include its high incidence of nondiagnostic examination, radiation
exposure, insufficient sensiti.it*, and in.asi.eness: #hese disad.antages ma"e
barium enema a poor screening examination for use b* emergenc* ph*sicians:
)arium enema has essentiall* no role in the diagnosis of acute appendicitis in the
era of ultrasonograph* and C#:
Radionuclide scanning
o !hole blood is &ithdra&n: /eutrophils and macrophages are labeled &ith
technetium 99m albumin and administered intra.enousl*: Images of the abdomen
and pel.is are obtained seriall* o.er 4 hours: 6ocali<ed upta"e of tracer in the R6D
suggests appendiceal inflammation: #he cost is approximatel* G4A0:
o %our earl* studies in adults &ith suspected appendicitis sho&ed a sensiti.it* of 90>
and specificit* of 92'9E>: #&o recent studies of ne&er labeling techniBues
achie.ed sensiti.ities of 9@> for the presence of appendicitis:
o !hile future studies ma* confirm sensiti.it* as high as 9@>, the acBuisition time of
A hours and the lac" of a.ailabilit* are disad.antages to its use as a high'sensiti.it*
E screen for appendicitis:
Ot*er Tests:
Clinical diagnostic scores
o 1e.eral in.estigators ha.e created diagnostic scoring s*stems in &hich a finite
number of clinical .ariables is elicited from the patient and each is gi.en a
numerical .alue: #he sum of these .alues is used to predict the li"elihood of acute
appendicitis:
o #he best "no&n of these is the $A/#RE61 score, &hich tabulates presence or
absence of migration of pain, anorexia, nausea8.omiting, tenderness in the R6D,
rebound tenderness, ele.ated temperature, leu"oc*tosis, and shift to the left:
o Clinical scoring s*stems are attracti.e because of their simplicit*5 ho&e.er, none
has been sho&n prospecti.el* to impro.e upon ph*sician ,udgment in the subset of
patients e.aluated in the E for abdominal pain suggesti.e of appendicitis: #he
$A/#RE61 score, in fact, &as based on a population of patients hospitali<ed for
suspected appendicitis, &hich differs mar"edl* from the population seen in the E:
Computer'aided diagnosis
o A retrospecti.e database of clinical features of patients &ith appendicitis and other
causes of abdominal pain is entered into a computer: It is then utili<ed in
prospecti.el* assessing the ris" of appendicitis:
o Computer'aided diagnosis can achie.e sensiti.it* greater than 90> &hile reducing
rates of perforation and negati.e laparotom* b* as much as A0>:
o #he principle disad.antages are that each institution must generate its o&n uniBue
database to reflect local population characteristics: 1peciali<ed eBuipment and
significant initiation time are reBuired:
o Computer'aided diagnosis is not &idel* a.ailable in -1 emergenc* departments:
TR+AT+NT Section 7 o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph*
+mer$ency %epartment #are:
#reatment guidelines for patients &ith suspected acute appendicitis include the follo&ing+
o Establish IC access and administer aggressi.e cr*stalloid therap* to patients &ith
clinical signs of deh*dration or septicemia:
o o not gi.e an*thing b* mouth to patients &ith suspected appendicitis:
o Administration of analgesics to patients &ith acute undifferentiated abdominal pain
has historicall* been discouraged and critici<ed because of concerns that the*
&ould render the ph*sical examination less reliable: At least @ randomi<ed
controlled studies no& report that administering opioid analgesic medications to
adult and pediatric patients &ith acute undifferentiated abdominal pain is safe5 no
stud* has found that analgesics ad.ersel* effect the accurac* of the ph*sical
examination:
o Consider ectopic pregnanc* in &omen of childbearing age and obtain a Bualitati.e
beta'hC9 in all cases:
o Administer IC antibiotics to those &ith signs of septicemia and those &ho are to
proceed to laparotom*:
/onsurgical treatment of appendicitis
o Anecdotal reports describe the success of IC antibiotics in treating acute
appendicitis in patients &ithout access to surgical inter.ention 3eg, submariners,
indi.iduals on ships at sea4: In one prospecti.e stud* of 20 patients &ith
ultrasound'pro.en appendicitis, 9A> had resolution of s*mptoms &ith antibiotics
alone, but F?> of these patients experienced recurrent appendicitis &ithin =4
months:
o #his ma* be useful &hen appendectom* is not accessible or &hen it is temporaril*
a high'ris" procedure:
(reoperati.e antibiotics
o (reoperati.e antibiotics ha.e a demonstrated efficac* in decreasing postoperati.e
&ound infection rates in numerous prospecti.e controlled studies:
o )road'spectrum gram'negati.e and anaerobic co.erage is indicated:
o #hese should be gi.en in con,unction &ith the surgical consultant:
#onsultations:
9eneral surgeon
+%I#ATION Section 8 o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph*
#he goals of therap* are to eradicate the infection and pre.ent complications:
rug Categor*+ Antibiotics '' #hese agents ha.e pro.en effecti.e in decreasing the rate of
postoperati.e &ound infection and in impro.ing outcome in patients &ith appendiceal abscess or
septicemia:
%ru$ Name
$etronida<ole 3%lag*l4 '' -sed in combination &ith an
aminogl*coside, such as gentamicin, pro.ides broad gram'
negati.e and anaerobic co.erage: Appears to be absorbed
into cells, and intermediate'metaboli<ed compounds that are
formed bind /A and inhibit protein s*nthesis, causing cell
death:
Adult %ose ?:A mg8"g IC before surger*
)ediatric %ose
=A'F0 mg8"g8d IC di.ided bid8tid for ? d, or 40 mg8"g (2 once5
not to exceed 2 g8d
#ontraindications ocumented h*persensiti.it*
Interactions
$a* increase toxicit* of anticoagulants, lithium, and phen*toin5
cimetidine ma* increase toxicit*5 disulfiram reaction ma* occur
&ith orall* ingested ethanol
)re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s:
)recautions
Ad,ust dose in hepatic disease5 monitor for sei<ures and
de.elopment of peripheral neuropath*
%ru$ Name
9entamicin 39entacidin, 9aram*cin4 '' Aminogl*coside
antibiotic for gram'negati.e co.erage: -sed in combination
&ith both an agent against gram'positi.e organisms and one
that co.ers anaerobes: /ot the 2C: Consider if penicillins or
other less toxic drugs are contraindicated, &hen clinicall*
indicated, and in mixed infections caused b* susceptible
staph*lococci and gram'negati.e organisms:
osing regimens are numerous5 ad,ust dose on the basis of
CrCl and changes in .olume of distribution: $a* be gi.en
IC8I$:
Adult %ose
2 mg8"g IC loading dose before surger*5 F'A mg8"g8d di.ided
tid8Bid thereafter
)ediatric %ose
Infants8neonates+ ?:A mg8"g8d IC di.ided tid
Children+ E'?:A mg8"g8d IC di.ided tid
#ontraindications
ocumented h*persensiti.it*, nonHdial*sis'dependent renal
insufficienc*
Interactions
Coadministration &ith other aminogl*cosides, cephalosporins,
penicillins, and amphotericin ) ma* increase nephrotoxicit*5
aminogl*cosides enhance effects of neuromuscular bloc"ing
agents5 thus, prolonged respirator* depression ma* occur5
coadministration &ith loop diuretics ma* increase ototoxicit* of
aminogl*cosides, &hich ma* cause irre.ersible hearing loss of
.ar*ing degrees 3monitor regularl*4
)re$nancy C ' 1afet* for use during pregnanc* has not been established:
)recautions
/arro& therapeutic index 3not intended for long'term therap*45
caution in renal failure 3not on dial*sis4, m*asthenia gra.is,
h*pocalcemia, and conditions that depress neuromuscular
transmission5 ad,ust dose in renal impairment
%ru$ Name
Cefotetan 3Cefotan4 '' 1econd'generation cephalosporin used
as single'drug therap* to pro.ide broad gram'negati.e
co.erage and anaerobic co.erage: 0alf'life is F:A h: 9i.e &ith
cefoxitin to achie.e effecti.eness of single'dose:
Adult %ose 2 g IC once before surger*
)ediatric %ose 20'40 mg8"g IC8I$ once before surger*
#ontraindications ocumented h*persensiti.it*
Interactions
Consumption of alcohol &ithin ?2 h of cefotetan ma* produce
disulfiramli"e reactions5 ma* increase h*poprothrombinemic
effects of anticoagulants5 coadministration &ith potent diuretics
3eg, loop diuretics4 or aminogl*cosides ma* increase
nephrotoxicit*
)re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s:
)recautions
Reduce dosage b* half if CrCl =0'F0 m68min and b* three
Buarters if I=0 m68min5 bacterial or fungal o.ergro&th of
nonsusceptible organisms ma* occur &ith prolonged or
repeated therap*
%ru$ Name
Cefoxitin 3$efoxin4 '' 1econd'generation cephalosporin
indicated for management of infections caused b* susceptible
gram'positi.e cocci and gram'negati.e rods: 0alf'life is 0:@ h:
Adult %ose
2 g IC before surger*, follo&ed b* F doses of 2 g B4'Eh for 24
h
)ediatric %ose
IF months+ /ot established
JF months+ F0'40 mg8"g IC before surger*, follo&ed b* F
doses of 2 g B4'Eh for 24 h
#ontraindications ocumented h*persensiti.it*
Interactions
(robenecid ma* increase effects5 coadministration &ith
aminogl*cosides or furosemide ma* increase nephrotoxicit*
3closel* monitor renal function4
)re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s:
)recautions
)acterial or fungal o.ergro&th of nonsusceptible organisms
ma* occur &ith prolonged use or repeated treatment5 caution
in patients &ith pre.iousl* diagnosed colitis
%ru$ Name
$eropenem 3$errem4 '' )actericidal broad'spectrum
carbapenem antibiotic that inhibits cell'&all s*nthesis:
Effecti.e against most gram'positi.e and gram'negati.e
bacteria:
Adult %ose = g IC B@h
)ediatric %ose 40 mg8"g IC B@h
#ontraindications ocumented h*persensiti.it*
Interactions
(robenecid ma* inhibit renal excretion of meropenem,
increasing meropenem le.els
)re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s:
)recautions
(seudomembranous colitis and thromboc*topenia ma* occur,
reBuiring immediate discontinuation of medication
rug Categor*+ Analgesics '' #hese agents can be used to relie.e acute undifferentiated
abdominal pain in patients presenting to the emergenc* department:
%ru$ Name $orphine sulfate 3Astramorph, uramorph, $1 Contin, $1IR,
2ramorph4 '' 2C for analgesia because of reliable and
predictable effects, safet* profile, and ease of re.ersibilit* &ith
naloxone: Carious IC doses are used5 commonl* titrated until
desired effect obtained:
Adult %ose
1tarting dose+ 0:= mg8"g IC8I$81C
$aintenance dose+ A'20 mg8?0 "g IC8I$81C B4h
Relati.el* h*po.olemic patients+ 1tart &ith 2 mg IC8I$81C5
reassess hemod*namic effects of dose
)ediatric %ose
Infants and children+ 0:='0:2 mg8"g dose IC8I$81C B2'4h prn5
not to exceed =A mg8dose5 ma* initiate at 0:0A mg8"g8dose
#ontraindications
ocumented h*persensiti.it*5 h*potension5 potentiall*
compromised air&a* in &hich establishing rapid air&a* control
&ould be difficult
Interactions
(henothia<ines ma* antagoni<e analgesic effects of opiate
agonists5 tric*clic antidepressants, $A2Is, and other C/1
depressants ma* potentiate ad.erse effects of morphine
)re$nancy C ' 1afet* for use during pregnanc* has not been established:
)recautions
Caution in h*potension, respirator* depression, nausea,
emesis, constipation, urinar* retention, atrial flutter, and other
supra.entricular tach*cardias5 has .agol*tic action and ma*
increase .entricular response rate
FOLLO&9U) Section : o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph*
Furt*er Inpatient #are:
2pen .ersus laparoscopic appendectom*
o Initiall* performed in =9@?, laparoscopic appendectom* has been performed in
thousands of patients and is successful in 90'94> of attempts:
o Ad.antages of laparoscopic appendectom* include increased cosmetic satisfaction
and a decrease in the postoperati.e &ound infection rate: 1ome studies find a
shorter con.alescent period compared to open appendectom* and a trend to&ard
shorter hospital sta*s:
o isad.antages of laparoscopic appendectom* include a slightl* longer operating
time 3approximatel* 20 min4 and increased cost:
o Contraindications to laparoscopic appendectom* include significant intra'abdominal
adhesions and pregnanc* be*ond the first trimester:
#omplications:
!ound infection
ehiscence
)o&el obstruction
Abdominal8pel.ic abscess
eath 3rare4
)ro$nosis:
Excellent
)atient +ducation:
%or excellent patient education resources, .isit e$edicine;s Esophagus, 1tomach, and
Intestine Center: Also, see e$edicine;s patient education articles, Appendicitis and
Abdominal (ain in Adults:
IS#+LLAN+OUS Section ; o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph*
edical1Le$al )it"alls:
Approximatel* =0> of adults &ho de.elop appendicitis are not diagnosed correctl* at the
first ph*sician encounter: %ailure to diagnose appendicitis is the leading cause of
successful malpractice claims and the fifth most expensi.e source of claims against
emergenc* ph*sicians:
Special #oncerns:
(regnanc*
o #he incidence of appendicitis is unchanged in pregnanc*, but the clinical
presentation becomes e.en more .ariable: uring pregnanc* the appendix
migrates in a countercloc"&ise direction to&ard the right "idne*, rising abo.e the
iliac crest at about 4:A months gestation: R6D pain and tenderness dominate in the
first trimester, but in the latter half of pregnanc*, right upper Buadrant 3R-D4 or right
flan" pain must be loo"ed upon as a possible sign of appendiceal inflammation:
/ausea, .omiting, and anorexia are common in uncomplicated first trimester
pregnancies, but their reappearance later in gestation should be .ie&ed &ith
suspicion:
o (h*siologic leu"oc*tosis during pregnanc* ma"es the !)C count less useful in the
diagnosis, and no reliable distinguishing !)C parameters are cited in the literature:
2ne stud* of 22 pregnant &omen in the first and second trimesters found that
graded compression ultrasound had a sensiti.it* of EE> and specificit* of 9A>:
iagnostic laparoscop* also has been suggested for pregnant patients in the first
trimester &ith suspected appendicitis:
o !hile negati.e appendectom* does not appear to affect maternal or fetal health
ad.ersel*, diagnostic dela* &ith perforation does increase fetal and maternal
morbidit*: #herefore, aggressi.e e.aluation of the appendix is &arranted in this
group:
/onpregnant &omen of childbearing age
o (atients in this group &ho de.elop appendicitis are misdiagnosed in FF> of cases:
#he most freBuent misdiagnoses are (I, follo&ed b* gastroenteritis and urinar*
tract infection:
o In distinguishing appendiceal pain from (I, presence of anorexia and onset of
pain more than =4 da*s after menses fa.ors appendicitis: (re.ious (I, presence
of .aginal discharge, or presence of urinar* s*mptoms indicates the diagnosis of
(I:
o 2n ph*sical examination, tenderness outside the R6D, cer.ical motion tenderness,
.aginal discharge, and positi.e urinal*sis fa.or the diagnosis of (I:
Children
o Children &ith appendicitis are misdiagnosed in 2A'F0> of cases o.erall, and the
rate of initial misdiagnosis is in.ersel* related to the age of the patient:
o #he most common misdiagnosis is gastroenteritis, follo&ed b* upper respirator*
infection and lo&er respirator* infection:
o $isdiagnosed children are more li"el* than their correctl* diagnosed counterparts
to ha.e .omiting before pain onset, diarrhea, constipation, d*suria, signs and
s*mptoms of upper respirator* infection, and letharg* or irritabilit*:
o (h*sical findings less li"el* to be documented in the children &ho are
misdiagnosed include findings of ear, nose, and throat exam5 bo&el sounds5
peritoneal signs5 and findings of rectal examination:
Elderl* patients
o Appendicitis in patients older than E0 *ears accounts for =0> of all
appendectomies:
o #he incidence of misdiagnosis is increased in the elderl*:
o In those patients &ith comorbid conditions, diagnostic dela* does correlate &ith
increased morbidit* and mortalit*:
o 2lder patients tend to see" medical attention later in the course of illness5
therefore, duration of s*mptoms in excess of 24'4@ hours should not dissuade the
ph*sician from the diagnosis:
)I#TUR+S Section !< o" !!
Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph*
#aption: (icture =: C# scan &ith colonic contrast re.eals an enlarged appendix &ith
thic"ened &alls, &hich do not fill &ith contrast, l*ing ad,acent to the right psoas
muscle:
Cie& %ull 1i<e Image
e$edicine Koom Cie&
3Interacti.eL4
)icture Type: C#
#aption: (icture 2: 9raded compression transabdominal ultrasound sho&s a
sagittal .ie& of an acutel* inflamed appendix: #he tubular structure is
noncompressible, lac"s peristalsis, and measures greater than E mm in diameter: A
thin rim of periappendiceal fluid is present:
Cie& %ull 1i<e Image
e$edicine Koom Cie&
3Interacti.eL4
)icture Type: (hoto
#aption: (icture F: 9raded compression transabdominal ultrasound sho&s a
trans.erse .ie& of an acutel* inflamed appendix: /ote the targetli"e appearance
due to thic"ened &all and surrounding loculated fluid collection:
Cie& %ull 1i<e Image
e$edicine Koom Cie&
3Interacti.eL4
)icture Type: (hoto
#aption: (icture 4: 7idne*s'ureters'bladder 37-)4 x'ra* sho&s an appendicolith in
the right lo&er Buadrant: #his is seen in fe&er than =0> of patients &ith appendicitis
but, &hen present, is essentiall* pathognomonic:
Cie& %ull 1i<e Image
e$edicine Koom Cie&
3Interacti.eL4
)icture Type: M'RAN
#aption: (icture A: #echnetium 99m radionuclide scan of the abdomen sho&s focal
upta"e of labeled &hite blood cells in the right lo&er Buadrant consistent &ith acute
appendicitis:
Cie& %ull 1i<e Image
e$edicine Koom Cie&
3Interacti.eL4
)icture Type: (hoto
Acute Appendicitis: Re(iew and Update
D. MIKE HARDIN, JR., M.D.,
Texas A&M University Health Science Center, Te!le, Texas
Appendicitis is common, &ith a lifetime occurrence of ? percent: Abdominal pain and anorexia are
the predominant s*mptoms: #he most important ph*sical examination finding is right lo&er
Buadrant tenderness to palpation: A complete blood count and urinal*sis are sometimes helpful in
determining the diagnosis and supporting the presence or absence of appendicitis, &hile
appendiceal computed tomographic scans and ultrasonograph* can be helpful in eBui.ocal
cases: ela* in diagnosing appendicitis increases the ris" of perforation and complications:
Complication and mortalit* rates are much higher in children and the elderl*: 3Am %am (h*sician
=9995E0+202?'F4:4
Appendicitis is the most common acute surgical condition of the abdomen:
=

Approximatel* ? percent of the population &ill ha.e appendicitis in their lifetime,
2

&ith the pea" incidence occurring bet&een the ages of =0 and F0 *ears:
F
espite technologic ad.ances, the diagnosis of appendicitis is still based
primaril* on the patient;s histor* and the ph*sical examination: (rompt diagnosis
and surgical referral ma* reduce the ris" of perforation and pre.ent
complications:
4
#he mortalit* rate in nonperforated appendicitis is less than =
percent, but it ma* be as high as A percent or more in *oung and elderl* patients,
in &hom diagnosis ma* often be dela*ed, thus ma"ing perforation more li"el*:
=
)at*o$enesis
#he appendix is a long di.erticulum that extends from the inferior tip of the
cecum:
A
Its lining is interspersed &ith l*mphoid follicles:
F
$ost of the time, the
appendix has an intraperitoneal location 3either anterior or retrocecal4 and, thus,
ma* come in contact &ith the anterior parietal peritoneum &hen it is inflamed: -p
to F0 percent of the time, the appendix ma* be OhiddenO from the anterior
peritoneum b* being in a pel.ic, retroileal or retrocolic 3retroperitoneal retrocecal4
position:
E
#he OhiddenO position of the appendix notabl* changes the clinical
manifestations of appendicitis:
2bstruction of the narro& appendiceal lumen initiates the clinical illness of acute
appendicitis: 2bstruction has multiple causes, including l*mphoid h*perplasia
3related to .iral illnesses, including upper respirator* infection, mononucleosis,
TA.L+ !
Common 1*mptoms of
Appendicitis
#ommon symptoms=
Fre0uency
>?@
Abdominal pain P=00
Anorexia P=00
/ausea 90
Comiting ?A
(ain migration A0
Classic s*mptom seBuence
3.ague periumbilical pain to
anorexia8nausea8unsustained
.omiting to migration of pain
to right lo&er Buadrant to lo&'
grade fe.er4
A0
"##$nset %& sy!t%s ty!ically 'ithin !ast () t%
*+ h%,rs.
In&%rati%n &r% re&erences * thr%,-h ..
gastroenteritis4, fecaliths, parasites, foreign bodies, Crohn;s disease, primar* or
metastatic cancer and carcinoid s*ndrome: 6*mphoid h*perplasia is more
common in children and *oung adults, accounting for the increased incidence of
appendicitis in these age groups:
=,A
History and )*ysical +2amination
Abdominal pain is the most common s*mptom of appendicitis:
F
In multiple
studies,
F'A
specific characteristics of the abdominal pain and other associated
s*mptoms ha.e pro.ed to be reliable indicators of acute appendicitis 3Table 14: A
thorough re.ie& of the histor* of the abdominal pain and of the patient;s recent
genitourinar*, g*necologic and pulmonar* histor* should be obtained:
Anorexia, nausea and .omiting are s*mptoms that are commonl* associated &ith
acute appendicitis: #he classic histor* of pain beginning in the periumbilical
region and migrating to the right lo&er Buadrant occurs in onl* A0 percent of
patients:
=
uration of s*mptoms exceeding 24 to FE hours is uncommon in
nonperforated appendicitis:
=
TA.L+ -
1ignificant 6i"elihood Ratios for 1*mptoms and 1igns of Acute
Appendicitis
Symptom1si$n
)ositi(e likeli*ood ratio
>LRA@ Symptom1si$n
Ne$ati(e
likeli*ood
ratio >LR9@
Right lo&er
Buadrant 3R6D4
pain
@:0 R6D painQ 0 to 0:2@R
(ain migration F:2 /o similar pain
pre.iousl*SS
0:F
(ain before
.omiting
2:@ (ain migration 0:A
Anorexia, nausea
and .omitingT
$uch lo&er 6RU than R6D
pain, pain migration and
pain before .omiting
9uarding 0 to 0:A4R
Rigidit* F:?E Rebound
tenderness
0 to 0:@ER
(soas sign 2:F@ %e.er, rigidit* and
psoas signV
Rebound
tenderness
=:= to E:FR
%e.er =:9W
9uarding and rectal
tendernessT
$uch lo&er 6RU than
rigidit*, psoas sign and
rebound tenderness
/2#E+ 6R is the amount b* &hich the odds of a disease change &ith ne& information,
as follo&s+
Likeli*ood ratio %e$ree o" c*an$e in pro'a'ility
J=0 or I0:= 6arge 3often conclusi.e4
A to =0 or 0:= to 0:2 $oderate
2 to A or 0:2 to 0:A 1mall 3but sometimes important4
= to 2 or 0:A to = 1mall 3rarel* important4
"##These sy!t%s an/ si-ns have ,ch l%'er 0R1.
2##Rati%s are !resente/ in ran-es &%r si-ns an/ sy!t%s that ha/ 'i/ely varyin- res,lts in
st,/ies.
3##4ever ha/ %nly 5%r/erline 0R1.
6##That is, the a5sence %& R07 !ain si-ni&icantly l%'ers the %//s %& havin- a!!en/icitis.
88##That is, the hist%ry %& ex!eriencin- a siilar !ain !revi%,sly l%'ers the %//s %& havin-
a!!en/icitis.
9##These si-ns have hi-her 0R#.
In&%rati%n &r% re&erences :, ; an/ <=
In a recent meta'anal*sis,
?
li"elihood ratios &ere calculated for man* of these
s*mptoms 3Table 24: A li"elihood ratio is the amount b* &hich the odds of a
disease change &ith ne& information 3e:g:, ph*sical examination findings,
laborator* results4:
@
#his change can be positi.e or negati.e: 1*mptoms such as
anorexia, nausea and .omiting commonl* occur in acute appendicitis5 ho&e.er,
the presence of these s*mptoms does not necessaril* increase the li"elihood of
appendicitis nor does their absence decrease the li"elihood of the diagnosis:
$oreo.er, other s*mptoms ha.e more notable positi.e and negati.e li"elihood
ratios 3Table 24:
A careful, s*stematic examination of
the abdomen is essential: !hile right
lo&er Buadrant tenderness to
palpation is the most important
ph*sical examination finding, other
signs ma* help confirm the diagnosis
3Table 34: #he abdominal examination
should begin &ith inspection follo&ed
b* auscultation, gentle palpation
3beginning at a site distant from the
pain4 and, finall*, abdominal
percussion: #he rebound tenderness
that is associated &ith peritoneal
irritation has been sho&n to be more
accuratel* identified b* percussion of
the abdomen than b* palpation &ith
Buic" release:
=
As pre.iousl* noted, the location of the appendix .aries: !hen the appendix is
hidden from the anterior peritoneum, the usual s*mptoms and signs of acute
appendicitis ma* not be present: (ain and tenderness can occur in a location
other than the right lo&er Buadrant:
E
A retrocecal appendix in a retroperitoneal
location ma* cause flan" pain: In this case, stretching the iliopsoas muscle can
elicit pain: #he psoas sign is elicited in this manner+ the patient lies on the left
side &hile the examiner extends the patient;s right thigh 3Figures 1a and 1b4: In
contrast, a patient &ith a pel.ic appendix ma* sho& no abdominal signs, but the
rectal examination ma* elicit tenderness in the cul'de'sac: In addition, an
obturator sign 3pain on passi.e internal rotation of the flexed right thigh4 ma* be
present in a patient &ith a pel.ic appendix
F
3Figures 2a and 2b4:
TA.L+ 3
Common 1igns of Appendicitis
X Right lo&er Buadrant pain on palpation 3the
single most important sign4
X 6o&'grade fe.er 3F@YC Zor =00:4Y%[4''
absence of fe.er or high fe.er can occur
X (eritoneal signs
X 6ocali<ed tenderness to percussion
X 9uarding
X 2ther confirmator* peritoneal signs
3absence of these signs does not exclude
appendicitis4
X (soas sign''pain on extension of right thigh
3retroperitoneal retrocecal appendix4
X 2bturator sign''pain on internal rotation of
right thigh 3pel.ic appendix4
X Ro.sing;s sign''pain in right lo&er Buadrant
&ith palpation of left lo&er Buadrant
X unph*;s sign''increased pain &ith coughing
X %lan" tenderness in right lo&er Buadrant
3retroperitoneal retrocecal appendix4
X (atient maintains hip flexion &ith "nees
dra&n up for comfort
In&%rati%n &r% re&erences * thr%,-h ..
FIBUR+ !AC #he psoas sign: (ain on passi.e
extension of the right thigh: (atient lies on left side:
Examiner extends patient;s right thigh &hile appl*ing
counter resistance to the right hip 3asteris"4:
FIBUR+ !.C Anatomic basis for the psoas sign+
inflamed appendix is in a retroperitoneal location in
contact &ith the psoas muscle, &hich is stretched b*
this maneu.er:
FIBUR+ -AC #he obturator sign: (ain on passi.e internal rotation of the
flexed thigh: Examiner mo.es lo&er leg laterall* &hile appl*ing
resistance to the lateral side of the "nee 3asteris"4 resulting in internal
rotation of the femur:
FIBUR+ -.C Anatomic basis for the obturator sign+ inflamed appendix
in the pel.is is in contact &ith the obturator internus muscle, &hich is
stretched b* this maneu.er:
#he differential diagnosis of appendicitis is broad, but the patient;s histor* and
the remainder of the ph*sical examination ma* clarif* the diagnosis 3Table 44:
)ecause man* g*necologic conditions can mimic appendicitis, a pel.ic
examination should be performed on all &omen &ith abdominal pain: 9i.en the
breadth of the differential diagnosis, the pulmonar*, genitourinar* and rectal
examinations are eBuall* important: 1tudies ha.e sho&n, ho&e.er, that the rectal
examination pro.ides useful information onl* &hen the diagnosis is unclear and,
thus, can be reser.ed for use in such cases:
A
La'oratory and Radiolo$ic +(aluation
If the patient;s histor* and the ph*sical examination do not clarif* the diagnosis,
laborator* and radiologic e.aluations ma* be helpful: A clear diagnosis of
appendicitis ob.iates the need for further testing and should prompt immediate
surgical referral:
La'oratory Tests
#he &hite blood cell 3!)C4 count is ele.ated 3greater than =0,000 per mm
F
Z=00
TA.L+ 4
ifferential iagnosis of Acute
Appendicitis
Bastrointestinal
Abdominal pain,
cause un"no&n
Cholec*stitis
Crohn;s disease
i.erticulitis
uodenal ulcer
9astroenteritis
Intestinal
obstruction
Intussusception
$ec"el;s
di.erticulitis
$esenteric
l*mphadenitis
/ecroti<ing
enterocolitis
/eoplasm
3carcinoid,
carcinoma,
l*mphoma4
2mental torsion
(ancreatitis
(erforated
.iscus
Col.ulus
Bynecolo$ic
Ectopic
pregnanc*
Endometriosis
2.arian
torsion
(el.ic
inflammator*
disease
Ruptured
o.arian c*st
3follicular,
corpus
luteum4
#ubo'o.arian
abscess
Systemic
iabetic
"etoacidosis
(orph*ria
1ic"le cell
disease
0enoch'
1ch\nlein
purpura
)ulmonary
(leuritis
(neumonia
3basilar4
(ulmonar*
infarction
Benitourinary
7idne* stone
(rostatitis
(*elonephritis
#esticular
torsion
-rinar* tract
infection
!ilms; tumor
Ot*er
(arasitic
infection
(soas
abscess
Rectus sheath
hematoma
Re!rinte/ 'ith !erissi%n &r% >ra&&e% CS,
C%,nselan 40. A!!en/icitis. Eer- Me/ Clin N%rth
A <==+?<)@+.*#:<.
F =0
9
per 6[4 in @0 percent of all cases of acute appendicitis:
9
-nfortunatel*, the
!)C is ele.ated in up to ?0 percent of patients &ith other causes of right lo&er
Buadrant pain:
=0
#hus, an ele.ated !)C has a lo& predicti.e .alue: 1erial !)C
measurements 3o.er 4 to @ hours4 in suspected cases ma* increase the
specificit*, as the !)C count often increases in acute appendicitis 3except in
cases of perforation, in &hich it ma* initiall* fall4:
A
In addition, 9A percent of patients ha.e neutrophilia
=
and, in the elderl*, an
ele.ated band count greater than E percent has been sho&n to ha.e a high
predicti.e .alue for appendicitis:
9
In general, ho&e.er, the !)C count and
differential are onl* moderatel* helpful in confirming the diagnosis of appendicitis
because of their lo& specificities:
A more recentl* suggested laborator* e.aluation is determination of the C'
reacti.e protein le.el: An ele.ated C'reacti.e protein le.el 3greater than 0:@ mg
per d64 is common in appendicitis, but studies disagree on its sensiti.it* and
specificit*:
4,A
An ele.ated C'reacti.e protein le.el in combination &ith an ele.ated
!)C count and neutrophilia are highl* sensiti.e 39? to =00 percent4: #herefore, if
all three of these findings are absent, the chance of appendicitis is lo&:
A
In patients &ith appendicitis, a urinal*sis ma* demonstrate changes such as mild
p*uria, proteinuria and hematuria,
=
but the test ser.es more to exclude urinar*
tract causes of abdominal pain than to diagnose appendicitis:
Radiolo$ic +(aluation
#he options for radiologic e.aluation of patients &ith suspected appendicitis ha.e
expanded in recent *ears, enhancing and sometimes replacing pre.iousl* used
radiologic studies:
(lain radiographs, &hile often re.ealing abnormalities in acute appendicitis, lac"
specificit* and are more helpful in diagnosing other causes of abdominal pain:
FIBUR+ 3C -ltrasonogram sho&ing
longitudinal section 3arro&s4 of inflamed
appendix:
6i"e&ise, barium enema is no& used infreBuentl* because of the ad.ances in
abdominal imaging:
A
-ltrasonograph* and computed tomographic 3C#4 scans are helpful in e.aluating
patients &ith suspected appendicitis:
==
-ltrasonograph* is appropriate in patients
in &hich the diagnosis is eBui.ocal b* histor* and ph*sical examination: It is
especiall* &ell suited in e.aluating right lo&er Buadrant or pel.ic pain in pediatric
and female patients: A normal appendix 3E mm or less in diameter4 must be
identified to rule out appendicitis: An inflamed appendix usuall* measures greater
than E mm in diameter 3Figure 34, is noncompressible and tender &ith focal
compression: 2ther right lo&er Buadrant conditions such as inflammator* bo&el
disease, cecal di.erticulitis, $ec"el;s di.erticulum, endometriosis and pel.ic
inflammator* disease can cause false'positi.e ultrasonograph* results:
=2
C#, specificall* the techniBue of
appendiceal C#, is more accurate
than ultrasonograph* 3Table 54:
Appendiceal C# consists of a
focused, helical, appendiceal C#
after a 9astrografin'saline enema
3&ith or &ithout oral contrast4 and
can be performed and interpreted
&ithin one hour: Intra.enous
contrast is unnecessar*:
=2
#he
accurac* of C# is due in part to its
abilit* to identif* a normal appendix
better than ultrasonograph*:
=F
An
inflamed appendix is greater than E
mm in diameter, but the C# also
demonstrates periappendiceal
inflammator* changes
=4
3Figures 4
and 54: If appendiceal C# is not
a.ailable, standard
abdominal8pel.ic C# &ith contrast
remains highl* useful and ma* be
more accurate than
ultrasonograph*:
=2
Treatment
#he standard for management of nonperforated appendicitis remains
appendectom*: )ecause prompt treatment of appendicitis is important in
pre.enting further morbidit* and mortalit*, a margin of error in o.er'diagnosis is
acceptable: Currentl*, the national rate of negati.e appendectomies is
approximatel* 20 percent:
=A
1ome studies ha.e in.estigated nonoperati.e
management &ith parenteral antibiotic treatment, but 40 percent of these patients
e.entuall* reBuired appendectom*:
F
Appendectom* ma* be performed b* laparotom* 3usuall* through a limited right
lo&er Buadrant incision4 or laparoscop*: iagnostic laparoscop* ma* be helpful
in eBui.ocal cases or in &omen of childbearing age, &hile therapeutic
laparoscop* ma* be preferred in certain subsets of patients 3e:g:, &omen, obese
patients, athletes4:
=E
!hile laparoscopic inter.ention has the ad.antages of decreased postoperati.e
pain, earlier return to normal acti.it* and better cosmetic results, its
TA.L+ 6
Comparison of -ltrasound and
Appendiceal C# E.aluation of
1uspected Appendicitis
#omparison
$raded
ultrasound
Appendiceal
computed
tomo$rap*ic
scan
1ensiti.it* @A> 90 to =00>
1pecificit* 92> 9A to 9?>
-se E.aluate
patients &ith
eBui.ocal
diagnosis of
appendicitis
E.aluate
patients &ith
eBui.ocal
diagnosis of
appendicitis
Ad.antages 1afe
Relati.el*
inexpensi.e
Can rule out
pel.ic
disease in
females
)etter for
children
$ore
accurate
)etter
identifies
phlegmon
and abscess
)etter
identifies
normal
appendix
isad.antages 2perator
dependent
#echnicall*
inadeBuate
studies due
to gas
(ain
Cost
Ioni<ing
radiation
Contrast
In&%rati%n &r% re&erences <<, <*, (A.
disad.antages include greater cost and longer operati.e time:
4
2pen
appendectom* ma* remain the primar* approach to treatment until further cost
and benefit anal*ses are conducted:
FIBUR+ 4C Computed tomographic scan sho&ing
cross'section of inflamed appendix 3A4 &ith
appendicolith 3a4:
FIBUR+ 6C Computed tomographic scan sho&ing enlarged
and inflamed appendix 3A4 extending from the cecum 3C4:
#omplications
Appendiceal rupture accounts for a ma,orit* of the complications of appendicitis:
%actors that increase the rate of perforation are dela*ed presentation to medical
care,
=?
age extremes 3*oung and old4
=@
and hidden location of appendix:
E
A brief
period of in'hospital obser.ation 3less than six hours4 in eBui.ocal cases does not
increase the perforation rate and ma* impro.e diagnostic accurac*:
=@
iagnosis of a perforated appendix is usuall* easier 3although immediatel* after
rupture, the patient;s s*mptoms ma* temporaril* subside4: #he ph*sical
examination findings are more ob.ious if peritonitis generali<es, &ith a more
generali<ed right lo&er Buadrant tenderness progressing to complete abdominal
tenderness: An ill'defined mass ma* be felt in the right lo&er Buadrant: %e.er is
#he classic histor* of pain
beginning in the periumbilical
region and migrating to the
right lo&er Buadrant occurs in
onl* A0 percent of patients:
more common &ith rupture, and the !)C count ma* ele.ate to 20,000 to F0,000
per mm
F
3200 to F00 F =0
9
per 64 &ith a prominent left shift:
F
A periappendiceal abscess ma* be treated immediatel* b* surger* or b*
nonoperati.e management:
4
/onoperati.e management consists of parenteral
antibiotics &ith obser.ation or C#'guided drainage, follo&ed b* inter.al
appendectom* six &ee"s to three months later:
=
Special #onsiderations
!hile appendicitis is uncommon in *oung children, it poses special difficulties in
this age group: Noung children are unable to relate a histor*, often ha.e
abdominal pain from other causes and ma* ha.e more nonspecific signs and
s*mptoms: #hese factors contribute to a perforation rate as high as A0 percent in
this group:
=
In pregnanc*, the location of the appendix begins to shift significantl* b* the
fourth to fifth months of gestation: Common s*mptoms of pregnanc* ma* mimic
appendicitis, and the leu"oc*tosis of pregnanc* renders the !)C count less
useful: !hile the maternal mortalit* rate is lo&, the o.erall fetal mortalit* rate is 2
to @:A percent, rising to as high as FA percent in perforation &ith generali<ed
peritonitis: As in nonpregnant patients, appendectom* is the standard for
treatment:
F

Elderl* patients ha.e the highest mortalit* rates: #he usual signs and s*mptoms
of appendicitis ma* be diminished, at*pical or absent in the elderl*, &hich leads
to a higher rate of perforation: $ore freBuent perforation combined &ith a higher
incidence of other medical problems and less reser.e to fight infection contribute
to a mortalit* rate of up to A percent or more:
=
Final #omment
(rompt diagnosis of appendicitis ensures timel* treatment and pre.ents
complications: )ecause abdominal pain is a common presenting s*mptom in
outpatient care, famil* ph*sicians ser.e an important role in the diagnosis of
appendicitis: 2b.ious cases of appendicitis reBuire urgent referral, &hile
eBui.ocal cases &arrant further e.aluation and, man* times, surgical
consultation:
#he techniBue of appendiceal
computed tomograph* is more
accurate than ultrasonograph*
in confirming the diagnosis of
appendicitis:
#he author than"s 9len Cr*er, epartment of (ublications, 1cott and !hite $emorial 0ospital,
#emple, #ex:, for help &ith the manuscript:
%igures F through A &ere pro.ided b* $ichael 6: /ipper, $::, epartment of Radiolog*, 1cott
and !hite $emorial 0ospital, #emple, #ex: