Appendicitis

Appendicitis
Classification and external resources

An acutely inflamed and enlarged appendix, sliced
lengthwise.
ICD-10 K35 (http://apps.who.int
/classifications/icd10/browse
/2010/en#/K35) - K37
(http://apps.who.int/classifications
/icd10/browse/2010/en#/K37)
ICD-9 540 (http://www.icd9data.com
/getICD9Code.ashx?icd9=540)-543
(http://www.icd9data.com
/getICD9Code.ashx?icd9=543)
DiseasesDB 885 (http://www.diseasesdatabase.com
/ddb885.htm)
MedlinePlus 000256 (http://www.nlm.nih.gov
/medlineplus/ency/article/000256.htm)
eMedicine med/3430 (http://www.emedicine.com
/med/topic3430.htm) emerg/41
(http://www.emedicine.com/emerg
/topic41.htm#) ped/127
(http://www.emedicine.com
/ped/topic127.htm#) ped/2925
Appendicitis
FromWikipedia, the free encyclopedia
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a
medical emergency and many cases require removal of the inflamed appendix, either by
laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture
leading to infection and inflammation of the intestinal lining (peritoneum) and eventual sepsis,
clinically known as peritonitis which can lead to circulatory shock.
[1]
Reginald Fitz first described
acute and chronic appendicitis in 1886,
[2]
and it has been recognized as one of the most common
causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute formof
appendicitis is known as "rumbling appendicitis".
[3]
The term"pseudoappendicitis" is used to describe a condition mimicking appendicitis.
[4]
It can be
associated with Yersinia enterocolitica.
[5]
Contents
1 Signs and symptoms
2 Causes
3 Diagnosis
3.1 Clinical
3.2 Blood and urine test
3.3 Imaging
3.4 Scoring systems
3.5 Pathology
3.6 Differential diagnosis
4 Management
4.1 Pain
4.2 Surgery
5 Prognosis
6 Epidemiology
7 Society and culture
7.1 Cost
8 References
Appendicitis - Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Appendicitis
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(http://www.emedicine.com
/ped/topic2925.htm#)
MeSH C06.405.205.099
(http://www.nlm.nih.gov/cgi/mesh
/2013/MB_cgi?mode=&
term=Appendicitis&
field=entry#TreeC06.405.205.099)
Location of the appendix in the
digestivesystem
9 External links
Signs and symptoms
Pain first, vomiting next and fever last has been described as the classic presentation of acute
appendicitis. Since the innervation of the appendix enters the spinal cord at the same level as the
umbilicus (belly button), the pain begins stomach-high. Later, as the appendix becomes more
swollen and irritates the adjoining abdominal wall, it tends to localize over several hours into the
right lower quadrant, except in children under three years. This pain can be elicited through various signs and
can be severe. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very
sensitive to gentle pressure (palpation). Also, there is severe pain on sudden release of deep pressure in the
lower abdomen (rebound tenderness). In case of a retrocecal appendix (appendix localized behind the cecum),
however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the
reason being that the cecum, distended with gas, protects the inflamed appendix fromthe pressure. Similarly,
if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity. In such
cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point
tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix.
If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of
peritonitis, requiring urgent surgical intervention.
[6]
Causes
On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction
of the appendix lumen (the inside space of a tubular structure).
[7][8]
Once this obstruction occurs, the appendix subsequently becomes filled with
mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and
stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then
necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this
cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death.
The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis, and, most commonly, calcified fecal deposits known as
appendicoliths or fecaliths
[9]
The occurrence of obstructing fecaliths has attracted attention since their presence in patients with appendicitis is
significantly higher in developed than in developing countries,
[10]
and an appendiceal fecalith is commonly associated with complicated
appendicitis.
[11]
Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in
2 of 14 6/7/2013 1:39 PM
patients with acute appendicitis compared with healthy controls.
[12]
The occurrence of a fecalith in the appendix seems to be attributed to a
right-sided fecal retention reservoir in the colon and a prolonged transit time.
[13]
Fromepidemiological data, it has been stated that diverticular
disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt fromappendicitis.
[14][15]
Also, acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum.
[16]
Several studies offer evidence that a low fiber intake is
involved in the pathogenesis of appendicitis.
[17][18][19]
This is in accordance with the occurrence of a right-sided fecal reservoir and the fact that
dietary fiber reduces transit time.
[20]
Diagnosis
Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Histories fall into
two categories, typical and atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the umbilicus for several hours,
associated with anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant (or the left lower quadrant in patients with situs
inversus totalis), where tenderness develops. The combination of pain, anorexia, leukocytosis, and fever is classic. Atypical histories lack this typical
progression and may include pain in the right lower quadrant as an initial symptom. Atypical histories often require imaging with ultrasound and/or
CT scanning.
[21]
Clinical
Aure-Rozanova sign
Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg's sign) - typical in retrocecal position of the
appendix.
[22]
Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure
causes the severe pain on the site indicating positive Blumberg's sign and peritonitis.
[23]
Bartomier-Michelson's sign
Increased pain on palpation at the right iliac region as patient lies on his/her left side compared to when patient was on supine position.
Dunphy's sign
Increased pain in the right lower quadrant with coughing.
[24]
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Kocher's (Kosher's) sign
Fromthe history given, the appearance of pain in the epigastric region or around the stomach at the beginning of disease with a subsequent shift to the
right iliac region.
Massouh sign
Main article: Massouh sign
This sign, developed in and popular in southwest England, describes a firmswish of the examiners index and middle finger across the patients
abdomen fromxiphoid sternumto first the left and then the right iliac fossa. A positive Massouh sign is a grimace of the patient upon a right sided
(and not left) sweep, because initial stage appendicitis usually causes localised irritation of the well-innervated peritoneum.
Obturator sign
Main article: Obturator sign
If an inflamed appendix is in contact with the obturator internus, spasmof the muscle (called the obturator sign) can be demonstrated by flexing and
internal rotation of the hip. This maneuver will cause pain in the hypogastrium.
Psoas sign
Main article: Psoas sign
Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with either the passive extension of the patient's right hip (patient lying
on left side, with knee in flexion) or by the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of the
peritoneumoverlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it
stretches these muscles, while flexing the hip activates the iliopsoas and therefore also causes pain.
Rovsing's sign
Main article: Rovsing's sign
Continuous deep palpation starting fromthe left iliac fossa upwards (counterclockwise along the colon) may cause pain in the right iliac fossa, by
pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix.
[25]
Sitkovskiy (Rosenstein)'s sign
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Increased pain in the right iliac region as patient lies on his/her left side.
Blood and urine test
Most people suspected of having appendicitis would be asked to do a blood test. Half of the time, the blood test is normal, so it is not that useful in
diagnosing appendicitis.
Two forms of blood tests are commonly done: Full blood count (FBC), also known as complete blood count (CBC), is an inexpensive and commonly
requested blood test. It involves measuring the blood for its richness in red blood cells, as well as the number of the various white blood cell
constituents in it. The number of white cells in the blood is usually less than 10,000 cells per cubic millimeter. An abnormal rise in the number of
white blood cells in the blood is a crude indicator of infection or inflammation going on in the body. Such a rise is not specific to appendicitis alone. If
it is abnormally elevated, with a good history and examination findings pointing towards appendicitis, the likelihood of having the disease is higher. In
pregnancy, elevation of white blood cells may be normal, without any infection present.
C-reactive protein (CRP) is an acute-phase response protein produced by the liver in response to any infection or inflammatory process in the body.
Again, like the FBC, it is not a specific test. It is another crude marker of infection or inflammation. Inflammation at ANY site can lead to a rise in
CRP. A significant rise in CRP, with corresponding signs and symptoms of appendicitis, is a useful indicator in the diagnosis of appendicitis. If the
CRP continues to be normal after 72 hours of the onset of pain, the appendicitis likely will resolve on its own without intervention. A worsening CRP
with good history is a sure signal of impending perforation or rupture and abscess formation.
A urine test in appendicitis is usually normal. It may, however, show blood if the appendix is rubbing on the bladder, causing irritation. It is important
to rule out an ectopic pregnancy in women of childbearing age.
Imaging
Appendicitis in children is common enough to merit special attention. Because of the health risks of exposing children to radiation, many medical
societies recommend that in confirming a diagnosis with children the ultrasound is a preferred first choice with x-rays being a legitimate follow-up
when warranted.
[26][27][28]
CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a
sensitivity of 94%, specificity of 95%. Ultrasonography had an overall sensitivity of 86%, a specificity of 81%.
[29]
XRay
In 10% of patients with appendicitis, plain abdominal X-ray may demonstrate hard formed feces in the lumen of the appendix (fecolith). It is agreed
that the finding of Fecolith in the appendix on X-ray alone is a reason to operate to remove the appendix, because of the potential to cause worsening
symptoms. In this respect, a plain abdominal X-ray may be useful in the diagnosis of appendicitis, though plain abdominal X- ray is no longer
requested routinely in suspected cases of appendicitis. An abdominal X-ray may be done with a bariumenema contrast to diagnose appendicitis.
Bariumenema is whitish fluid that is passed up into the rectumto act as a contrast. It will usually fill the whole of the large bowel. In normal
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Ultrasound imageof an acute
appendicitis
A CT scan demonstrating acute
appendicitis (notethe appendix has a
diameter of 17.1mmand there is
surrounding fat stranding.)
appendix, the lumen will be present and the bariumfills it up and is seen when the X-ray filmis shot. In appendicitis, the lumen of the appendix will
not be visible on the bariumfilm.
Ultrasound
Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children,
and shows free fluid collection in the right iliac fossa, along with a visible appendix without blood flow in
color Doppler. In some cases (15% approximately), however, ultrasonography of the iliac fossa does not
reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis
before the appendix has become significantly distended and in adults where larger amounts of fat and bowel
gas make actually seeing the appendix technically difficult. Despite these limitations, sonographic imaging in
experienced hands can often distinguish between appendicitis and other diseases with very similar symptoms,
such as inflammation of lymph nodes near the appendix or pain originating fromother pelvic organs such as
the ovaries or fallopian tubes.
Computed tomography
Where it is readily available, CT scan has become frequently used, especially in adults whose diagnosis is not
obvious on history and physical examination. Concerns about radiation, however, tend to limit use of CT in
pregnant women and children. A properly performed CT scan with modern equipment has a detection rate
(sensitivity) of over 95%, and a similar specificity. Signs of appendicitis on CT scan include lack of oral
contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mmin
cross-sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye). The inflammation
caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT,
providing a mechanismto detect early appendicitis and a clue that appendicitis may be present even when the
appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children, both of whomtend to lack significant fat within the abdomen. The utility of CT scanning is
made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for
diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery
from20% in the pre-CT era to only 3% according to data fromthe Massachusetts General Hospital.
Scoring systems
Alvarado score
A number of clinical and laboratory-based scoring systems have been devised to assist diagnosis. The most widely used is Alvarado score. A score
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A fecalith marked by the arrow which
has resulted in acute appendicitis.
Migratory right iliac fossa pain 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Right iliac fossa tenderness 2 points
Rebound tenderness 1 point
Fever 1 point
Leukocytosis 2 points
Shift to left (segmented neutrophils) 1 point
Total score 10 points
Alvarado score
Micrograph of appendicitis and
periappendicitis. H&E stain.
below 5 is strongly against a diagnosis of appendicitis,
[30]
while a score of 7 or more is strongly predictive of acute
appendicitis. In patients with an equivocal score of 5 or 6, a
CT scan is used to further reduce the rate of negative
appendicectomy.
Tzanakis scoring
Tzanakis scoring: Tzanakis and colleagues, in 2005
published a simplified system, now called the Tzanakis
scoring systemfor appendicitis, to aid the diagnosis of
appendicitis. It incorporates the presence of four variables
made up of specific signs and symptoms (presence of right
lower abdominal tenderness =4 points and rebound
tenderness =3), laboratory findings (presence of white
blood cells greater than 12,000 in the blood =2), as well as ultrasound findings (presence of positive ultrasound scan findings of appendicitis =6), to
which scores are allocated, in the computing of a scoring to predict the presence of appendicitis.
The maximumscore is a total score of 15; where a patient scores 8 or more points, there is greater than 96% chance that appendicitis exists.
Pathology
The definitive diagnosis is based on pathology. The histologic findings of appendicits are neutrophils in the
muscularis propria.
Periappendicits, inflammation of tissues around the appendix, is often found in conjunction with other
abdominal pathology.
[31]
Differential diagnosis
In children: Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, Henoch-Schnlein
purpura, lobar pneumonia, urinary tract infection (abdominal pain in the absence of other symptoms can occur
in children with UTI), new-onset Crohn's disease or ulcerative colitis, pancreatitis, and abdominal trauma from
child abuse; distal intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in children with
leukemia;
In women: A pregnancy test is important in all women of child bearing age, as ectopic pregnancies and appendicitis present similar symptoms. Other
causes menarche, dysmenorrhea, pelvic inflammatory disease, endometriosis, Mittelschmerz (the passing of an egg in the ovaries approximately two
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Micrograph of
appendicitis
showing
neutrophils in
the muscularis
propria. H&E
stain.
Inflamed appendix removal by open
surgery
weeks before an expected menstruation cycle).
In men: testicular torsion;
In adults: new-onset Crohn's disease, ulcerative colitis, regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus
sheath hematoma;
In elderly: diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.
Management
Acute appendicitis is typically managed by surgery however in uncomplicated cases antibiotics are both effective and safe.
[32]
While antibiotics are effective for treating uncomplicated appendicitis 20% of people had a recurrence within a year and required
eventual appendectomy.
[32]
Pain
Pain medications (such as morphine) do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given early
in the persons care.
[33]
Historically there were concerns among some general surgeons that analgesics would affect the clinical examin children and
thus some recommended that they not be given until the surgeon in question was able to examine the person for themselves.
[33]
Surgery
See also: Appendectomy
The surgical procedure for the removal of the appendix is called an appendicectomy. Laparoscopic removal
(via three small incisions with a camera to visualize the area of interest in the abdomen) seemto have some
advantages over an open procedures especially in young females and the obese.
[34]
Laparotomy
Laparotomy is the traditional type of surgery used for treating appendicitis. This procedure consists in the
removal of the infected appendix through a single larger incision in the lower right area of the abdomen.
[35]
The incision in a laparotomy is usually 2 to 3 inches (51 to 76 mm) long. This type of surgery is used also for
visualizing and examining structures inside the abdominal cavity and it is called exploratory laparotomy.
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Laparoscopic appendectomy.
During a traditional appendectomy procedure, the patient is placed under general anesthesia to keep the
muscles completely relaxed and to keep the patient unconscious. The incision is two to three inches (76 mm)
long and it is made in the right lower abdomen, several inches above the hip bone.
[36]
Once the incision opens
the abdomen cavity and the appendix is identified, the surgeon removes the infected tissue and cuts the
appendix fromthe surrounding tissue. After the surgeon inspects carefully and closely the infected area and
there are no signs that surrounding tissues are damaged or infected, he will start closing the incision. This
means sewing the muscles and using surgical staples or stitches to close the skin up. In order to prevent
infections the incision is covered with a sterile bandage.
The entire procedure does not last longer than an hour if complications do not occur.
Laparoscopic surgery
The newer method to treat appendicitis is the laparoscopic surgery. This surgical procedure consists of making three to four incisions in the abdomen,
each 0.25 to 0.5 inches (6.4 to 13 mm) long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of the
incisions. The laparoscope is connected to a monitor outside the patient's body and it is designed to help the surgeon to inspect the infected area in the
abdomen. The other two incisions are made for the specific removal of the appendix by using surgical instruments. Laparoscopic surgery also requires
general anesthesia and it can last up to two hours. The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there is no
incision on the external skin
[37]
and SILS (Single incision laparoscopic Surgery) where a single 2.5 cmincision is made to performthe surgery. This
finding was very significant to the appendicitis patients and now thousands of people every year survive.
Pre surgery
The treatment begins by keeping the patient away fromeating or drinking in preparation for surgery. An intravenous drip is used to hydrate the
patient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce the
spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess
with antibiotic treatment and benefit fromserial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually
used. Otherwise, spinal anaesthesia may be used.
Once the decision to performan appendectomy has been made, the preparation procedure takes approximately one to two hours. Meanwhile, the
surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. With all surgeries
there are certain risks that must be evaluated before performing the procedures. However, the risks are different depending on the state of the
appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to
almost 59%.
[38]
The most usual complications that can occur are pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesions. Recent
evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in patient outcomes.
[39]
The surgeon will also explain how long the recovery process should take. Abdomen hair is usually removed in order to avoid complications that may
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The stitches the day after having his
appendix removed by laparoscopic
surgery
appear regarding the incision. In most of the cases patients experience nausea or vomiting which requires specific medication before surgery.
Antibiotics along with pain medication may also be administrated prior to appendectomies.
After surgery
Hospital lengths of stay typically range froma few hours to a few days, but can be a few weeks if
complications occur. The recovery process may vary depending on the severity of the condition, if the
appendix had ruptured or not before surgery. Appendix surgery recovery is generally a lot faster if the
appendix did not rupture.
[40]
It is important that patients respect their doctor's advice and limit their physical
activity so the tissues can heal faster. Recovery after an appendectomy may not require diet changes or a
lifestyle change.
After surgery occurs, the patient will be transferred to an postanesthesia care unit so his or her vital signs can
be closely monitored to detect anesthesia- and/or surgery-related complications. Pain medication may also be
administered if necessary. After patients are completely awake, they are moved into a hospital roomto
recover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular diet
when the intestines start to function properly. Patients are recommended to sit up on the edge of the bed and
walk short distances for several times a day. Moving is mandatory and pain medication may be given if
necessary. Full recovery fromappendectomies takes about four to six weeks, but can be prolonged to up to
eight weeks if the appendix had ruptured.
Prognosis
Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs.
Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is
between 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks.
The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may
have to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e., outside of a proper
hospital), when a timely medical evaluation was impossible.
Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it
remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical
appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In
either condition, prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe
complications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked about
quite often. It happens when appendix is not removed early during infection and omentumand intestine get adherent to it forming a palpable lump.
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Disability-adjusted life year for
appendicitis per 100,000 inhabitants in
2004.
[42]
no
data
less
than 2.5
2.5-5
5-7.5

7.5-10

10-12.5

12.5-15

15-17.5

17.5-20

20-22.5

22.5-25

25-27.5
more
than 27.5
During this period, operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition.
An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior
incomplete appendectomy.
[41]
Epidemiology
Appendicitis is most common between the ages of 5 and 40.
[43]
The median age is 28. It tends to affect males,
those in lower income groups, and, for unknown reasons, people living in rural areas.
[44]
Society and culture
Cost
While appendectomy is a standard surgical procedure, its cost has been found to vary considerably,
particularly in the United States. A 2012 study fromthe University of California, San Francisco published in
the Archives of Internal Medicine analyzed 2009 data fromnearly 20,000 adult patients treated for
appendicitis in California hospitals. Researchers examined only uncomplicated episodes of acute
appendicitis that involved visits for patients 18 to 59 years old with hospitalization that lasted fewer than
four days with routine discharges to home. The lowest charge for removal of an appendix was $1,529 and the
highest $182,955, almost 120 times greater. The median charge was $33,611.
[45][46]
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External links
CT of the abdomen showing acute appendicitis (http://www.claripacs.com/case/CL0012)
Anatomy of Appendix and Appendicits | Medchrome (http://medchrome.com/basic-science/anatomy/anatomy-appendix-appendicitis/)
Podcast on the management of appendicitis (http://www.learncolorectalsurgery.com/Podcasts.php)
Appendicitis and Appendectomy author Dennis Lee, M.D. editor Jay Marks, M.D. - MedicineNet.com(http://www.medicinenet.com
/appendicitis/article.htm), Doctor Produced information plus Patient Discussions provided by MedicineNet.com
Appendicitis - MayoClinic.com(http://www.mayoclinic.com/invoke.cfm?id=DS00274), fromthe Web site of the Mayo Clinic
Appendicitis, history, diagnosis and treatment (http://www.surgeons.org.uk/general-surgery-tutorials/appendicitis.html) by Surgeons Net
Education
Appendicitis Research (http://appendicitis.researchtoday.net) Latest research fromthe literature on appendicitis
Acute and Suppurative Appendicitis (http://xnet.kp.org/permanentejournal/spring98pj/appendicitis.html) fromthe Spring 1998 issue of The
Permanente Medical Journal
Appendicitis Update (http://www.appendicitisreview.com) Complete information including laparoscopic appendectomy
History of Appendicitis Vermiformis: Its diseases and treatment. (http://www.innominatesociety.com/Articles
/History%20of%20Appendicitis.htm) By Arthur C. McCarty, M.D.
How to Recognize the Symptoms of Appendicitis, a how-to article fromwikiHow
Appendicitis: Acute Abdomen and Surgical Gastroenterology (http://www.merck.com/mmpe/sec02/ch011/ch011e.html) fromthe Merck
Manual Professional (Content last modified September 2007)
Abdominal Emergencies, 'Surgical Abdomen'.By DR David Bednarczyk; Pediatric Surgery (http://www.kco.unibe.ch/daten_e/pathologien
/abdo.html)
Retrieved from"http://en.wikipedia.org/w/index.php?title=Appendicitis&oldid=558469895"
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