eMedicine Specialties > Emergency Medicine > Gastrointestinal

Appendicitis, Acute
Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University
of North Carolina at Chapel Hill, Carolinas Medical Center
Updated Apr !", "#!#
Introduction
Background
Appendicitis is a common and urgent surgical illness $ith protean manifestations, generous
overlap $ith other clinical syndromes, and significant mor%idity, $hich increases $ith diagnostic
delay& No single sign, symptom, or diagnostic test accurately confirms the diagnosis of
appendiceal inflammation in all cases&
'he surgeon(s goals are to evaluate a relatively small population of patients referred for suspected
appendicitis and to minimi)e the negative appendectomy rate $ithout increasing the incidence of
perforation& 'he emergency department clinician must evaluate the larger group of patients $ho
present to the ED $ith a%dominal pain of all etiologies $ith the goal of approaching !##*
sensitivity for the diagnosis in a time+, cost+, and consultation+efficient manner&
,ee Medscape(s -astroenterology ,pecialty page for more information&
Pathophysiology
.%struction of the appendiceal lumen is the primary cause of appendicitis& An anatomic %lind
pouch, o%struction of the appendiceal lumen leads to distension of the appendi/ due to
accumulated intraluminal fluid& 0neffective lymphatic and venous drainage allo$s %acterial invasion
of the appendiceal $all and, in advanced cases, perforation and spillage of pus into the peritoneal
cavity&
Frequency
United States
Appendicitis occurs in 1* of the U, population, $ith an incidence of !&! cases per !### people
per year& ,ome familial predisposition e/ists&
International
0ncidence of appendicitis is lo$er in cultures $ith a higher inta2e of dietary fi%er& Dietary fi%er is
thought to decrease the viscosity of feces, decrease %o$el transit time, and discourage formation
of fecaliths, $hich predispose individuals to o%structions of the appendiceal lumen&
Mortality/Morbidity
'he overall mortality rate of #&"+#&3* is attri%uta%le to complications of the disease rather
than to surgical intervention&
Mortality rate rises a%ove "#* in patients older than 1# years, primarily %ecause of
diagnostic and therapeutic delay&
Perforation rate is higher among patients younger than !3 years and patients older than 4#
years, possi%ly %ecause of delays in diagnosis& Appendiceal perforation is associated $ith a
sharp increase in mor%idity and mortality rates&
Sex
'he incidence of appendicitis is appro/imately !&5 times greater in men than in $omen& 'he
incidence of primary appendectomy is appro/imately e6ual in %oth se/es&
Age
0ncidence of appendicitis gradually rises from %irth, pea2s in the late teen years, and
gradually declines in the geriatric years& 'he median age at appendectomy is "" years&
Although rare, neonatal and even prenatal appendicitis have %een reported&
'he emergency department clinician must maintain a high inde/ of suspicion in all age
groups&
Clinical
istory
7ariations in the position of the appendi/, age of the patient, and degree of inflammation
ma2e the clinical presentation of appendicitis notoriously inconsistent&
0t is important to remem%er that the position of the appendi/ is varia%le& .f !## patients
undergoing 8+D multidetector C', the %ase of the appendi/ $as located at Mc9urney(s point
in only 5* of patients& 0n 8:* of patients, the %ase $as $ithin 8 cm of Mc9urney(s point; in
"3*, it $as 8+4 cm from Mc9urney(s point; and, in 8:* of patients, the %ase of the
appendi/ $as more than 4 cm from Mc9urney(s point&
<! =
0n addition, patients $ith many other disorders present $ith symptoms similar to those of
appendicitis& E/amples include the follo$ing
o Pelvic inflammatory disease >P0D? or tu%o+ovarian a%scess
o Endometriosis
o .varian cyst or torsion
o Ureterolithiasis and renal colic
o Degenerating uterine leiomyomata
o Diverticulitis
o Crohn disease
o Colonic carcinoma
o @ectus sheath hematoma
o Cholecystitis
o 9acterial enteritis
o Mesenteric adenitis
o .mental torsion
'he classic history of anore/ia and perium%ilical pain follo$ed %y nausea, right lo$er
6uadrant >@AB? pain, and vomiting occurs in only 4#* of cases&
Migration of pain from the perium%ilical area to the @AB is the most discriminating feature of
the patient(s history& 'his finding has a sensitivity and specificity of appro/imately 3#*&
Positive li2elihood ratio is 8&!3 >"&5!+5&"!?, and negative li2elihood ratio is #&4 >#&5"+#&4C?&
<" =
Dhen vomiting occurs, it nearly al$ays follo$s the onset of pain& 7omiting that precedes
pain is suggestive of intestinal o%struction, and the diagnosis of appendicitis should %e
reconsidered&
Nausea is present in :!+C"* of patients; anore/ia is present in 15+13* of patients& Neither
finding is statistically different from findings in ED patients $ith other etiologies of a%dominal
pain&
Diarrhea or constipation is noted in as many as !3* of patients and should not %e used to
discard the possi%ility of appendicitis&
Duration of symptoms is less than 53 hours in appro/imately 3#* of adults %ut tends to %e
longer in elderly persons and in those $ith perforation& Appro/imately "* of patients report
duration of pain in e/cess of " $ee2s&
A history of similar pain is reported in as many as "8* of cases& A history of similar pain, in
and of itself, should not %e used to rule out the possi%ility of appendicitis&
An inflamed appendi/ near the urinary %ladder or ureter can cause irritative voiding
symptoms and hematuria or pyuria& Cystitis in male patients is rare in the a%sence of
instrumentation& Consider the possi%ility of an inflamed pelvic appendi/ in male patients
$ith apparent cystitis&
Also consider the possi%ility of appendicitis in pediatric or adult patients $ho present $ith
acute urinary retention&
<8 =
Physical
@AB tenderness is present in C:* of patients, %ut this is a nonspecific finding& @arely, left
lo$er 6uadrant >AAB? tenderness has %een the major manifestation in patients $ith situs
inversus or in patients $ith a lengthy appendi/ that e/tends into the AAB&
'he most specific physical findings are re%ound tenderness, pain on percussion, rigidity,
and guarding&
'he @ovsing sign >@AB pain $ith palpation of the AAB? suggests peritoneal irritation in the
right lo$er 6uadrant precipitated %y palpation at a remote location&
'he o%turator sign >@AB pain $ith internal and e/ternal rotation of the fle/ed right hip?
suggests that the inflamed appendi/ is located deep in the right hemipelvis&
'he psoas sign >@AB pain $ith e/tension of the right hip or $ith fle/ion of the right hip
against resistance? suggests that an inflamed appendi/ is located along the course of the
right psoas muscle&
'hese signs are present in a minority of patients $ith acute appendicitis& 'heir a%sence
never should %e used to rule out appendiceal inflammation&
Dunphy(s sign >sharp pain in the @AB elicited %y a voluntary cough? may %e helpful in
ma2ing the clinical diagnosis of locali)ed peritonitis& ,imilarly, @AB pain in response to
percussion of a remote 6uadrant of the a%domen, or to firm percussion of the patient(s heel,
suggests peritoneal inflammation&
'he Mar2le sign, pain elicited in a certain area of the a%domen $hen the standing patient
drops from standing on toes to the heels $ith a jarring landing, $as studied in !C# patients
undergoing appendectomy and found to have a sensitivity of 15*&
<5 =
'here is no evidence in the medical literature that the digital rectal e/amination >D@E?
provides useful information in the evaluation of patients $ith suspected appendicitis;
ho$ever, failure to perform a rectal e/amination is fre6uently cited in successful malpractice
claims& 0n "##3, ,edla2 et al studied 411 patients $ho under$ent D@E as part of an
evaluation for suspected appendicitis and found no value as a means of distinguishing
patients $ith and $ithout appendicitis&
<4 =
Male infants and children occasionally present $ith an inflamed hemiscrotum due to
migration of an inflamed appendi/ or pus through a patent processus vaginalis& 'his is often
initially misdiagnosed as acute testicular torsion&
Causes
.%struction of the appendiceal lumen usually precipitates appendicitis&
'he most common causes of luminal o%struction are fecaliths and lymphoid follicle
hyperplasia&
o Eecaliths form $hen calcium salts and fecal de%ris %ecome layered around a nidus
of inspissated fecal material located $ithin the appendi/&
o Aymphoid hyperplasia is associated $ith a variety of inflammatory and infectious
disorders including Crohn disease, gastroenteritis, ame%iasis, respiratory infections,
measles, and mononucleosis&
o .%struction of the appendiceal lumen has less commonly %een associated $ith
parasites >eg, Schistosomes species, Strongyloides species?, foreign material >eg,
shotgun pellet, intrauterine device, tongue stud, activated charcoal?, tu%erculosis,
and tumors&
!i""erential !iagnoses
A%dominal A%scess Mesenteric Aymphadenitis
Cholecystitis and 9iliary Colic .mental 'orsion
Constipation .varian Cysts
Crohn Disease .varian 'orsion
Diverticular Disease Pediatrics, 0ntussusception
Ectopic Pregnancy Pelvic 0nflammatory Disease
Endometriosis @enal Calculi
-astroenteritis ,pider Envenomations, Dido$
-astroenteritis, 9acterial Urinary 'ract 0nfection, Eemale
0nflammatory 9o$el Disease Urinary 'ract 0nfection, Male
Mec2el Diverticulum
Mesenteric 0schemia
#ther Proble$s to Be Considered
Appendiceal stump appendicitis
'yphilitis
Epiploic appendagitis
Psoas a%scess
Fersiniosis
%orkup
&aboratory Studies
Complete blood cell count
,tudies consistently sho$ that 3#+34* of adults $ith appendicitis have a D9C count greater than
!#,4## cellsGmm
8
& Neutrophilia greater than 14* occurs in 13* of patients& Ee$er than 5* of
patients $ith appendicitis have a D9C count less than !#,4## cellsGmm
8
and neutrophilia less than
14*&
Dueholm et al, in !C3C, further delineated the relationship %et$een D9C count and the li2elihood
of appendicitis %y calculating li2elihood ratios for defined intervals of the D9C count&
<: =
'a%le !& D9C Count and Ai2elihood of Appendicitis
WBC (X 10,000) Likeliood !atio ("#$ C%&)
5+1 #&!# >#+#&8C?
1+C #&4" >#+!&41?
C+!! #&"C >#+#&:"?
!!+!8 "&3 >!&"+5&5?
!8+!4 !&1 >#+8&:?
!4+!1 "&3 >#+:&#?
!1+!C 8&4 >#+!#?
!C+"" H
IC0, confidence interval&
C9C tests are ine/pensive, rapid, and $idely availa%le; ho$ever, the findings are nonspecific&
'he literature is inconsistent $ith regard to D9C counts in children and elderly patients $ith
appendicitis&
C'reacti(e protein te)t
C+reactive protein >C@P? is an acute+phase reactant synthesi)ed %y the liver in response to
infection or inflammation& A rapid assay is $idely availa%le&
,everal prospective studies >'himsen !C3C, Al%u !CC5, de Carvalho "##8? have sho$n that, in
adults $ho have had symptoms for longer than "5 hours, a normal C@P level has a negative
predictive value of C1+!##* for appendicitis&
<1,3,C =
0n a !C3C study of 1# patients, 'himsen et al noted that a normal C@P level after !" hours of
symptoms $as !##* predictive of %enign, self+limited illness&
<1 =
Multiple studies have e/amined the sensitivity of C@P alone for the diagnosis of appendicitis in
patients selected to undergo appendectomy&
-urleyi2 et al, in !CC4, found that 31 of C# patients $ith histologically proven appendicitis
had an elevated C@P, a sensitivity of C:&:*&
<!# =
,ha2hetrah, in "###, found that 34 of 3C patients $ith histologically proven appendicitis had
an elevated C@P, a sensitivity of C4&4*&
<!! =
Asfar et al, in "###, completed a prospective dou%le %lind study of 13 patients undergoing
appendectomy and found that C@P had a sensitivity of C8&:*&
<!" =
Er2asap et al, in "###, prospectively studied the more relevant group of !#" adult patients
$ith @AB pain, 44 of $hom proceeded to appendectomy& 0n this group, the sensitivity of
C@P $as C:*&
<!8 =
0nvestigators have also studied the a%ility of com%inations of D9C and C@P to relia%ly rule out the
diagnosis of appendicitis&
-ronroos, in !CCC, studied 8## patients operated for suspected appendicitis >"## positive,
!## negative? and found that D9C or C@P $as a%normal in all "## patients $ith
appendicitis&
<!5 =
.rtega+De%allon et al, in "##3, prospectively studied patients referred to a surgeon for @AB
pain and found that normal D9C and C@P had a negative predictive value of C"&8* for the
presence of appendicitis&
<!4 =
Fang, in "##:, retrospectively studied 3C1 patients $ho under$ent appendectomy >15#
$ith appendicitis, !41 $ithout? and found that only : of 15# patients $ith appendicitis had
D9C J!#,4## cellsGmm
8
AND neutrophilia J14*, AND a normal C@P& 'his yields a
sensitivity of CC&"* for the Ktriple screenK&
<!: =
,ome studies have e/amined the sensitivity of com%ined D9C and C@P in the su%population of
patients older than :# years&
-ronroos, in !CCC, studied 38 patients older than :# years $ho under$ent appendectomy
>18 found to have appendicitis? and found that no patient $ith appendicitis had %oth normal
D9C and C@P&
<!1 =
Fang et al, in "##4, retrospectively studied 11 patients older than :# years $ith
histologically proven appendicitis and found that only " had a normal Ktriple screen&K
<!3 =
,everal studies have e/amined the accuracy of C@P and D9C in the su%population of pediatric
patients $ith suspected appendicitis&
-ronroos, in "##!, studied !## children $ith pathology+proven appendicitis and found that
%oth D9C and C@P $ere normal in 1 of the !## patients&
<!C =
Mohammed, in "##5, prospectively studied "!: children admitted for suspected
appendicitis and found triple screen sensitivity and negative predictive value of 3:* and
3!*, respectively&
<"# =
,tefanutti et al, in "##1, prospectively studied more than !## children undergoing surgery
for suspected appendicitis and found that either D9C or C@P $as elevated in C3* of those
$ith pathology+proven appendicitis >C0, C4&8+!##*?&
<"! =
C@P is nonspecific and does not distinguish %et$een various types of infection or inflammation&
*rinaly)i)
.ne study of 4## patients $ith acute appendicitis revealed that appro/imately one third reported
urinary symptoms, most commonly dysuria or right flan2 pain& .ne in 1 patients had pyuria greater
than !# D9C per high po$er field, and ! in : patients had greater than 8 @9C per high po$er
field& 'hus, the diagnosis of appendicitis should not %e dismissed due to the presence of urologic
symptoms or a%normal urinalysis&
<"" =
I$aging Studies
Computed tomography
o A%dominal C' has %ecome the most important imaging study in the evaluation of
patients $ith atypical presentations of appendicitis& ,tudies have found a decrease in
negative laparotomy rate and appendiceal perforation rate $hen pelvic C' $as used
in selected patients $ith suspected appendicitis&
<"8,"5,"4,": =
An enlarged appendi/ is
sho$n in the C' %elo$&
o
C' scan re(eals an enlarged appendix )ith thickened )alls* )hich
do not "ill )ith colonic contrast agent* lying ad+acent to the right
psoas $uscle,
o Note that one study of asymptomatic volunteers undergoing pelvic C' found that
5"* had an Ka%normalK appendiceal diameter of greater than : mm and 13* of
appendices did not fill after oral contrast& 'hus, findings on C' must %e correlated
$ith the clinical scenario&
<"1 =
o Advantages of C' scanning include its superior sensitivity and accuracy compared
$ith those of other imaging techni6ues, ready availa%ility, noninvasiveness, and
potential to reveal alternative diagnoses& Disadvantages include radiation e/posure,
potential for anaphylactic reaction if intravenous contrast agent is used, lengthy
ac6uisition time if oral contrast is used, and patient discomfort if rectal contrast is
used&
o 0nitial studies evaluated se6uential >nonhelical? C' in the diagnosis of appendicitis& 0n
!CC8, Malone evaluated nonenhanced, se6uential C' in "!! patients and reported a
sensitivity of 31* and a specificity of C1*&
<"3 =
'he addition of intravenous and oral
contrast agent increased sensitivity to C:+C3*& 'hus, se6uential C' $ith oral and
intravenous contrast enhancement is highly accurate %ut time consuming and
e/pensive; it is %est used for e6uivocal presentations $hen helical C' is not
availa%le&
o 0n !CC1, Aane et al evaluated helical C' $ithout contrast enhancement and found a
sensitivity of C#* and specificity of C1*&
<"C =
More recent studies of noncontrast helical
C' in adults $ith suspected appendicitis sho$ed a sensitivity of C!+C:* and a
specificity of C"+!##*&
<8#,8!,8",88,85 =

o 0n a "##5 study of pediatric patients, Laiser et al found that nonenhanced C' $as
::* sensitive&
<84 =
,ensitivity increased to C#* $ith the use of intravenous contrast
material& 0n a "##4 study of !!" pediatric patients, Hoec2er and 9ilman found that
unenhanced C' achieved a sensitivity of 31&4*, specificity of C3&1*, positive
predictive value of C!&8*, and negative predictive value of C#&3*&
<8: =
o 0n !CC1, @ao et al found that focused >lo$er a%dominal and upper pelvic? helical C'
$ith 8* -astrografin instilled into the colon >$ithout intravenous contrast agent? had
a superior sensitivity of C3* and specificity of C3*&
<81 =
Eocused helical scanning
$ithout intravenous contrast agent eliminates the ris2 of anaphyla/is and reduces
the cost to a%out M"8#& Ac6uisition time is less than !4 minutes& @adiation e/posure
is less than that of a standard o%struction series& Alternative diagnoses are revealed
in up to :"* of patients and include diverticulitis, nephrolithiasis, adne/al pathology,
@AB tumor, small+%o$el hernias, and ischemia&
o 'he literature suggests that limited helical C' $ith rectal contrast enhancement is a
highly accurate, time+efficient, cost+effective $ay to evaluate adults $ith e6uivocal
presentations for appendicitis& '$o studies of focused helical C' $ith rectal contrast
in children suggest a sensitivity of C4+C1*& 'his is an e/cellent diagnostic approach
in patients $ith e6uivocal presentations $ho are poor candidates for intravenous
contrast&
o .ne recent retrospective study of !18 adults found that helical C' $ith intravenous
contrast only has a sensitivity of !##*, specificity of C1*, positive predictive value of
C1*, and negative predictive value of !##*&
<83 =
An earlier study of 13 patients $ith
appendicitis found sensitivity of C!&C*, specificity of 31&4*, and accuracy of C!*&
<8C =
0n a "##4 retrospective revie$ of "8 pu%lished reports, Anderson et al found that C'
$ithout oral contrast $as at least as accurate as C' $ith oral contrast, achieving
sensitivity of C4*, specificity of C1*, positive predictive value of C1*, and negative
predictive value of C:*&
<5# =
Elimination of oral contrast reduces emergency
department length of stay and delay to operative intervention&
o Continued improvements in helical C' technology may allo$ nonenhanced helical
C' to %e the imaging test of choice for adults $ith suspected appendicitis& Additional
studies are needed to identify su%groups that derive the most %enefit from diagnostic
imaging&
Ultrasonography
o 'ransa%dominal sonograms are sho$n %elo$&
o
Sagittal graded co$pression transabdo$inal sonogra$ sho)s an
acutely in"la$ed appendix, 'he tubular structure is
nonco$pressible* lacks peristalsis* and $easures greater than -
$$ in dia$eter, A thin ri$ o" periappendiceal "luid is present,
o
'rans(erse graded co$pression transabdo$inal sonogra$ o" an
acutely in"la$ed appendix, .ote the targetlike appearance due to
thickened )all and surrounding loculated "luid collection,
o 0n !C3:, Puylaert descri%ed a graded compression techni6ue for evaluating the
appendi/ $ith transa%dominal sonography&
<5! =
A 4+MH) transducer is used& -entle
%ut firm pressure is applied on the @AB to displace intervening %o$el gas and to
decrease the distance %et$een the transducer and the appendi/, improving image
6uality& An outer diameter of greater than : mm, noncompressi%ility, lac2 of
peristalsis, or periappendiceal fluid collection characteri)es an inflamed appendi/&
'he normal appendi/ is not visuali)ed in most cases& A posterolateral approach is
suggested to evaluate the retrocecal area& ,cattered case reports endorse
transvaginal sonography in $omen $ith lo$ pelvic tenderness if the appendi/ is not
visuali)ed on transa%dominal scans&
o Numerous studies have documented a sensitivity of 34+C#* and a specificity of C"+
C:*& Eive studies of graded compression ultrasonography in children sho$ed overall
sensitivities of 34+C4* and specificities ranging from 51+C:*& .ne study found
sensitivity of 84* and specificity of C3* in pediatric patients $ith perforated
appendicitis& 'he cost is appro/imately M""4&
o Advantages of sonography include its noninvasiveness, short ac6uisition time, lac2
of radiation e/posure, and potential for diagnosis of other causes of a%dominal pain,
particularly in the su%set of $omen of child%earing age& Many authorities %elieve that
ultrasonography should %e the initial imaging test in pregnant $omen and in pediatric
patients %ecause radiation e/posure is particularly undesira%le in these groups&
o .ne ne$ study suggests that ultrasonography should %e incorporated as a first+line
imaging modality for the diagnosis of acute appendicitis in adults&
<5" =
0n this study, !4! patients $ith suspected appendicitis under$ent the
designed protocol& -raded+compression ultrasonography $as performed first&
Patients $ith positive results on graded+compression ultrasonography
under$ent surgery& 'hose $ith inconclusive or negative results under$ent
contrast+enhanced multidetector C'& Patients $ith positive findings on C'
also under$ent surgery& Patients $ith negative C' findings $ere admitted for
o%servation& Positive ultrasonography $as confirmed at surgery in 1! of 1C
patients, and positive C' $as confirmed in "! patients& 'hirty+nine patients
$ith normal C' results recovered and did not re6uire surgery& 'he sensitivity
and specificity of this protocol $as !##* and 3:*, respectively&
Poortman et al concluded that this diagnostic path$ay using primary graded+
compression ultrasonography and complementary multidetector C' yields a
high diagnostic accuracy for acute appendicitis $ithout adverse events from
delay in treatment& Although ultrasonography is less accurate than C', it can
%e used as a primary imaging modality and avoids the disadvantages of C'&
.%servation is safe for patients $ith negative findings on ultrasonography or
C'&
o 'he principal disadvantage is that ultrasonography is operator dependent& 9ecause
nonvisuali)ation is interpreted as a noninflamed appendi/, technical e/pertise and
commitment to a thorough e/amination are essential in o%taining ma/imum
sensitivity&
o 0f graded compression sonogram of the @AB is positive for appendicitis,
appendectomy should %e performed& 0f negative, this finding is not sufficiently
sensitive to rule out the possi%ility of appendicitis& Consideration should %e given to
further o%servation and focused helical C' $ith rectal contrast enhancement&
o ')ana2is and others proposed a clinical scoring system that assigns : points if
appendiceal ultrasonogram is positive, 5 points for @AB tenderness, 8 points for
re%ound tenderness, and " points for D9C count greater than !",###& 0n their
prospective study of 8#8 adults using a total score cut+off of 3 points or greater, they
found sensitivity, specificity, and accuracy of C4&5*, C1&5*, and C:&4*, respectively&
<58 =
'hese findings should %e confirmed %y additional studies %efore routine clinical
use&
A%dominal radiography
o 'he 2idneys+ureters+%ladder >LU9? vie$ is typically used; this is sho$n %elo$&
7isuali)ation of an appendicolith in a patient $ith symptoms consistent $ith
appendicitis is highly suggestive of appendicitis, %ut this occurs in fe$er than !#* of
cases&
o
/idneys0ureters0bladder 1/UB2 radiograph sho)s an
appendicolith in the right lo)er quadrant, An appendicolith is seen
in "e)er than 345 o" patients )ith appendicitis* but* )hen
present* it is essentially pathogno$onic,
o 'he consensus in the literature is that plain radiographs are insensitive, nonspecific,
and not cost+effective&
9arium enema study
o A single+contrast study can %e performed on an unprepared %o$el& A%sent or
incomplete filling of the appendi/ coupled $ith pressure effect or spasm in the cecum
suggests appendicitis& 'he cost is appro/imately M5"#&
o Multiple studies have found that the sensitivity of a %arium enema study is in the
range of 3#+!##*& Ho$ever, as many as !:* of studies in adults >""+8C* in
children? $ere technically unsuita%le for interpretation and e/cluded from data
analysis&
o Advantages of %arium enema study are its $ide availa%ility, use of simple
e6uipment, and potential for diagnosis of other diseases >eg, Crohn disease, colon
cancer, ischemic colitis? that may mimic appendicitis&
o Disadvantages include its high incidence of nondiagnostic results, radiation
e/posure, insufficient sensitivity, and invasiveness& 'hese disadvantages ma2e
%arium enema study a poor screening e/amination for use %y emergency
departments&
o 9arium enema study has essentially no role in the diagnosis of acute appendicitis in
the era of ultrasonography and C'&
@adionuclide scanning
o Dhole %lood is $ithdra$n for radionuclide scanning& Neutrophils and macrophages
are la%eled $ith technetium+CCm al%umin and administered intravenously& 0mages of
the a%domen and pelvis are o%tained serially over 5 hours& Aocali)ed upta2e of
tracer in the @AB suggests appendiceal inflammation; this is sho$n in the image
%elo$&
o
'echnetiu$066$ radionuclide scan o" the abdo$en sho)s "ocal
uptake o" labeled %BCs in the right lo)er quadrant consistent
)ith acute appendicitis,
o Eour early studies in adults $ith suspected appendicitis sho$ed a sensitivity of 3#+
C#* and specificity of C"+!##*&
<55,54,5:,51 =
'$o studies of ne$er la%eling techni6ues
achieved sensitivities of C3* for the presence of appendicitis&
<53,5C =
o Although future studies may confirm sensitivity as high as C3*, the ac6uisition time
of 4 hours and the lac2 of availa%ility are disadvantages to its use as a high+
sensitivity ED screening test for appendicitis&
Magnetic resonance imaging
o M@0 plays a relatively limited role in the evaluation %ecause of high cost, long scan
times, and limited availa%ility, though the lac2 of ioni)ing radiation ma2es it an
attractive modality in pregnant patients&
o A single retrospective study assessed the accuracy of M@0 in 4! pregnant patients
$ith suspected appendicitis in $hom ultrasonography $as nondiagnostic& ,ensitivity,
specificity, positive and negative predictive values, and accuracy for M@0 $as !##*,
C8&:*, C!&5*, !##*, and C5&#*, respectively&
<4# =
o Co%%en et al sho$ed that M@0 is far superior to transa%dominal ultrasonography in
evaluating pregnant patients $ith suspected appendicitis&
<4! =
o Dhen evaluating pregnant patients $ith suspected appendicitis, graded compression
ultrasound should %e the imaging test of choice& 0f ultrasonography demonstrates an
inflamed appendi/, the patient should undergo appendectomy& 0f graded
compression ultrasonography is nondiagnostic, the patient should undergo M@0 of
the a%domen and pelvis&
#ther 'ests
Clinical diagno)tic )core)
,everal investigators have created diagnostic scoring systems in $hich a finite num%er of clinical
varia%les is elicited from the patient and each is given a numerical value& 'he sum of these values
is used to predict the li2elihood of acute appendicitis&
'he %est 2no$n of these is the MAN'@EA, score, $hich ta%ulates migration of pain, anore/ia,
nausea andGor vomiting, tenderness in the @AB, re%ound tenderness, elevated temperature,
leu2ocytosis, and shift to the left >'a%le "?&
'a%le "& MAN'@EA, ,core
Characteristic Score
M N Migration of pain to the @AB !
A N Anore/ia !
N N Nausea and vomiting !
' N 'enderness in @AB "
@ N @e%ound pain !
E N Elevated temperature !
A N Aeu2ocytosis "
, N ,hift of D9C to the left !
'otal !#
,ource&OAlvarado, !C3:&
<4" =
Clinical scoring systems are attractive %ecause of their simplicity; ho$ever, none has %een sho$n
prospectively to improve on the clinician(s judgment in the su%set of patients evaluated in the ED
for a%dominal pain suggestive of appendicitis& 'he MAN'@EA, score, in fact, $as %ased on a
population of patients hospitali)ed for suspected appendicitis, $hich differs mar2edly from the
population seen in the ED&
McLay et al revie$ed !4# emergency department patients $ho under$ent a%dominopelvic C' to
rule out appendicitis& 0n that series, patients $ith a MAN'@EA, score of 8 or lo$er had a 8&:*
incidence of appendicitis, patients $ith scores of 5+: had a 8"* incidence of appendicitis, and
patients $ith scores of 1+!# had a 13* incidence of appendicitis& 'hese investigators suggested
that patients $ith an Alvarado score of #+8 could %e discharged $ithout imaging, that those $ith
scores of 1 or a%ove receive surgical consultation, and those $ith scores of 5+: undergo computed
tomography&
<48 =
,chneider et al, in "##1, studied 433 patients aged 8+"! years and found that a MAN'@EA, score
of 1 or greater had a positive predictive value of :4* and a negative predictive value of 34*& 'hey
concluded that the MAN'@EA, score $as not sufficiently accurate to %e used as the sole method
for determining the need for appendectomy in the pediatric population&
<45 =
Computer'aided diagno)i)
A retrospective data%ase of clinical features of patients $ith appendicitis and other causes of
a%dominal pain is entered into a computer& 0t is then used in prospectively assessing the ris2 of
appendicitis&
Computer+aided diagnosis can achieve a sensitivity greater than C#* $hile reducing rates of
perforation and negative laparotomy %y as much as 4#*&
'he principle disadvantages are that each institution must generate its o$n data%ase to reflect
characteristics of its local population& ,peciali)ed e6uipment and significant initiation time are
re6uired&
Computer+aided diagnosis is not $idely availa%le in U, EDs&
'reat$ent
7$ergency !epart$ent Care
'reatment guidelines for patients $ith suspected acute appendicitis
o Esta%lish intravenous access and administer aggressive crystalloid therapy to
patients $ith clinical signs of dehydration or septicemia&
o Patients $ith suspected appendicitis should not receive anything %y mouth&
o Administer parenteral analgesic and antiemetic as needed for patient comfort& 'he
administration of analgesics to patients $ith acute undifferentiated a%dominal pain
has historically %een discouraged and critici)ed %ecause of concerns that they
render the physical findings less relia%le& At least 3 randomi)ed controlled studies
no$ demonstrate that administering opioid analgesic medications to adult and
pediatric patients $ith acute undifferentiated a%dominal pain is safe; no study has
sho$n that analgesics adversely affect the accuracy of physical e/amination&
o Consider ectopic pregnancy in $omen of child%earing age, and o%tain a 6ualitative
%etaPhuman chorionic gonadotropin >%eta+hC-? measurement in all cases&
o Administer intravenous anti%iotics to those $ith signs of septicemia and to those $ho
are to proceed to laparotomy&
Nonsurgical treatment of appendicitis
o Anecdotal reports descri%e the success of intravenous anti%iotics in treating acute
appendicitis in patients $ithout access to surgical intervention >eg, su%mariners,
individuals on ships at sea?&
o 0n one prospective study of "# patients $ith sonography+proven appendicitis,
symptoms resolved in C4* of patients receiving anti%iotics alone, %ut 81* of these
patients had recurrent appendicitis $ithin !5 months&
<44 =
o Nonsurgical treatment may %e useful $hen appendectomy is not accessi%le or $hen
it is temporarily a high+ris2 procedure&
Preoperative anti%iotics
o Preoperative anti%iotics have demonstrated efficacy in decreasing postoperative
$ound infection rates in numerous prospective controlled studies&
o 9road+spectrum gram+negative and anaero%ic coverage is indicated&
o Preoperative anti%iotics should %e given in conjunction $ith the surgical consultant&
o Penicillin+allergic patients should avoid %eta+lactamase type anti%iotics and
cephalosporins& Car%apenems are a good option in these patients&
o Pregnant patients should receive pregnancy category A or 9 anti%iotics&
Consultations
Consult a general surgeon&
Medication
'he goals of therapy are to eradicate the infection and to prevent complications&
Antibiotics
'hese agents are effective in decreasing the rate of postoperative $ound infection and in
improving outcome in patients $ith appendiceal a%scess or septicemia& 'he ,urgical 0nfection
,ociety recommends starting prophylactic anti%iotics %efore surgery, using appropriate spectrum
agents for less than "5 hours for nonperforated appendicitis and for less than 4 days for perforated
appendicitis& @egimens are of appro/imately e6ual efficacy, so consideration should %e given to
features such as medication allergy, pregnancy category >if applica%le?, to/icity, and cost&
Metronida8ole 1Flagyl2
Used in com%ination $ith aminoglycoside >eg, gentamicin?; %road gram+negative and anaero%ic
coverage& Appears to %e a%sor%ed into cells; intermediate meta%oli)ed compounds %ind DNA and
inhi%it protein synthesis, causing cell death&
!osing
Adult
1&4 mgG2g 07 %efore surgery
Pediatric
!4+8# mgG2gGd 07 divided %idGtid for 1 d, or 5# mgG2g P. once; not to e/ceed " gGd
Interactions
May increase to/icity of anticoagulants, lithium, and phenytoin; cimetidine may increase to/icity;
disulfiram reaction may occur $ith orally ingested ethanol
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
9 + Eetal ris2 not confirmed in studies in humans %ut has %een sho$n in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for sei)ures and peripheral neuropathy
9enta$icin 19entacidin* 9ara$ycin2
Aminoglycoside anti%iotic for gram+negative coverage& Used in com%ination $ith agent against
gram+positive organisms and one against anaero%es& Not D.C& Consider if penicillins or other
less to/ic drugs contraindicated, $hen clinically indicated, and in mi/ed infections caused %y
suscepti%le staphylococci and gram+negative organisms& Numerous regimens; adjust dose for
CrCl and changes in volume of distri%ution& May %e given 07G0M&
!osing
Adult
" mgG2g 07 loading dose %efore surgery; 8+4 mgG2gGd divided tidG6id thereafter
Pediatric
0nfantsGneonates 1&4 mgG2gGd 07 divided tid
Children :+1&4 mgG2gGd 07 divided tid
Interactions
Coadministration $ith other aminoglycosides, cephalosporins, penicillins, and amphotericin 9 may
increase nephroto/icity; aminoglycosides enhance effects of neuromuscular %loc2ing agents;
prolonged respiratory depression may occur; coadministration $ith loop diuretics may increase
ototo/icity of aminoglycosides, $hich may cause irreversi%le hearing loss of varying degrees
>monitor regularly?
Contraindications
Documented hypersensitivity; nonPdialysis+dependent renal insufficiency
Precautions
Pregnancy
C + Eetal ris2 revealed in studies in animals %ut not esta%lished or not studied in humans; may use
if %enefits out$eigh ris2 to fetus
Precautions
Narro$ therapeutic inde/ >not intended for long+term therapy?; caution in renal failure >not on
dialysis?, myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular
transmission; adjust dose in renal impairment
Ce"otetan 1Ce"otan2
,econd+generation cephalosporin used as single+drug therapy for %road gram+negative and
anaero%ic coverage& Half+life is 8&4 h& -ive $ith cefo/itin to achieve effectiveness of single dose&
!osing
Adult
" g 07 once %efore surgery
Pediatric
"#+5# mgG2g 07G0M once %efore surgery
Interactions
Consumption of alcohol $ithin 1" h may produce disulfiramli2e reactions; may increase
hypoprothrom%inemic effects of anticoagulants; coadministration $ith potent diuretics >eg, loop
diuretics? or aminoglycosides may increase nephroto/icity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
9 + Eetal ris2 not confirmed in studies in humans %ut has %een sho$n in some studies in animals
Precautions
@educe dose %y half if CrCl !#+8# mAGmin and %y three 6uarters if J!# mAGmin; %acterial or fungal
overgro$th of nonsuscepti%le organisms may occur $ith prolonged or repeated therapy
Ce"oxitin 1Me"oxin2
,econd+generation cephalosporin indicated as single agent for management of infections caused
%y suscepti%le gram+positive cocci and gram+negative rods& Half+life is #&3 h&
!osing
Adult
" g 07 %efore surgery, follo$ed %y 8 doses of " g 65+:h for "5 h
Pediatric
J8 months Not esta%lished
Q8 months 8#+5# mgG2g 07 %efore surgery, follo$ed %y 8 doses of " g 65+:h for "5 h
Interactions
Pro%enecid may increase effects; coadministration $ith aminoglycosides or furosemide may
increase nephroto/icity >closely monitor renal function?
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
9 + Eetal ris2 not confirmed in studies in humans %ut has %een sho$n in some studies in animals
Precautions
9acterial or fungal overgro$th of nonsuscepti%le organisms may occur $ith prolonged use or
repeated treatment; caution in patients $ith previously diagnosed colitis
Meropene$ 1Merre$2
9actericidal %road+spectrum car%apenem anti%iotic that inhi%its cell $all synthesis& Used as a
single agent, effective against most gram+positive and gram+negative %acteria&
!osing
Adult
! g 07 63h
Pediatric
5# mgG2g 07 63h
Interactions
Pro%enecid may inhi%it renal e/cretion, increasing levels
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
9 + Eetal ris2 not confirmed in studies in humans %ut has %een sho$n in some studies in animals
Precautions
Pseudomem%ranous colitis and throm%ocytopenia may occur >immediate discontinue?
Piperacillin and ta8obacta$ sodiu$ 1:osyn2
Drug com%ination of %eta+lactamase inhi%itor $ith piperacillin& Activity against some gram+positive
organisms, gram+negative organisms, and anaero%ic %acteria& Used as a single agent, inhi%its
%iosynthesis of cell $all mucopeptide and is effective during stage of active multiplication&
!osing
Adult
8&814 g 07 6:h
Pediatric
8##+5## mg piperacillinG2gGd 07 divided 6:+3h
Interactions
'etracyclines may decrease effects of piperacillin; high concentrations of piperacillin may
physically inactivate aminoglycosides if administered in same 07 line; effects $hen administered
concurrently $ith aminoglycosides are synergistic; pro%enecid may increase penicillin levels; high
dose parenteral penicillins may result in increased ris2 of %leeding
Contraindications
Documented hypersensitivity; severe pneumonia, %acteremia, pericarditis, emphysema,
meningitis, and purulent or septic arthritis should not %e treated $ith an oral penicillin during the
acute stage
Precautions
Pregnancy
C + Eetal ris2 revealed in studies in animals %ut not esta%lished or not studied in humans; may use
if %enefits out$eigh ris2 to fetus
Precautions
Perform C9Cs prior to initiation of therapy and at least $ee2ly during therapy; monitor for liver
function a%normalities %y measuring A,' and AA' during therapy; e/ercise caution in patients
diagnosed $ith hepatic insufficiencies; perform urinalysis, and 9UN and creatinine determinations
during therapy and adjust dose if values %ecome elevated; monitor %lood levels to avoid possi%le
neuroto/ic reactions
A$picillin and sulbacta$ 1Unasyn2
Drug com%ination of %eta+lactamase inhi%itor $ith ampicillin& 0nterferes $ith %acterial cell $all
synthesis during active replication, causing %actericidal activity against suscepti%le organisms&
Used as a single agent&
Activity against some gram+positive organisms, gram+negative organisms >nonpseudomonal
species?, and anaero%ic %acteria&
!osing
Adult
!&4 >! g ampicillin R #&4 g sul%actam? to 8 g >" g ampicillin R ! g sul%actam? 07G0M 6:+3h; not to
e/ceed 5 gGd sul%actam or 3 gGd ampicillin
Pediatric
J8 months Not esta%lished
8 months to !" years !##+"## mg ampicillinG2gGd >!4#+8## mg Unasyn? 07 divided 6:h
Q!" years Administer as in adults; not to e/ceed 5 gGd sul%actam or 3 gGd ampicillin
Interactions
Pro%enecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and
has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
9 + Eetal ris2 not confirmed in studies in humans %ut has %een sho$n in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Analgesics
'hese agents can %e used to relieve acute undifferentiated a%dominal pain in patients presenting
to the ED&
Morphine sul"ate 1Astra$orph* !ura$orph* MS Contin* MSI;* #ra$orph2
D.C for analgesia %ecause of relia%le and predicta%le effects, safety profile, and ease of
reversi%ility $ith nalo/one& 7arious 07 doses are used; commonly titrated to desired effect&
!osing
Adult
,tarting dose #&! mgG2g 07G0MG,C
Maintenance dose 4+"# mgG1# 2g 07G0MG,C 65h
@elative hypovolemia ,tart $ith " mg 07G0MG,C; reassess hemodynamic effects of dose
Pediatric
0nfants and children #&!+#&" mgG2g dose 07G0MG,C 6"+5h prn; not to e/ceed !4 mgGdose; may start
at #&#4 mgG2gGdose
Interactions
Phenothia)ines may antagoni)e analgesic effects of opiate agonists; tricyclic antidepressants,
MA.0s, and other CN, depressants may potentiate adverse effects of morphine
Contraindications
Documented hypersensitivity; hypotension; potentially compromised air$ay in $hich rapid air$ay
control may %e difficult
Precautions
Pregnancy
C + Eetal ris2 revealed in studies in animals %ut not esta%lished or not studied in humans; may use
if %enefits out$eigh ris2 to fetus
Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention,
atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase
ventricular response rate
Follo)0up
Further Inpatient Care
.pen versus laparoscopic appendectomy
o 0nitially performed in !C31, laparoscopic appendectomy has %een performed in
thousands of patients and is successful in C#+C5* of attempts& @ecent e/perience
has also demonstrated that laparoscopic appendectomy is successful in
appro/imately C#* of cases of perforated appendicitis&
o Advantages of laparoscopic appendectomy include increased cosmetic satisfaction
and a decrease in the postoperative $ound+infection rate& ,ome studies sho$ that
laparoscopic appendectomy shortens the hospital stay and convalescent period
compared $ith open appendectomy&
o Disadvantages of laparoscopic appendectomy are increased cost and an operating
time appro/imately "# minutes longer than that of open appendectomy& 'he latter
may resolve $ith increasing e/perience $ith laparoscopic techni6ue&
o Aaparoscopic appendectomy is contraindicated in patients $ith significant intra+
a%dominal adhesions&
Emergent versus urgent appendectomy
o .ne retrospective study suggests that the ris2 of appendiceal rupture is minimal in
patients $ith less than "5+8: hours of untreated symptoms&
<4: =
Another recent
retrospective study suggests that appendectomy $ithin !"+"5 hours of presentation
is not associated $ith an increase in hospital length of stay, operative time,
advanced stages of appendicitis, or complications compared to appendectomy $ithin
!" hours of presentation&
<41 =
o Additional studies are needed to demonstrate $hether initiation of anti%iotic therapy
follo$ed %y urgent appendectomy is as effective as emergent appendectomy for
patients $ith unperforated appendicitis&
0mmediate versus interval appendectomy for appendicitis $ith perforation
o Historically, immediate >emergent? appendectomy $as recommended for all patients
$ith appendicitis, $hether perforated or unperforated&
o @ecent clinical e/perience suggests that patients $ith perforated appendicitis $ith
mild symptoms and locali)ed a%scess or phlegmon on a%dominopelvic C' scans can
%e initially treated $ith intravenous anti%iotics and percutaneous or transrectal
drainage of any locali)ed a%scess& 0f the patient(s symptoms, D9C count, and fever
satisfactorily resolve, therapy can %e changed to oral anti%iotics and the patient can
%e discharged home& Delayed >interval? appendectomy can then %e performed 5+3
$ee2s later& 'his approach is successful in the vast majority of patients $ith
perforated appendicitis and locali)ed symptoms& ,ome have suggested that interval
appendectomy is not necessary unless the patient presents $ith recurrent
symptoms& Eurther studies are needed to clarify $hether routine interval
appendectomy is indicated&
o Eurther studies are necessary to identify the optimal treatment strategy in patients
$ith perforated appendicitis&
Co$plications
Complications of appendicitis may include the follo$ing
Dound infection
Dehiscence
9o$el o%struction
A%dominalGpelvic a%scess
,tump appendicitis + Although rare, appro/imately 8: reported cases of appendicitis in the
surgical stump after prior appendectomy e/ist&
<43 =
Death >rare?
Prognosis
'he prognosis is e/cellent&
Patient 7ducation
Eor e/cellent patient education resources, visit eMedicine(s Esophagus, ,tomach, and
0ntestine Center& Also, see eMedicine(s patient education articles, Appendicitis and
A%dominal Pain in Adults&
Miscellaneous
Medicolegal Pit"alls
Eor appro/imately !#* of adults $ith appendicitis, the condition is not diagnosed correctly
on their first visit to the health care provider&
Eailure to diagnose appendicitis is the leading cause of successful malpractice claims and
the fifth most e/pensive source of claims against emergency physicians&
Special Concerns
Pregnant $omen
o 'he incidence of appendicitis is unchanged in pregnancy, %ut the clinical
presentation is more varia%le than at other times&
o During pregnancy, the appendi/ migrates in a countercloc2$ise direction to$ard the
right 2idney, rising a%ove the iliac crest at a%out 5&4 months( gestation&
o @AB pain and tenderness dominate in the first trimester, %ut in the latter half of
pregnancy, right upper 6uadrant >@UB? or right flan2 pain must %e considered a
possi%le sign of appendiceal inflammation&
o Nausea, vomiting, and anore/ia are common in uncomplicated first trimester
pregnancies, %ut their reappearance later in gestation should %e vie$ed $ith
suspicion&
o Physiologic leu2ocytosis during pregnancy ma2es the D9C count less useful in the
diagnosis than at other times, and no relia%le distinguishing D9C parameters are
cited in the literature&
o .ne study of "" pregnant $omen in the first and second trimesters sho$ed that
graded compression ultrasonography had a sensitivity of ::* and specificity of C4*&
<4C =
o Diagnostic laparoscopy has also %een suggested for pregnant patients in the first
trimester $ith suspected appendicitis&
o Although negative appendectomy does not appear to adversely affect maternal or
fetal health, diagnostic delay $ith perforation does increase fetal and maternal
mor%idity& 'herefore, aggressive evaluation of the appendi/ is $arranted in this
group&
Nonpregnant $omen of child%earing age
o Appendicitis is misdiagnosed in 88* of nonpregnant $omen of child%earing age&
'he most fre6uent misdiagnoses are P0D, follo$ed %y gastroenteritis and urinary
tract infection&
o 0n distinguishing appendiceal pain from that of P0D, anore/ia and onset of pain more
than !5 days after menses suggests appendicitis& Previous P0D, vaginal discharge,
or urinary symptoms indicates P0D&
o .n physical e/amination, tenderness outside the @AB, cervical motion tenderness,
vaginal discharge, and positive urinalysis support the diagnosis of P0D&
Children
o Appendicitis is misdiagnosed in "4+8#* of children, and the rate of initial
misdiagnosis is inversely related to the age of the patient&
o 'he most common misdiagnosis is gastroenteritis, follo$ed %y upper respiratory
infection and lo$er respiratory infection&
o Children $ith misdiagnosed appendicitis are more li2ely than their counterparts to
have vomiting %efore pain onset, diarrhea, constipation, dysuria, signs and
symptoms of upper respiratory infection, and lethargy or irrita%ility&
o Physical findings less li2ely to %e documented in children $ith a misdiagnosis than in
others include %o$el sounds; peritoneal signs; rectal findings; and ear, nose, and
throat findings&
Elderly patients
o Appendicitis in patients older than :# years accounts for !#* of all appendectomies&
o 'he incidence of misdiagnosis is increased in elderly patients&
o 0n patients $ith comor%id conditions, diagnostic delay is correlated $ith increased
mor%idity and mortality&
o .lder patients tend to see2 medical attention later in the course of illness; therefore,
a duration of symptoms in e/cess of "5+53 hours should not dissuade the clinician
from the diagnosis&