7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

Appendicitis
Author:SandyCraig,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Dec27,2015

PracticeEssentials
Appendicitisisdefinedasaninflammationoftheinnerliningofthevermiform
appendixthatspreadstoitsotherparts.Despitediagnosticandtherapeutic
advancementinmedicine,appendicitisremainsaclinicalemergencyandisoneof
themorecommoncausesofacuteabdominalpain.Seetheimagebelow.

Transversegradedcompressiontransabdominalsonogramofanacutelyinflamedappendix.
Notethetargetlikeappearanceduetothickenedwallandsurroundingloculatedfluidcollection.

SeeAppendicitis:AvoidingPitfallsinDiagnosis,aCriticalImagesslideshow,to
helpmakeanaccuratediagnosis.
Also,seetheCan'tMissGastrointestinalDiagnosesslideshowtohelpdiagnosethe
potentiallylifethreateningconditionsthatpresentwithgastrointestinalsymptoms.

Essentialupdate:Newscreeningalgorithmforpediatricappendicitis
mayreduceCTuse
Anewalgorithmforscreeningpediatricpatients(18y)withsuspectedappendicitis
appearstoreducetheuseofcomputedtomography(CT)scanningwithoutaffecting
diagnosticaccuracy. [1,2]Thistoolalsohasimplicationsforreducingthelevelsof
radiationexposureandthecostofusingthisimagingmodality.Thealgorithm
includespediatricsurgeryconsultationwithoutimagingstudiesinpatientswithan
unequivocalhistoryforthosewithanequivocalhistory,physicalexamination,and
ultrasonographicfindings,thealgorithmincludesconsultationandphysical
examinationbeforeobtainingCTstudies. [2]
Investigatorsanalyzeddatafrom331pediatricpatientswithsuspectedappendicitis
2yearsbefore(41%n=136)and3yearsafter(59%n=195)implementationof
thenewalgorithmandfoundasignificantdecreaseintheuseofCTscanningfrom
39%to18%,respectively. [1,2]Moreover,althoughthenegativeappendectomyrate
rosefrom9%preimplementationofthealgorithmto11%postimplementation,this
increasewasnotsignificantandtherewasnoassociationbetweennegative
appendectomyandCTscanutilization. [1,2]

Signsandsymptoms
Theclinicalpresentationofappendicitisisnotoriouslyinconsistent.Theclassic
historyofanorexiaandperiumbilicalpainfollowedbynausea,rightlowerquadrant
(RLQ)pain,andvomitingoccursinonly50%ofcases.Featuresincludethe
following:
Abdominalpain:Mostcommonsymptom
Nausea:6192%ofpatients
Anorexia:7478%ofpatients
Vomiting:Nearlyalwaysfollowstheonsetofpainvomitingthatprecedes
painsuggestsintestinalobstruction

http://emedicine.medscape.com/article/773895overview#showall

1/8

7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

Diarrheaorconstipation:Asmanyas18%ofpatients
Featuresoftheabdominalpainareasfollows:
Typicallybeginsasperiumbilicalorepigastricpain,thenmigratestotheRLQ
[3]

Patientsusuallyliedown,flextheirhips,anddrawtheirkneesuptoreduce
movementsandtoavoidworseningtheirpain
Thedurationofsymptomsislessthan48hoursinapproximately80%of
adultsbuttendstobelongerinelderlypersonsandinthosewithperforation.
Physicalexaminationfindingsincludethefollowing:
Reboundtenderness,painonpercussion,rigidity,andguarding:Most
specificfinding
RLQtenderness:Presentin96%ofpatients,butnonspecific
Leftlowerquadrant(LLQ)tenderness:Maybethemajormanifestationin
patientswithsitusinversusorinpatientswithalengthyappendixthat
extendsintotheLLQ
Maleinfantsandchildrenoccasionallypresentwithaninflamedhemiscrotum
Inpregnantwomen,RLQpainandtendernessdominateinthefirst
trimester,butinthelatterhalfofpregnancy,rightupperquadrant(RUQ)or
rightflankpainmayoccur
Thefollowingaccessorysignsmaybepresentinaminorityofpatients:
Rovsingsign(RLQpainwithpalpationoftheLLQ):Suggestsperitoneal
irritation
Obturatorsign(RLQpainwithinternalandexternalrotationoftheflexed
righthip):Suggeststheinflamedappendixislocateddeepintheright
hemipelvis
Psoassign(RLQpainwithextensionoftherighthiporwithflexionofthe
righthipagainstresistance):Suggeststhataninflamedappendixislocated
alongthecourseoftherightpsoasmuscle
Dunphysign(sharppainintheRLQelicitedbyavoluntarycough):Suggests
localizedperitonitis
RLQpaininresponsetopercussionofaremotequadrantoftheabdomenor
tofirmpercussionofthepatient'sheel:Suggestsperitonealinflammation
Marklesign(painelicitedinacertainareaoftheabdomenwhenthe
standingpatientdropsfromstandingontoestotheheelswithajarring
landing):Hasasensitivityof74% [4]
SeeClinicalPresentationformoredetail.

Diagnosis
Thefollowinglaboratorytestsdonothavefindingsspecificforappendicitis,butthey
maybehelpfultoconfirmdiagnosisinpatientswithanatypicalpresentation:
CBC
Creactiveprotein(CRP)
Liverandpancreaticfunctiontests
Urinalysis(fordifferentiatingappendicitisfromurinarytractconditions)
UrinarybetahCG(fordifferentiatingappendicitisfromearlyectopic
pregnancyinwomenofchildbearingage)
Urinary5hydroxyindoleaceticacid(5HIAA)
CBC
WBC>10,500cells/L:8085%ofadultswithappendicitis
Neutrophilia>7578%ofpatients
Lessthan4%ofpatientswithappendicitishaveaWBCcountlessthan
10,500cells/Landneutrophilialessthan75%
Ininfantsandelderlypatients,aWBCcountisespeciallyunreliablebecausethese
patientsmaynotmountanormalresponsetoinfection.Inpregnantwomen,the
physiologicleukocytosisrenderstheCBCcountuselessforthediagnosisof
appendicitis.
Creactiveprotein
CRPlevels>1mg/dLarecommoninpatientswithappendicitis
VeryhighlevelsofCRPinpatientswithappendicitisindicategangrenous
evolutionofthedisease,especiallyifitisassociatedwithleukocytosisand
neutrophilia
Inadultswhohavehadsymptomsforlongerthan24hours,anormalCRP
levelhasanegativepredictivevalueof97100%forappendicitis [5,6,7]
Urinary5HIAA
HIAAlevelsincreasesignificantlyinacuteappendicitisanddecreasewhenthe
inflammationshiftstonecrosisoftheappendix. [8]Therefore,suchdecreasecould
beanearlywarningsignofperforationoftheappendix.
CTscanning
CTscanningwithoralcontrastmediumorrectalGastrografinenemahas
becomethemostimportantimagingstudyintheevaluationofpatientswith

http://emedicine.medscape.com/article/773895overview#showall

2/8

7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

atypicalpresentationsofappendicitis
LowdoseabdominalCTmaybepreferablefordiagnosingchildrenand
youngadultsinwhomexposuretoCTradiationisofparticularconcern [9]
Ultrasonography
Ultrasonographymayofferasaferalternativeasaprimarydiagnostictoolfor
appendicitis,withCTscanningusedinthosecasesinwhichultrasonograms
arenegativeorinconclusive
Inpediatricpatients,AmericanCollegeofEmergencyPhysicians(ACEP)
clinicalpolicyrecommendsultrasonographyforconfirmation,butnot
exclusion,ofacuteappendicitistodefinitivelyexcludeacuteappendicitis,
theACEPrecommendsCT [10,11]
Ahealthyappendixusuallycannotbeviewedwithultrasonographywhen
appendicitisoccurs,theultrasonogramtypicallydemonstratesa
noncompressibletubularstructureof79mmindiameter
Vaginalultrasonographyaloneorincombinationwithtransabdominalscan
maybeusefultodeterminethediagnosisinwomenofchildbearingage [12]
Otherimagingstudies
Kidneysuretersbladderradiographs:Insensitive,nonspecific,andnotcost
effective
Bariumenemastudy:Hasessentiallynoroleinthediagnosisofacute
appendicitis
Radionuclidescanning:LocalizeduptakeoftracerintheRLQsuggests
appendicealinflammation
MRI:Usefulinpregnantpatientsifgradedcompressionultrasonographyis
nondiagnostic
SeeWorkupformoredetail.

Management
Emergencydepartmentcareisasfollows:
EstablishIVaccessandadministeraggressivecrystalloidtherapytopatients
withclinicalsignsofdehydrationorsepticemia
KeeppatientswithsuspectedappendicitisNPO
Administerparenteralanalgesicandantiemeticasneededforpatient
comfortnostudyhasshownthatanalgesicsadverselyaffecttheaccuracyof
physicalexamination [13]
Appendectomyremainstheonlycurativetreatmentofappendicitis,but
managementofpatientswithanappendicealmasscanusuallybedividedintothe
following3treatmentcategories:
Phlegmonorasmallabscess:AfterIVantibiotictherapy,aninterval
appendectomycanbeperformed46weekslater
Largerwelldefinedabscess:AfterpercutaneousdrainagewithIVantibiotics
isperformed,thepatientcanbedischargedwiththecatheterinplace
intervalappendectomycanbeperformedafterthefistulaisclosed
Multicompartmentalabscess:Thesepatientsrequireearlysurgicaldrainage
Antibiotics
Antibioticprophylaxisshouldbeadministeredbeforeeveryappendectomy
Preoperativeantibioticsshouldbeadministeredinconjunctionwiththe
surgicalconsultant
Broadspectrumgramnegativeandanaerobiccoverageisindicated
Cefotetanandcefoxitinseemtobethebestchoicesofantibiotics
Inpenicillinallergicpatients,carbapenemsareagoodoption
PregnantpatientsshouldreceivepregnancycategoryAorBantibiotics
Antibiotictreatmentmaybestoppedwhenthepatientbecomesafebrileand
theWBCcountnormalizes
SeeTreatmentandMedicationformoredetail.

Background
Appendicitisisdefinedasaninflammationoftheinnerliningofthevermiform
appendixthatspreadstoitsotherparts.Thisconditionisacommonandurgent
surgicalillnesswithproteanmanifestations,generousoverlapwithotherclinical
syndromes,andsignificantmorbidity,whichincreaseswithdiagnosticdelay(see
ClinicalPresentation).Infact,despitediagnosticandtherapeuticadvancementin
medicine,appendicitisremainsaclinicalemergencyandisoneofthemore
commoncausesofacuteabdominalpain.
Nosinglesign,symptom,ordiagnostictestaccuratelyconfirmsthediagnosisof
appendicealinflammationinallcases,andtheclassichistoryofanorexiaand
periumbilicalpainfollowedbynausea,rightlowerquadrant(RLQ)pain,and
vomitingoccursinonly50%ofcases(seeClinicalPresentation).
Appendicitismayoccurforseveralreasons,suchasaninfectionoftheappendix,
butthemostimportantfactoristheobstructionoftheappendiceallumen(see
PathogenesisandEtiology).Leftuntreated,appendicitishasthepotentialforsevere
complications,includingperforationorsepsis,andmayevencausedeath(see

http://emedicine.medscape.com/article/773895overview#showall

3/8

7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

PrognosisandComplications).However,thedifferentialdiagnosisofappendicitisis
oftenaclinicalchallengebecauseappendicitiscanmimicseveralabdominal
conditions(seeDiagnosticConsiderationsandDifferentials). [14]
Appendectomyremainstheonlycurativetreatmentofappendicitis(seeTreatment
andManagement).Thesurgeon'sgoalsaretoevaluatearelativelysmallpopulation
ofpatientsreferredforsuspectedappendicitisandtominimizethenegative
appendectomyratewithoutincreasingtheincidenceofperforation.Theemergency
department(ED)clinicianmustevaluatethelargergroupofpatientswhopresentto
theEDwithabdominalpainofalletiologieswiththegoalofapproaching100%
sensitivityforthediagnosisinatime,cost,andconsultationefficientmanner.
GotoPediatricAppendicitisformoreinformationonthistopic.

Anatomy
Theappendixisawormlikeextensionofthececumand,forthisreason,hasbeen
calledthevermiformappendix.Theaveragelengthoftheappendixis810cm
(rangingfrom220cm).Theappendixappearsduringthefifthmonthofgestation,
andseverallymphoidfolliclesarescatteredinitsmucosa.Suchfolliclesincreasein
numberwhenindividualsareaged820years.Anormalappendixisseenbelow.

Normalappendixbariumenemaradiographicexamination.Acompletecontrastfilledappendix
isobserved(arrows),whicheffectivelyexcludesthediagnosisofappendicitis.

Theappendixiscontainedwithinthevisceralperitoneumthatformstheserosa,and
itsexteriorlayerislongitudinalandderivedfromthetaeniacolithedeeper,interior
musclelayeriscircular.Beneaththeselayersliesthesubmucosallayer,which
containslymphoepithelialtissue.Themucosaconsistsofcolumnarepitheliumwith
fewglandularelementsandneuroendocrineargentaffincells.
Taeniacoliconvergeontheposteromedialareaofthececum,whichisthesiteof
theappendicealbase.Theappendixrunsintoaserosalsheetoftheperitoneum
calledthemesoappendix,withinwhichcoursestheappendicularartery,whichis
derivedfromtheileocolicartery.Sometimes,anaccessoryappendicularartery
(derivingfromtheposteriorcecalartery)maybefound.

Appendicealvasculature
Thevasculatureoftheappendixmustbeaddressedtoavoidintraoperative
hemorrhages.Theappendiculararteryiscontainedwithinthemesentericfoldthat
arisesfromaperitonealextensionfromtheterminalileumtothemedialaspectof
thececumandappendixitisaterminalbranchoftheileocolicarteryandruns
adjacenttotheappendicularwall.Venousdrainageisviatheileocolicveinsandthe
rightcolicveinintotheportalveinlymphaticdrainageoccursviatheileocolicnodes
alongthecourseofthesuperiormesentericarterytotheceliacnodesandcisterna
chyli.

Appendiceallocation
Theappendixhasnofixedposition.Itoriginates1.72.5cmbelowtheterminal
ileum,eitherinadorsomediallocation(mostcommon)fromthececalfundus,
directlybesidetheilealorifice,orasafunnelshapedopening(23%ofpatients).
Theappendixhasaretroperitoneallocationin65%ofpatientsandmaydescend
intotheiliacfossain31%.Infact,manyindividualsmayhaveanappendixlocated
intheretroperitonealspaceinthepelvisorbehindtheterminalileum,cecum,
ascendingcolon,orliver.Thus,thecourseoftheappendix,thepositionofitstip,
andthedifferenceinappendicealpositionconsiderablychangesclinicalfindings,
accountingforthenonspecificsignsandsymptomsofappendicitis.

Congenitalappendicealdisorders
Appendicealcongenitaldisordersareextremelyrarebutoccasionallyreported(eg,
agenesis,duplication,triplication).

Pathophysiology
http://emedicine.medscape.com/article/773895overview#showall

4/8

7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

Reportedly,appendicitisiscausedbyobstructionoftheappendiceallumenfroma
varietyofcauses(seeEtiology).Independentoftheetiology,obstructionisbelieved
tocauseanincreaseinpressurewithinthelumen.Suchanincreaseisrelatedto
continuoussecretionoffluidsandmucusfromthemucosaandthestagnationof
thismaterial.Atthesametime,intestinalbacteriawithintheappendixmultiply,
leadingtotherecruitmentofwhitebloodcells(seetheimagebelow)andthe
formationofpusandsubsequenthigherintraluminalpressure.

Technetium99mradionuclidescanoftheabdomenshowsfocaluptakeoflabeledWBCsinthe
rightlowerquadrantconsistentwithacuteappendicitis.

Ifappendicealobstructionpersists,intraluminalpressurerisesultimatelyabovethat
oftheappendicealveins,leadingtovenousoutflowobstruction.Asaconsequence,
appendicealwallischemiabegins,resultinginalossofepithelialintegrityand
allowingbacterialinvasionoftheappendicealwall.
Withinafewhours,thislocalizedconditionmayworsenbecauseofthrombosisof
theappendiculararteryandveins,leadingtoperforationandgangreneofthe
appendix.Asthisprocesscontinues,aperiappendicularabscessorperitonitismay
occur.

Etiology
Appendicitisiscausedbyobstructionoftheappendiceallumen.Themostcommon
causesofluminalobstructionincludelymphoidhyperplasiasecondaryto
inflammatoryboweldisease(IBD)orinfections(morecommonduringchildhoodand
inyoungadults),fecalstasisandfecaliths(morecommoninelderlypatients),
parasites(especiallyinEasterncountries),or,morerarely,foreignbodiesand
neoplasms.
Fecalithsformwhencalciumsaltsandfecaldebrisbecomelayeredaroundanidus
ofinspissatedfecalmateriallocatedwithintheappendix.Lymphoidhyperplasiais
associatedwithvariousinflammatoryandinfectiousdisordersincludingCrohn
disease,gastroenteritis,amebiasis,respiratoryinfections,measles,and
mononucleosis.
Obstructionoftheappendiceallumenhaslesscommonlybeenassociatedwith
bacteria(Yersiniaspecies,adenovirus,cytomegalovirus,actinomycosis,
Mycobacteriaspecies,Histoplasmaspecies),parasites(eg,Schistosomesspecies,
pinworms,Strongyloidesstercoralis),foreignmaterial(eg,shotgunpellet,
intrauterinedevice,tonguestud,activatedcharcoal),tuberculosis,andtumors.

Epidemiology
Appendicitisisoneofthemorecommonsurgicalemergencies,anditisoneofthe
mostcommoncausesofabdominalpain.IntheUnitedStates,250,000casesof
appendicitisarereportedannually,representing1millionpatientdaysofadmission.
Theincidenceofacuteappendicitishasbeendecliningsteadilysincethelate
1940s,andthecurrentannualincidenceis10casesper100,000population.
Appendicitisoccursin7%oftheUSpopulation,withanincidenceof1.1casesper
1000peopleperyear.Somefamilialpredispositionexists.
InAsianandAfricancountries,theincidenceofacuteappendicitisisprobablylower
becauseofthedietaryhabitsoftheinhabitantsofthesegeographicareas.The
incidenceofappendicitisislowerincultureswithahigherintakeofdietaryfiber.
Dietaryfiberisthoughttodecreasetheviscosityoffeces,decreaseboweltransit
time,anddiscourageformationoffecaliths,whichpredisposeindividualsto
obstructionsoftheappendiceallumen.
Inthelastfewyears,adecreaseinfrequencyofappendicitisinWesterncountries
hasbeenreported,whichmayberelatedtochangesindietaryfiberintake.Infact,

http://emedicine.medscape.com/article/773895overview#showall

5/8

7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

thehigherincidenceofappendicitisisbelievedtoberelatedtopoorfiberintakein
suchcountries.
Thereisaslightmalepreponderanceof3:2inteenagersandyoungadultsin
adults,theincidenceofappendicitisisapproximately1.4timesgreaterinmenthan
inwomen.Theincidenceofprimaryappendectomyisapproximatelyequalinboth
sexes.
Theincidenceofappendicitisgraduallyrisesfrombirth,peaksinthelateteenyears,
andgraduallydeclinesinthegeriatricyears.Themeanagewhenappendicitis
occursinthepediatricpopulationis610years.Lymphoidhyperplasiaisobserved
moreoftenamonginfantsandadultsandisresponsiblefortheincreasedincidence
ofappendicitisintheseagegroups.Youngerchildrenhaveahigherrateof
perforation,withreportedratesof5085%.Themedianageatappendectomyis22
years.Althoughrare,neonatalandevenprenatalappendicitishavebeenreported.
Cliniciansmustmaintainahighindexofsuspicioninallagegroups.
GotoPediatricAppendicitisformoreinformationonthistopic.

Prognosis
Acuteappendicitisisthemostcommonreasonforemergencyabdominalsurgery.
Appendectomycarriesacomplicationrateof415%,aswellasassociatedcosts
andthediscomfortofhospitalizationandsurgery.Therefore,thegoalofthe
surgeonistomakeanaccuratediagnosisasearlyaspossible.Delayeddiagnosis
andtreatmentaccountformuchofthemortalityandmorbidityassociatedwith
appendicitis.
Theoverallmortalityrateof0.20.8%isattributabletocomplicationsofthedisease
ratherthantosurgicalintervention.Themortalityrateinchildrenrangesfrom0.1%
to1%inpatientsolderthan70years,theraterisesabove20%,primarilybecause
ofdiagnosticandtherapeuticdelay.
Appendicealperforationisassociatedwithincreasedmorbidityandmortality
comparedwithnonperforatingappendicitis.Themortalityriskofacutebutnot
gangrenousappendicitisislessthan0.1%,buttheriskrisesto0.6%ingangrenous
appendicitis.Therateofperforationvariesfrom16%to40%,withahigher
frequencyoccurringinyoungeragegroups(4057%)andinpatientsolderthan50
years(5570%),inwhommisdiagnosisanddelayeddiagnosisarecommon.
Complicationsoccurin15%ofpatientswithappendicitis,andpostoperativewound
infectionsaccountforalmostonethirdoftheassociatedmorbidity.

PatientEducation
Forpatienteducationinformation,seetheEsophagus,Stomach,andIntestine
Center,aswellasAppendicitisandAbdominalPaininAdults.
ClinicalPresentation

ContributorInformationandDisclosures
Author
SandyCraig,MDResidencyProgramDirector,CarolinasMedicalCenterAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofNorthCarolinaatChapel
HillSchoolofMedicine
SandyCraig,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,
UniversityHospitals,CaseWesternReserveUniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanHeartAssociation,AmericanThoracicSociety,
ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyofEmergency
Medicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergencyMedicine,CharlesDrewUniversityofMedicineandScience
FormerChair,DepartmentofEmergencyMedicine,MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
WilliamLober,MD,MSAssociateProfessor,HealthInformaticsandGlobalHealth,SchoolsofMedicine,Nursing,andPublicHealth,UniversityofWashington
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1.PolitesSF,MohamedMI,HabermannEB,etal.Asimplealgorithmreducescomputedtomographyuseinthediagnosisofappendicitisinchildren.Surgery.2014
Jun19.[Medline].
2.DouglasD.AlgorithmcutspediatricCTuseinsuspectedappendicitis.ReutersHealthInformation.July10,2014.[FullText].

http://emedicine.medscape.com/article/773895overview#showall

6/8

7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

3.YehB.Evidencebasedemergencymedicine/rationalclinicalexaminationabstract.Doesthisadultpatienthaveappendicitis?.AnnEmergMed.2008Sep.52(3):301
3.[Medline].
4.MarkleGB4th.Heeldropjarringtestforappendicitis.ArchSurg.1985Feb.120(2):243.[Medline].
5.ThimsenDA,TongGK,GruenbergJC.ProspectiveevaluationofCreactiveproteininpatientssuspectedtohaveacuteappendicitis.AmSurg.1989Jul.55(7):4668.
[Medline].
6.deCarvalhoBR,DiogoFilhoA,FernandesC,BarraCB.[Leukocytecount,Creactiveprotein,alpha1acidglycoproteinanderythrocytesedimentationrateinacute
appendicitis].ArqGastroenterol.2003JanMar.40(1):2530.[Medline].
7.AlbuE,MillerBM,ChoiY,etal.DiagnosticvalueofCreactiveproteininacuteappendicitis.DisColonRectum.1994Jan.37(1):4951.[Medline].
8.BolandparvazS,VaseiM,OwjiAA,AtaEeN,AminA,DaneshbodY,etal.Urinary5hydroxyindoleaceticacidasatestforearlydiagnosisofacuteappendicitis.
ClinBiochem.2004Nov.37(11):9859.[Medline].
9.KimK,KimYH,KimSY,KimS,LeeYJ,KimKP,etal.LowdoseabdominalCTforevaluatingsuspectedappendicitis.NEnglJMed.2012Apr26.366(17):1596
605.[Medline].
10.HowellJM,EddyOL,LukensTW,ThiessenME,WeingartSD,DeckerWW.Clinicalpolicy:Criticalissuesintheevaluationandmanagementofemergency
departmentpatientswithsuspectedappendicitis.AnnEmergMed.2010Jan.55(1):71116.[Medline].
11.[Guideline]NationalGuidelineClearinghouse(NGC).Guidelinesummary:Clinicalpolicy:criticalissuesintheevaluationandmanagementofemergencydepartment
patientswithsuspectedappendicitis.NationalGuidelineClearinghouse(NGC),Rockville(MD).Availableathttp://guideline.gov/content.aspx?id=15598.Accessed:
November18,2013.
12.BarloonTJ,BrownBP,AbuYousefMM,WarnockN,BerbaumKS.Sonographyofacuteappendicitisinpregnancy.AbdomImaging.1995MarApr.20(2):14951.
[Medline].
13.ManterolaC,VialM,MoragaJ,AstudilloP.Analgesiainpatientswithacuteabdominalpain.CochraneDatabaseSystRev.2011Jan19.1:CD005660.[Medline].
14.KaramanakosSN,SdralisE,PanagiotopoulosS,KehagiasI.Laparoscopyintheemergencysetting:aretrospectivereviewof540patientswithacuteabdominal
pain.SurgLaparoscEndoscPercutanTech.2010Apr.20(2):11924.[Medline].
15.NiwaH,HiramatsuT.Ararepresentationofappendicealdiverticulitisassociatedwithpelvicpseudocyst.WorldJGastroenterol.2008Feb28.14(8):12935.
[Medline].[FullText].
16.PlaceRC.Acuteurinaryretentionina9yearoldchild:anatypicalpresentationofacuteappendicitis.JEmergMed.2006Aug.31(2):1735.[Medline].
17.OtoA,ErnstRD,MileskiWJ,NishinoTK,LeO,WolfeGC,etal.LocalizationofappendixwithMDCTandinfluenceoffindingsonchoiceofappendectomyincision.
AJRAmJRoentgenol.2006Oct.187(4):98790.[Medline].
18.SedlakM,WagnerOJ,WildB,PapagrigoriadesS,ExadaktylosAK.Istherestillaroleforrectalexaminationinsuspectedappendicitisinadults?.AmJEmergMed.
2008Mar.26(3):35960.[Medline].
19.AlvaradoA.Apracticalscorefortheearlydiagnosisofacuteappendicitis.AnnEmergMed.1986May.15(5):55764.[Medline].
20.SchneiderC,KharbandaA,BachurR.Evaluatingappendicitisscoringsystemsusingaprospectivepediatriccohort.AnnEmergMed.2007Jun.49(6):77884,
784.e1.[Medline].
21.SchneiderC,KharbandaA,BachurR.Evaluatingappendicitisscoringsystemsusingaprospectivepediatriccohort.AnnEmergMed.2007Jun.49(6):77884,
784.e1.[Medline].
22.MigraineS,AtriM,BretPM,LoughJO,HincheyJE.Spontaneouslyresolvingacuteappendicitis:clinicalandsonographicdocumentation.Radiology.1997Oct.
205(1):558.[Medline].
23.CobbenLP,deVanOtterlooAM,PuylaertJB.Spontaneouslyresolvingappendicitis:frequencyandnaturalhistoryin60patients.Radiology.2000May.215(2):349
52.[Medline].
24.DueholmS,BagiP,BudM.Laboratoryaidinthediagnosisofacuteappendicitis.Ablinded,prospectivetrialconcerningdiagnosticvalueofleukocytecount,
neutrophildifferentialcount,andCreactiveprotein.DisColonRectum.1989Oct.32(10):8559.[Medline].
25.GurleyikE,GurleyikG,UnalmiserS.AccuracyofserumCreactiveproteinmeasurementsindiagnosisofacuteappendicitiscomparedwithsurgeon'sclinical
impression.DisColonRectum.1995Dec.38(12):12704.[Medline].
26.ShakhatrehHS.TheaccuracyofCreactiveproteininthediagnosisofacuteappendicitiscomparedwiththatofclinicaldiagnosis.MedArh.2000.54(2):10910.
[Medline].
27.AsfarS,SafarH,KhoursheedM,DashtiH,alBaderA.WouldmeasurementofCreactiveproteinreducetherateofnegativeexplorationforacuteappendicitis?.JR
CollSurgEdinb.2000Feb.45(1):214.[Medline].
28.ErkasapS,AtesE,UstunerZ,SahinA,YilmazS,YasarB,etal.Diagnosticvalueofinterleukin6andCreactiveproteininacuteappendicitis.SwissSurg.2000.
6(4):16972.[Medline].
29.GronroosJM,GronroosP.LeucocytecountandCreactiveproteininthediagnosisofacuteappendicitis.BrJSurg.1999Apr.86(4):5014.[Medline].
30.OrtegaDeballonP,RuizdeAdanaBelbelJC,HernandezMatiasA,GarciaSeptiemJ,MorenoAzcoitaM.Usefulnessoflaboratorydatainthemanagementofright
iliacfossapaininadults.DisColonRectum.2008Jul.51(7):10939.[Medline].
31.GronroosJM.IstherearoleforleukocyteandCRPmeasurementsinthediagnosisofacuteappendicitisintheelderly?.Maturitas.1999Mar15.31(3):2558.
[Medline].
32.YangHR,WangYC,ChungPK,etal.Roleofleukocytecount,neutrophilpercentage,andCreactiveproteininthediagnosisofacuteappendicitisintheelderly.Am
Surg.2005Apr.71(4):3447.[Medline].
33.GronroosJM.DonormalleucocytecountandCreactiveproteinvalueexcludeacuteappendicitisinchildren?.ActaPaediatr.2001Jun.90(6):64951.[Medline].
34.StefanuttiG,GhirardoV,GambaP.Inflammatorymarkersforacuteappendicitisinchildren:aretheyhelpful?.JPediatrSurg.2007May.42(5):7736.[Medline].
35.MohammedAA,DaghmanNA,AboudSM,OshibiHO.ThediagnosticvalueofCreactiveprotein,whitebloodcellcountandneutrophilpercentageinchildhood
appendicitis.SaudiMedJ.2004Sep.25(9):12125.[Medline].

http://emedicine.medscape.com/article/773895overview#showall

7/8

7/29/2016

Appendicitis:PracticeEssentials,Background,Anatomy

36.YangHR,WangYC,ChungPK,ChenWK,JengLB,ChenRJ.Laboratorytestsinpatientswithacuteappendicitis.ANZJSurg.2006JanFeb.76(12):714.
[Medline].
37.TundidorBermudezAM,AmadoDieguezJA,MontesdeOcaMastrapaJL.[Urologicalmanifestationsofacuteappendicitis].ArchEspUrol.2005Apr.58(3):20712.
[Medline].
38.RaoPM,RheaJT,RattnerDW,etal.IntroductionofappendicealCT:impactonnegativeappendectomyandappendicealperforationrates.AnnSurg.1999Mar.
229(3):3449.[Medline].
39.McGoryML,ZingmondDS,NanayakkaraD,MaggardMA,KoCY.Negativeappendectomyrate:influenceofCTscans.AmSurg.2005Oct.71(10):8038.[Medline].
40.HarswickC,UyenishiAA,KordickMF,ChanSB.Clinicalguidelines,computedtomographyscan,andnegativeappendectomies:acaseseries.AmJEmergMed.
2006Jan.24(1):6872.[Medline].
41.FreiSP,BondWF,BazuroRK,RichardsonDM,SierzegaGM,ReedJF.Appendicitisoutcomeswithincreasingcomputedtomographicscanning.AmJEmergMed.
2008Jan.26(1):3944.[Medline].
42.PickhardtPJ,LawrenceEM,PoolerBD,BruceRJ.Diagnosticperformanceofmultidetectorcomputedtomographyforsuspectedacuteappendicitis.AnnInternMed.
2011Jun21.154(12):78996.[Medline].
43.KepnerAM,BacasnotJV,StahlmanBA.Intravenouscontrastalonevsintravenousandoralcontrastcomputedtomographyforthediagnosisofappendicitisinadult
EDpatients.AmJEmergMed.2012May23.[Medline].
44.BrennerDJ,HallEJ.Computedtomographyanincreasingsourceofradiationexposure.NEnglJMed.2007Nov29.357(22):227784.[Medline].
45.ZilbertNR,StamellEF,EzonI,SchlagerA,GinsburgHB,NadlerEP.Managementandoutcomesforchildrenwithacuteappendicitisdifferbyhospitaltype:areas
forimprovementatpublichospitals.ClinPediatr(Phila).2009Jun.48(5):499504.[Medline].
46.DoriaAS,MoineddinR,KellenbergerCJ,EpelmanM,BeyeneJ,SchuhS,etal.USorCTforDiagnosisofAppendicitisinChildrenandAdults?AMetaAnalysis.
Radiology.2006Oct.241(1):8394.[Medline].
47.BoggsW.Ultrasound/MRIStrategyDiagnosesAppendicitisinKidsWithoutRadiation.MedscapeMedicalNews.Availableat
http://www.medscape.com/viewarticle/821332.Accessed:March12,2014.
48.AspelundG,FingeretA,GrossE,KesslerD,KeungC,ThirumoorthiA,etal.Ultrasonography/MRIVersusCTforDiagnosingAppendicitis.Pediatrics.2014Mar3.
[Medline].
49.CobbenLP,GrootI,HaansL,BlickmanJG,PuylaertJ.MRIforclinicallysuspectedappendicitisduringpregnancy.AJRAmJRoentgenol.2004Sep.183(3):6715.
[Medline].
50.RepplingerMD,LevyJF,PeethumnongsinE,etal.SystematicreviewandmetaanalysisoftheaccuracyofMRItodiagnoseappendicitisinthegeneralpopulation.J
MagnResonImaging.2015Dec22.[Medline].
51.ThiemeME,LeeuwenburghMM,ValdehuezaZD,BoumanDE,deBruinIG,SchreursWH,etal.DiagnosticaccuracyandpatientacceptanceofMRIinchildrenwith
suspectedappendicitis.EurRadiol.2013Oct19.[Medline].
52.SingerDD,ThodeHCJr,SingerAJ.EffectsofpainseverityandCTimagingonanalgesiaprescriptioninacuteappendicitis.AmJEmergMed.2016Jan.34(1):36
9.[Medline].
53.ErikssonS,GranstrmL.Randomizedcontrolledtrialofappendicectomyversusantibiotictherapyforacuteappendicitis.BrJSurg.1995Feb.82(2):1669.
[Medline].
54.SalminenP,PaajanenH,RautioT,etal.AntibioticTherapyvsAppendectomyforTreatmentofUncomplicatedAcuteAppendicitis:TheAPPACRandomizedClinical
Trial.JAMA.2015Jun16.313(23):23408.[Medline].
55.BonadioW,RebillotK,UkwuomaO,SaracinoC,IskhakovA.Managementofpediatricperforatedappendicitis:comparingoutcomesusingearlyappendectomyvs
solelymedicalmanagement.PediatrInfectDisJ.2015Dec14.[Medline].
56.BickellNA,AufsesAHJr,RojasM,BodianC.Howtimeaffectstheriskofruptureinappendicitis.JAmCollSurg.2006Mar.202(3):4016.[Medline].
57.AbouNuktaF,BakhosC,ArroyoK,KooY,MartinJ,ReinholdR,etal.Effectsofdelayingappendectomyforacuteappendicitisfor12to24hours.ArchSurg.2006
May.141(5):5046discussion5067.[Medline].
58.FairBA,KubasiakJC,JanssenI,etal.Theimpactofoperativetimingonoutcomesofappendicitis:aNationalSurgicalQualityImprovementProjectanalysis.AmJ
Surg.2015Mar.209(3):498502.[Medline].
59.BoomerLA,CooperJN,AnandalwarS,etal.Delayingappendectomydoesnotleadtohigherratesofsurgicalsiteinfections:amultiinstitutionalanalysisofchildren
withappendicitis.AnnSurg.2015Dec16.[Medline].
60.[Guideline]KorndorfferJRJr,FellingerE,ReedW.SAGESguidelineforlaparoscopicappendectomy.SurgEndosc.2010Apr.24(4):75761.[Medline].[FullText].
61.WilasrusmeeC,SukratB,McEvoyM,AttiaJ,ThakkinstianA.Systematicreviewandmetaanalysisofsafetyoflaparoscopicversusopenappendicectomyfor
suspectedappendicitisinpregnancy.BrJSurg.2012Nov.99(11):14708.[Medline].
62.LiangMK,LoHG,MarksJL.Stumpappendicitis:acomprehensivereviewofliterature.AmSurg.2006Feb.72(2):1626.[Medline].
63.BarclayL.Ultrasound,CTComparabletoDetectAppendicitisinChildren.MedscapeMedicalNews.Availableathttp://www.medscape.com/viewarticle/817370.
Accessed:December9,2013.
64.LeJ,KurianJ,CohenHW,WeinbergG,ScheinfeldMH.Doclinicaloutcomessufferduringtransitiontoanultrasoundfirstparadigmfortheevaluationofacute
appendicitisinchildren?.AJRAmJRoentgenol.2013Dec.201(6):134852.[Medline].
65.HurstAL,OlsonD,SommeS,etal.Oncedailyceftriaxoneplusmetronidazoleversusertapenemand/orcefoxitinforpediatricappendicitis.JPediatricInfectDis
Soc.2015Dec24.[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/773895overview#showall

8/8