Acute Appendicitis: Introduction

Acute appendicitis is a rapidly progressing inflammation of a small part of the large intestine called the
appendix. Acute appendicitis is a medical emergency that generally requires prompt removal of the
appendix to prevent life-threatening complications, such as ruptured appendix and peritonitis.

In contrast, chronic appendicitis develops slowly, has milder symptoms, and can often be treated
with antibiotics. Chronic appendicitis is far less common than acute appendicitis.

The appendix is a pouch-like structure located in the lower right quadrant of the abdomen near
the area where the small intestine links into the large intestine. The exact function of the
appendix is not known, although it might be useful in protecting beneficial bacteria of the colon.

Acute appendicitis can occur when a piece of food, stool or object becomes trapped in the
appendix. Acute appendicitis can also happen after a gastrointestinal infection. A tumor may also
cause acute appendicitis in rare cases. Sometimes the cause of acute appendicitis isn't known.

Any of these conditions result in the abnormal growth of bacteria, swelling and inflammation of
the appendix. The appendix then fills with pus, resulting in the typical symptoms of acute
appendicitis. Symptoms of acute appendicitis include abdominal pain in the right lower area of
the abdomen, fever, nausea, vomiting and loss of appetite. However, not all people with acute
appendicitis will experience typical symptoms. Acute appendicitis can also lead to serious
complications, especially if left untreated. For more details on symptoms and complications,
refer to symptoms of acute appendicitis.

Acute appendicitis is a very common condition and a frequent cause of emergency surgery.
Acute appendicitis can occur in any age group or population. However, it most often occurs in
teens and young adults. It is rare in children under two years of age.

Making a diagnosis of acute appendicitis begins with taking a thorough medical history,
including symptoms, and completing a physical examination. Examination of the abdomen
frequently reveals severe pain and tenderness in the right lower area of the abdomen. This area is
where the appendix is located and is called McBurney's point.

Diagnostic testing includes a blood test called a complete blood count with differential (CBC).
A CBC can determine if there is a rise in the number of certain types of white blood cells, which
indicates that an inflammatory and/or infectious process, such as acute appendicitis, is occurring
in the body.

More specific diagnostic imaging tests may include an abdominal ultrasound and/or abdominal
CT scan, which may reveal the inflamed appendix. These imaging tests are not always
conclusive, and in some cases, a surgery called a diagnostic laparoscopy may be needed to look
inside the abdomen and make the diagnosis. Other tests, such as urinalysis, are also done to rule
out other common diseases and conditions that have similar symptoms, such as a kidney stone.

It is possible that a diagnosis of acute appendicitis can be missed or delayed because symptoms
can vary amongst individuals. In addition, some symptoms of acute appendicitis are also
common to other conditions, such as gastroenteritis or pelvic inflammatory disease. For more
information on misdiagnosis, refer to misdiagnosis of acute appendicitis.

Acute appendicitis is treated by the surgical removal of the appendix. If the appendix has
ruptured, more intensive treatment and longer hospitalization is necessary.
Rovsing's sign

Continuous deep palpation starting from the left iliac fossa upwards (anti clockwise 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. This is the Rovsing's sign.

Psoas sign

Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with the
patient extending the hip due to inflammation of the peritoneum overlying the iliopsoas
muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes
the pain because it stretches the muscles, and flexing the hip into the "fetal position" relieves
the pain.

Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be
demonstrated by flexing and internal rotation of the hip. This maneuver will cause pain in the
hypogastrium.

Blumberg sign

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.[4]

Volkovich-Kocher (Kosher)'s sign

During anamnesis, 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.

Sitkovskiy's sign

Increased pain in the right iliac region as patient lies on his/her left side.

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.

Aure-Rozanova's sign

Increase pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-
Bloomberg's sign) - typical in retroceacal position of the appendix.

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, where tenderness develops. 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.[20] A pregnancy test is vital
in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar
symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life
threatening. Furthermore the general principles of approaching abdominal pain in women (in so
much that it is different from the approach in men) should be appreciated.

[edit] Ultrasound

Ultrasound image of an acute appendicitis.

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially
in children. 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, in experienced hands sonographic imaging can often distinguish between
appendicitis and other diseases with very similar symptoms such as inflammation of lymph
nodes near the appendix or pain originating from other pelvic organs such as the ovaries or
fallopian tubes.

[edit] Computed tomography

A cat scan demonstrating acute appendicitis (note the appendix has a diameter of 17.1mm and there is
surrounding fat stranding.)

A fecalith marked by the arrow which has resulted in acute appendicitis.

In places where it is readily available, CT scan has become frequently used, especially in adults
whose diagnosis is not obvious on history and physical. 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 mm in 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 mechanism to 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 whom tend 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 from 20% in the pre-CT
era to only 3% according to data from the Massachusetts General Hospital.

[edit] Ultrasound and CT compared

According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, 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%, a positive likelihood ratio of 13.3 (CI, 9.9
to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an
overall sensitivity of 86%, a specificity of 81%, a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5),
and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27).[21]

[edit] Alvarado score

A number of clinical and laboratory based scoring systems have been devised to assist diagnosis.
The most widely used is Alvarado score.

Symptoms

Migratory right iliac fossa pain 1 point

Anorexia 1 point

Nausea and vomiting 1 point

Signs

Right iliac fossa tenderness 2 points

Rebound tenderness 1 point

Fever 1 point

Laboratory

Leucocytosis 2 points

Shift to left (segmented neutrophils) 1 point

Total score 10 points

A score below 5 is strongly against a diagnosis of appendicitis[22], while a score of 7 or more is

strongly predictive of acute appendicitis. In patients with an equivocal score of 5-6, CT scan is
used in the USA to further reduce the rate of negative appendicectomy.
[edit] Other Data

Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of

appendiceal rupture among patients with acute appendicitis according to a cohort study.[23] MMP-
1 was higher in gangrenous (p<0.05) and perforated appendicitis (p<0.01) compared with
controls. MMP-9 was most abundantly expressed in inflamed appendix and reached a tenfold
higher expression in all groups with appendicitis compared with controls (p<0.001)

What is new about appendicitis?

Recently it has been hypothesized that some episodes of appendicitis-like symptoms, especially
recurrent symptoms, may be due to an increased sensitivity of the intestine and appendix from a
prior episode of inflammation. That is, the recurrent symptoms are not due to recurrent episodes
of inflammation. Rather, prior inflammation has made the nerves of the intestines and appendix
or the central nervous system that innervate them more sensitive to normal stimuli, that is, with
stimuli other than inflammation. This will be a difficult, if not impossible, hypothesis to confirm.

Appendectomy

During an appendectomy, an incision two to three inches in length is made through the skin and
the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen
and looks for the appendix which usually is in the right lower abdomen. After examining the area
around the appendix to be certain that no additional problem is present, the appendix is removed.
This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon,
cutting the appendix from the colon, and sewing over the hole in the colon. If an abscess is
present, the pus can be drained with drains that pass from the abscess and out through the skin.
The abdominal incision then is closed.

Newer techniques for removing the appendix involve the use of the laparoscope. The
laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the
inside of the abdomen through a small puncture wound (instead of a larger incision). If
appendicitis is found, the appendix can be removed with special instruments that can be passed
into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the
laparoscopic technique include less post-operative pain (since much of the post-surgery pain
comes from incisions) and a speedier return to normal activities. An additional advantage of
laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in
cases in which the diagnosis of appendicitis is in doubt. For example, laparoscopy is especially
helpful in menstruating women in whom a rupture of an ovarian cyst may mimic appendicitis.
If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent
home from the hospital after surgery in one or two days. Patients whose appendix has perforated
are sicker than patients without perforation, and their hospital stay often is prolonged (four to
seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the
hospital to fight infection and assist in resolving any abscess.

Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the
patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in these
cases is that it is better to remove a normal-appearing appendix than to miss and not treat
appropriately an early or mild case of appendicitis.

The appendix is a vermiform structure that derives from the first portion of the large intestine. Its
lengthy ranges by around 10 cm and it is located in the lower part of the abdomen. The appendix
has a canal in its interior that communicates with the large intestine in which there are semi fluid
feces.