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Acute appendicitis in adults: Clinical manifestations

and differential diagnosis
Author: Ronald F Martin, MD
Section Editor: Martin Weiser, MD
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2020. | This topic last updated: Feb 26, 2020.

INTRODUCTION

Appendicitis, an inflammation of the vestigial vermiform appendix, is one of the most

common causes of the acute abdomen and one of the most frequent indications for an
emergency abdominal surgical procedure worldwide [1,2].

The clinical manifestations and differential diagnosis of appendicitis in adults will be

reviewed here. The diagnostic evaluation and management of appendicitis in adults and
appendicitis in pregnancy and children are discussed separately. (See "Acute appendicitis in
adults: Diagnostic evaluation" and "Management of acute appendicitis in adults" and "Acute
appendicitis in pregnancy" and "Acute appendicitis in children: Clinical manifestations and
diagnosis".)

ANATOMY

The vermiform appendix is located at the base of the cecum, near the ileocecal valve where
the taenia coli converge on the cecum ( figure 1) [3,4]. The appendix is a true diverticulum
of the cecum. In contrast to acquired diverticular disease, which consists of a protuberance
of a subset of the enteric wall layers, the appendiceal wall contains all of the layers of the
colonic wall: mucosa, submucosa, muscularis (longitudinal and circular), and the serosal
covering [5].

The appendiceal orifice opens into the cecum. Its blood supply, the appendiceal artery, is a
terminal branch of the ileocolic artery, which traverses the length of the mesoappendix and
terminates at the tip of the organ ( figure 2) [4].
The attachment of the appendix to the base of the cecum is constant. However, the tip may
migrate to the retrocecal, subcecal, preileal, postileal, and pelvic positions. These normal
anatomic variations can complicate the diagnosis as the site of pain and findings on the
clinical examination will reflect the anatomic position of the appendix.

The presence of B and T lymphoid cells in the mucosa and submucosa of the lamina propria
make the appendix histologically distinct from the cecum [5]. These cells create a lymphoid
pulp that aids immunologic function by increasing lymphoid products such as IgA and
operating as part of the gut-associated lymphoid tissue system [3]. Lymphoid hyperplasia
can cause obstruction of the appendix and lead to appendicitis. The lymphoid tissue
undergoes atrophy with age [6].

EPIDEMIOLOGY

Appendicitis occurs most frequently in the second and third decades of life. The incidence is
approximately 233/100,000 population and is highest in the 10-to-19-year-old age group [7].
It is also higher among men (male to female ratio of 1.4:1), who have a lifetime incidence of
8.6 percent compared with 6.7 percent for women [7].

PATHOGENESIS

The natural history of appendicitis is similar to that of other inflammatory processes

involving hollow visceral organs. Initial inflammation of the appendiceal wall is followed by
localized ischemia, perforation, and the development of a contained abscess or generalized
peritonitis.

Appendiceal obstruction has been proposed as the primary cause of appendicitis [3,8-11].
Obstruction is frequently implicated but not always identified. A study of patients with
appendicitis showed that there was elevated intraluminal pressure in only one-third of the
patients with nonperforated appendicitis [12].

Appendiceal obstruction may be caused by fecaliths (hard fecal masses), calculi, lymphoid
hyperplasia, infectious processes, and benign or malignant tumors. However, some patients
with a fecalith have a histologically normal appendix, and the majority of patients with
appendicitis do not have a fecalith [13,14].

When obstruction of the appendix is the cause of appendicitis, the obstruction leads to an
increase in luminal and intramural pressure, resulting in thrombosis and occlusion of the
small vessels in the appendiceal wall, and stasis of lymphatic flow. As the appendix becomes
engorged, the visceral afferent nerve fibers entering the spinal cord at T8 to T10 are
stimulated, leading to vague central or periumbilical abdominal pain [8]. Well-localized pain
occurs later in the course when inflammation involves the adjacent parietal peritoneum.

The mechanism of luminal obstruction varies depending upon the patient's age. In the
young, lymphoid follicular hyperplasia due to infection is thought to be the main cause. In
older patients, luminal obstruction is more likely to be caused by fibrosis, fecaliths, or
neoplasia (carcinoid, adenocarcinoma, or mucocele). In endemic areas, parasites can cause
obstruction in any age group. (See "Well-differentiated neuroendocrine tumors of the
appendix".)

Once obstructed, the lumen becomes filled with mucus and distends, increasing luminal and
intramural pressure. This results in thrombosis and occlusion of the small vessels, and stasis
of lymphatic flow. As lymphatic and vascular compromise progresses, the wall of the
appendix becomes ischemic and then necrotic.

Bacterial overgrowth occurs within the diseased appendix. Aerobic organisms predominate
early in the course, while mixed infection is more common in late appendicitis [15]. Common
organisms involved in gangrenous and perforated appendicitis include Escherichia coli,
Peptostreptococcus, Bacteroides fragilis, and Pseudomonas species [16]. Intraluminal bacteria
subsequently invade the appendiceal wall and further propagate a neutrophilic exudate. The
influx of neutrophils causes a fibropurulent reaction on the serosal surface, irritating the
surrounding parietal peritoneum [6]. This results in stimulation of somatic nerves, causing
pain at the site of peritoneal irritation [5].

During the first 24 hours after symptoms develop, approximately 90 percent of patients
develop inflammation and perhaps necrosis of the appendix, but not perforation. The type of
luminal obstruction may be a predictor of perforation of an acutely inflamed appendix.
Fecaliths were six times more common than true calculi in the appendix, but calculi were
more often associated with perforated appendicitis or periappendiceal abscess (45 percent)
than were fecaliths (19 percent). This is presumably due to the rigidity of true calculi as
compared with the softer, more crushable fecaliths [13].

Once significant inflammation and necrosis occur, the appendix is at risk of perforation,
which leads to localized abscess formation or diffuse peritonitis. The time course to
perforation is variable. One study showed that 20 percent of patients developed perforation
less than 24 hours after the onset of symptoms [17]. Sixty-five percent of patients in whom
the appendix perforated had symptoms for longer than 48 hours.

CLINICAL FEATURES

Clinical manifestations
 History — Abdominal pain is the most common symptom and is reported in nearly all
confirmed cases of appendicitis [18,19]. The clinical presentation of acute appendicitis is
described as a constellation of the following classic symptoms:

● Right lower quadrant (right anterior iliac fossa) abdominal pain

● Anorexia
● Nausea and vomiting

In the classic presentation, the patient describes the onset of abdominal pain as the first
symptom. The pain is typically periumbilical in nature with subsequent migration to the right
lower quadrant as the inflammation progresses [18]. Although considered a classic symptom,
migratory pain occurs only in 50 to 60 percent of patients with appendicitis [8,20]. Nausea
and vomiting, if they occur, usually follow the onset of pain. Fever-related symptoms
generally occur later in the course of illness.

In many patients, initial features are atypical or nonspecific and can include:

● Indigestion
● Flatulence
● Bowel irregularity
● Diarrhea
● Generalized malaise

Because the early symptoms of appendicitis are often subtle, patients and clinicians may
minimize their importance. The symptoms of appendicitis vary depending upon the location
of the tip of the appendix ( figure 1) (see 'Anatomy' above). For example, an inflamed
anterior appendix produces marked, localized pain in the right lower quadrant, while a
retrocecal appendix may cause a dull abdominal ache [21]. The location of the pain may also
be atypical in patients who have the tip of the appendix located in the pelvis, which can cause
tenderness below McBurney's point. Such patients may complain of urinary frequency and
dysuria or rectal symptoms, such as tenesmus and diarrhea.

Physical examination — The early signs of appendicitis are often subtle. Low-grade fever
reaching 101.0°F (38.3°C) may be present. The physical examination may be unrevealing in
the very early stages of appendicitis since the visceral organs are not innervated with
somatic pain fibers.

However, as the inflammation progresses, involvement of the overlying parietal peritoneum

causes localized tenderness in the right lower quadrant and can be detected on the
abdominal examination. Rectal examination, although often advocated, has not been shown
to provide additional diagnostic information in cases of appendicitis [22]. In women, right
adnexal area tenderness may be present on pelvic examination, and differentiating between
tenderness of pelvic origin versus that of appendicitis may be challenging. High-grade fever
(>101.0°F/38.3°C) occurs as inflammation progresses. (See "Causes of abdominal pain in
adults".)

Patients with a retrocecal appendix may not exhibit marked localized tenderness in the right
lower quadrant since the appendix does not come into contact with the anterior parietal
peritoneum ( figure 1) [21]. The rectal and/or pelvic examination is more likely to elicit
positive signs than the abdominal examination. Tenderness may be more prominent on
pelvic examination and may be mistaken for adnexal tenderness.

Several findings on physical examination have been described to facilitate diagnosis, but
these findings predated definitive imaging for appendicitis, and the wide variation in their
sensitivity and specificity suggests that they be used with caution to broaden, or narrow, a
differential diagnosis. There are no physical findings, taken alone or in concert, that
definitively confirm a diagnosis of appendicitis.

Commonly described physical signs include:

● McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from

the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus
[23] (sensitivity 50 to 94 percent; specificity 75 to 86 percent [24-26]).

● Rovsing's sign refers to pain in the right lower quadrant with palpation of the left lower
quadrant. This sign is also called indirect tenderness and is indicative of right-sided local
peritoneal irritation [27] (sensitivity 22 to 68 percent; specificity 58 to 96 percent [25,28-
30]).

● The psoas sign is associated with a retrocecal appendix. This is manifested by right lower
quadrant pain with passive right hip extension. The inflamed appendix may lie against
the right psoas muscle, causing the patient to shorten the muscle by drawing up the
right knee. Passive extension of the iliopsoas muscle with hip extension causes right
lower quadrant pain (sensitivity 13 to 42 percent; specificity 79 to 97 percent [28,31,32]).

● The obturator sign is associated with a pelvic appendix. This test is based on the
principle that the inflamed appendix may lie against the right obturator internus muscle.
When the clinician flexes the patient's right hip and knee, followed by internal rotation of
the right hip, this elicits right lower quadrant pain (sensitivity 8 percent; specificity 94
percent [31]). The sensitivity is low enough that experienced clinicians no longer perform
this assessment.

Laboratory findings — A mild leukocytosis (white blood cell count >10,000 cells/microL) is
present in most patients with acute appendicitis [33]. Approximately 80 percent of patients
have a leukocytosis and a left shift (increase in total white blood cell (WBC) count, bands
[immature neutrophils], and neutrophils) in the differential [34-36]. The sensitivity and
specificity of an elevated WBC count in acute appendicitis are 80 and 55 percent, respectively.

Acute appendicitis is unlikely when the WBC count is normal, except in the very early course
of the illness [36,37]. In comparison, mean WBC counts are higher in patients with a
gangrenous (necrotic) or perforated appendix [38]:

● Acute − 14,500±7300 cells/microL

● Gangrenous − 17,100±3900 cells/microL
● Perforated − 17,900±2100 cells/microL (see 'Perforated appendix' below)

Mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been noted to be a marker
for appendiceal perforation with a sensitivity of 70 percent and a specificity of 86 percent
[39]. However, the test is not discriminatory and generally not helpful in the evaluation of
patients suspected of acute appendicitis

Imaging exams — Representative images of appendicitis are shown in this section. The

choice of imaging examination for the diagnosis of acute appendicitis is discussed in detail
separately. (See "Acute appendicitis in adults: Diagnostic evaluation", section on 'Imaging'.)

Computed tomography findings — The following findings suggest acute appendicitis on

standard abdominal computed tomography (CT) scanning with contrast including (
image 1 and image 2) [40-42]:

● Enlarged appendiceal diameter >6 mm with an occluded lumen

● Appendiceal wall thickening (>2 mm)
● Periappendiceal fat stranding
● Appendiceal wall enhancement
● Appendicolith (seen in approximately 25 percent of patients)

Ultrasound findings — The most accurate ultrasound finding for acute appendicitis is an

appendiceal diameter of >6 mm ( image 3 and image 4) [8,43,44].

Plain radiograph findings — Plain radiographs are usually not helpful for establishing
the diagnosis of appendicitis ( image 5).

Magnetic resonance imaging — Magnetic resonance imaging (MRI) can assist with the
evaluation of acute abdominal and pelvic pain during pregnancy ( image 6) [45,46]. A
normal appendix is visualized as a tubular structure less than or equal to 6 mm in diameter
and filled with air and/or oral contrast material [47]. An enlarged fluid-filled appendix (>7 mm
in diameter) is considered an abnormal finding, while an appendix with a diameter of 6 to 7
mm is considered an inconclusive finding [47]. (See "Approach to acute abdominal pain in
pregnant and postpartum women" and "Acute appendicitis in pregnancy".)
DIFFERENTIAL DIAGNOSIS

A variety of inflammatory and infectious conditions in the right lower quadrant can mimic the
signs and symptoms of acute appendicitis. (See "Causes of abdominal pain in adults".)

Perforated appendix — During the first 24 hours after the onset of abdominal pain and
associated symptoms, approximately 90 percent of patients develop inflammation and
perhaps necrosis of the appendix, but not perforation. Once significant inflammation and
necrosis occur, the appendix is at risk for perforation, which leads to localized abscess
formation or diffuse peritonitis. The time course to perforation is variable. One study showed
that 20 percent of patients developed perforation less than 24 hours after the onset of
symptoms [17]. Sixty-five percent of patients in whom the appendix perforated had
symptoms for longer than 48 hours.

A perforated appendix must be considered in a patient whose temperature exceeds 103.0°F

(39.4°C), whose WBC count is greater than 15,000 cells/microL, and whose imaging studies
reveal a fluid collection in the right lower quadrant. (See 'Pathogenesis' above and
'Laboratory findings' above and 'Imaging exams' above and "Acute appendicitis in adults:
Diagnostic evaluation".)

Cecal diverticulitis — Cecal diverticulitis usually occurs in young adults and presents with
signs and symptoms that can be virtually identical to those of acute appendicitis. Right-sided
diverticulitis occurs in only 1.5 percent of patients in Western countries but is more common
in Asian populations (accounting for as many as 75 percent of cases of diverticulitis). Patients
with right-sided diverticulitis tend to be younger than those with left-sided disease and often
are misdiagnosed with acute appendicitis. Computed tomographic (CT) scanning of the
abdomen with intravenous and oral contrast is the diagnostic test of choice in patients
suspected of having acute diverticulitis. (See "Clinical manifestations and diagnosis of acute
diverticulitis in adults" and "Acute colonic diverticulitis: Medical management", section on
'Right-sided (cecal) diverticulitis'.)

Meckel's diverticulitis — Meckel's diverticulitis presents in a fashion similar to acute

appendicitis. A Meckel's diverticulum is a congenital remnant of the omphalomesenteric duct
and is located on the small intestine two feet from the ileocecal valve [48,49]. Meckel's
diverticulitis should be included in the differential diagnosis, as the small bowel may migrate
into the right lower quadrant and mimic the symptoms of appendicitis. If an inflamed
appendix is not found on abdominal exploration for acute appendicitis, the surgeon should
search for an inflamed Meckel's diverticulum. (See "Meckel's diverticulum", section on
'Clinical presentations'.)

Acute ileitis — Acute ileitis, due most commonly to an acute self-limited bacterial infection
(Yersinia, Campylobacter, Salmonella, and others), should be considered when acute diarrhea
is a prominent symptom. Other clinical manifestations of acute yersiniosis include abdominal
pain, fever, nausea, and/or vomiting. Yersiniosis cannot be readily distinguished clinically
from other causes of acute diarrhea that present with these symptoms. However, localization
of abdominal pain to the right lower quadrant along with acute diarrhea may be a diagnostic
clue for yersiniosis. (See "Clinical manifestations and diagnosis of Yersinia infections", section
on 'Acute yersiniosis'.)

Acute yersiniosis presenting with right lower abdominal pain, fever, vomiting, leukocytosis,
and understated diarrhea may be confused with acute appendicitis. At surgery, findings
include visible inflammation around the appendix and terminal ileum and inflammation of
the mesenteric lymph nodes; the appendix itself is generally normal. Yersinia can be cultured
from the appendix and involved lymph nodes. (See "Clinical manifestations and diagnosis of
Yersinia infections", section on 'Pseudoappendicitis'.)

Crohn's disease — Crohn's disease can present with symptoms similar to appendicitis,

particularly when localized to the distal ileum. Fatigue, prolonged diarrhea with abdominal
pain, weight loss, and fever, with or without gross bleeding, are the hallmarks of Crohn's
disease. An acute exacerbation of Crohn's disease can mimic acute appendicitis and may be
indistinguishable by clinical evaluation and imaging.

Crohn's disease should be suspected in patients who have persistent pain after surgery,
especially if the appendix is histologically normal. (See "Clinical manifestations, diagnosis,
and prognosis of Crohn disease in adults".)

Gynecologic and obstetrical conditions — The following gynecologic diseases may present

with symptoms and/or clinical findings that are included in the differential of acute
appendicitis:

Tubo-ovarian abscess — A tubo-ovarian abscess (TOA) is an inflammatory mass involving

the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs (eg, bowel, bladder).
These abscesses are found most commonly in reproductive-age women and typically result
from upper genital tract infection. Tubo-ovarian abscess is usually a complication of pelvic
inflammatory disease. The classic presentation includes acute lower abdominal pain, fever,
chills, and vaginal discharge. However, fever is not present in all patients, some patients
report only low-grade nocturnal fevers or chills, and not all women present in an acute
fashion. Clinical history and CT imaging can help differentiate TOA from acute appendicitis (
picture 1). (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian
abscess", section on 'Clinical presentation'.)

Pelvic inflammatory disease — Lower abdominal pain is the cardinal presenting

symptom in women with pelvic inflammatory disease (PID), although the character of the
pain may be quite subtle. The recent onset of pain that worsens during coitus or with jarring
movement may be the only presenting symptom of PID; the onset of pain during or shortly
after menses is particularly suggestive. On physical examination, only approximately one-
half of patients with PID have fever. Abdominal examination reveals diffuse tenderness
greatest in the lower quadrants, which may or may not be symmetrical. Rebound tenderness
and decreased bowel sounds are common. On pelvic examination, the finding of a purulent
endocervical discharge and/or acute cervical motion and adnexal tenderness with bimanual
examination is strongly suggestive of PID. Clinical history and CT imaging can help
differentiate PID from acute appendicitis. (See "Pelvic inflammatory disease: Clinical
manifestations and diagnosis".)

Ruptured ovarian cyst — Rupture of an ovarian cyst is a common occurrence in women

of reproductive age and may be associated with the sudden onset of unilateral lower
abdominal pain. The right lower quadrant is most commonly affected, possibly because the
rectosigmoid colon protects the left ovary from the effects of abdominal trauma. The pain
often begins during strenuous physical activity, such as exercise or sexual intercourse, and
may be accompanied by light vaginal bleeding due to a drop in secretion of ovarian
hormones and subsequent endometrial sloughing. Blood from the rupture site may seep
into the ovary, which can cause pain from stretching of the ovarian cortex, or it may flow into
the abdomen, which has an irritant effect on the peritoneum. Serous or mucinous fluid
released upon cyst rupture is not very irritating; the patient may remain asymptomatic
despite accumulation of a large volume of intraperitoneal fluid. On the other hand, spillage
of sebaceous material upon rupture of a dermoid cyst causes a marked granulomatous
reaction and chemical peritonitis, which is usually quite painful. Intra-abdominal hemorrhage
may be associated with Cullen's sign (ie, periumbilical ecchymoses). Clinical history and CT
imaging can help differentiate a ruptured ovarian cyst from acute appendicitis ( image 7
and image 8). (See "Evaluation and management of ruptured ovarian cyst".)

Mittelschmerz — Mittelschmerz refers to midcycle pain in an ovulatory woman caused by

normal follicular enlargement just prior to ovulation or to normal follicular bleeding at
ovulation. The pain is typically mild and unilateral; it occurs midway between menstrual
periods and lasts for a few hours to a couple of days. Fluid or blood is released from the
ruptured egg follicle and can cause irritation of the lining of the abdominal wall. (See
"Physiology of the normal menstrual cycle".)

Ovarian and fallopian tube torsion — Ovarian torsion refers to the twisting of the ovary
on its ligamentous supports, often resulting in impedance of its blood supply ( picture 2).
Isolated fallopian tube torsion is uncommon ( picture 3). Expedient diagnosis is important
to preserve ovarian function and prevent adverse sequelae. However, the diagnosis can be
challenging because the symptoms are relatively nonspecific.

The most common symptom of ovarian torsion is sudden-onset lower abdominal pain, often
associated with waves of nausea and vomiting. Fever, although an uncommon finding in
ovarian torsion, may be a marker of necrosis, particularly in the setting of an increased white
blood cell count. Clinical history and CT imaging can help differentiate the diagnosis from
acute appendicitis ( picture 4). (See "Ovarian and fallopian tube torsion".)

Endometriosis — Endometriosis is defined as the presence of endometrial glands and

stroma at extrauterine sites. These ectopic endometrial implants are usually located in the
pelvis but can occur nearly anywhere in the body ( picture 5).

Common symptoms of endometriosis include pelvic pain (which is usually chronic and often
more severe during menses or at ovulation), dysmenorrhea, deep dyspareunia, cyclical bowel
or bladder symptoms, abnormal menstrual bleeding, and infertility. There are often no
abnormal findings on physical examination; when findings are present, the most common is
tenderness upon palpation of the posterior fornix. Ultrasound is mostly useful for diagnosing
ovarian endometriomas; it lacks adequate resolution for visualizing adhesions and superficial
peritoneal/ovarian implants, which are more common than endometriomas. (See
"Endometriosis: Pathogenesis, clinical features, and diagnosis".)

Ovarian hyperstimulation syndrome — Ovarian hyperstimulation syndrome (OHSS) is

an iatrogenic complication of ovulation induction therapy and may be accompanied by or
mistaken for cyst rupture. Clinical findings include bloating, nausea, vomiting, diarrhea,
lethargy, shortness of breath, and rapid weight gain.

Severe ovarian hyperstimulation syndrome is characterized by large ovarian cysts, ascites,

and, in some patients, pleural and/or pericardial effusion, electrolyte imbalance
(hyponatremia, hyperkalemia), hypovolemia, and hypovolemic shock. Marked
hemoconcentration, increased blood viscosity, and thromboembolic phenomena, including
disseminated intravascular coagulation, occur in the most severe cases. (See "Pathogenesis,
clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome".)

Ectopic pregnancy — Ectopic pregnancy has clinical symptoms and sonographic features

similar to those of a ruptured ovarian cyst. In women with acute pelvic pain or abnormal
vaginal bleeding, a positive pregnancy test strongly suggests the presence of an ectopic
pregnancy if an intrauterine pregnancy cannot be visualized sonographically. If an
intrauterine pregnancy is visualized, then pelvic pain and intraperitoneal fluid could be due
to a ruptured ovarian cyst (eg, corpus luteum cyst, theca lutein cyst) or heterotopic
pregnancy. (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on
'Heterotopic pregnancy'.)

Acute endometritis — Acute endometritis occurs after an obstetrical delivery or, rarely,

after an invasive uterine procedure. The diagnosis is largely based upon the presence of
fever, gradual onset of uterine tenderness, foul uterine discharge, and leukocytosis in an at-
risk setting. (See "Postpartum endometritis" and "Endometritis unrelated to pregnancy".)
Urologic conditions

Renal colic — Pain is the most common symptom and varies from a mild and barely
noticeable ache to discomfort that is so intense that it requires parenteral analgesics. The
pain typically waxes and wanes in severity and develops in waves or paroxysms that are
related to movement of the stone in the ureter and associated ureteral spasm. Paroxysms of
severe pain usually last 20 to 60 minutes. Pain is thought to occur primarily from urinary
obstruction with distention of the renal capsule. (See "Diagnosis and acute management of
suspected nephrolithiasis in adults" and "Acute management of nephrolithiasis in children".)

Testicular torsion — Testicular torsion is a urologic emergency that is more common in

neonates and postpubertal boys, although it can occur at any age. Testicular torsion results
from inadequate fixation of the testis to the tunica vaginalis. If fixation of the lower pole of
the testis to the tunica vaginalis is insufficiently broad based or absent, the testis may torse
(twist) on the spermatic cord, potentially producing ischemia from reduced arterial inflow
and venous outflow obstruction. (See "Causes of scrotal pain in children and adolescents",
section on 'Testicular torsion' and "Acute scrotal pain in adults", section on 'Testicular
torsion'.)

Epididymitis — Epididymitis occurs more frequently among late adolescents but also

occurs in younger boys who deny sexual activity and is the most common cause of scrotal
pain in adults in the outpatient setting. Several factors may predispose postpubertal boys to
develop subacute epididymitis, including sexual activity, heavy physical exertion, and direct
trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in prepubertal boys is
associated with structural anomalies of the urinary tract. In acute infectious epididymitis,
palpation reveals induration and swelling of the involved epididymis with exquisite
tenderness. More advanced cases often present with testicular swelling and pain (epididymo-
orchitis) with scrotal wall erythema and a reactive hydrocele. (See "Causes of scrotal pain in
children and adolescents", section on 'Epididymitis' and "Acute scrotal pain in adults".)

Torsion of the appendix testis or appendix epididymis — The appendix testis is a small

vestigial structure on the anterosuperior aspect of the testis (an embryologic remnant of the
Müllerian duct system). The appendix epididymis is a vestigial remnant of the Wolffian duct
that is located at the head of the epididymis. The pedunculated shape of these appendages
predisposes them to torsion, which can produce scrotal pain that ranges from mild to severe.
Most cases of torsion of the appendix testis occur between the ages of 7 and 14 years and
rarely occur in adults. (See "Causes of scrotal pain in children and adolescents", section on
'Torsion of the appendix testis or appendix epididymis' and "Acute scrotal pain in adults",
section on 'Other etiologies'.)

TREATMENT
The management of acute appendicitis in children and adults is discussed in detail
separately. (See "Acute appendicitis in children: Management" and "Management of acute
appendicitis in adults".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Appendicitis in
adults".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Appendicitis in adults (The Basics)").

SUMMARY AND RECOMMENDATIONS

Appendicitis is one of the most common causes of the acute abdomen and one of the most
frequent indications for an emergent abdominal surgical procedure worldwide.

● The tip of the appendix can be found in a retrocecal or pelvic location, as well as medial,
lateral, anterior, or posterior to the cecum. Anatomic variability can complicate the
diagnosis, as clinical presentation will reflect the anatomic position of the appendix. (See
'Anatomy' above.)

● Appendiceal obstruction plays a role in the pathogenesis of appendicitis, but it is not

required for the development of appendicitis. (See 'Pathogenesis' above.)
 ● The classic symptoms of appendicitis include right lower quadrant abdominal pain,
anorexia, fever, nausea, and vomiting. The abdominal pain is initially periumbilical in
nature with subsequent migration to the right lower quadrant as the inflammation
progresses (see 'Clinical manifestations' above). Patients with appendicitis can also
present with atypical or nonspecific symptoms, such as indigestion, flatulence, bowel
irregularity, and generalized malaise; not all patients will have migratory abdominal
pain.

● The differential diagnosis of right lower quadrant abdominal pain includes inflammatory
disease processes (eg, Crohn's disease, ruptured cyst), infectious diseases (eg, acute
ileitis, tubo-ovarian abscess), and obstetrical conditions (eg, ectopic pregnancy). (See
'Differential diagnosis' above.)

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Topic 1386 Version 33.0

GRAPHICS

Variations in the position of the appendix

Graphic 64911 Version 2.0

Blood supply to the colon and rectum

The blood supply to the colon originates from the SMA and the IMA. The SMA arises approximately 1
cm below the celiac artery and runs inferiorly toward the cecum, terminating as the ileocolic artery.
The SMA gives rise to the inferior pancreaticoduodenal artery, several jejunal and ileal branches, the
middle colic artery, and the right colic artery.
As a general rule, the middle colic artery arises from the proximal SMA and supplies blood to the
proximal to midtransverse colon. However, it occasionally provides the predominant blood flow to
the splenic flexure.
The right colic artery supplies blood to the mid-distal ascending colon. In anatomical studies, the
right colic artery arises independently from the SMA in 28 percent of individuals, which is depicted in
this figure. More frequently, the right colic artery arises with, or as a branch of, the middle colic,
ileocolic, or left colic arteries. The right colic artery is absent in 13 percent of individuals. [1]
The ileocolic artery supplies blood to the distal ileum, cecum, and proximal ascending colon.
The IMA arises approximately 6 to 7 cm below the SMA. The IMA gives rise to the left colic artery and
sigmoid arteries continuing as the superior rectal (hemorrhoidal) artery. It is largely responsible for
supplying blood distal to the transverse colon.

SMA: superior mesenteric artery; IMA: inferior mesenteric artery.

Reference:
1. Bergman RA, Thompson SA, Afifi AK, Saadeh FA. Compendium of Human Anatomic Variation: Text, Atlas,
and World Literature, Urban & Schwarzenberg, Baltimore, MD 1988.

Graphic 73756 Version 11.0

CT normal appendix

Normal appendix. Images of the pelvis from a CT with intravenous and oral contrast
shows an appendix (arrow) that is air-filled with double-layer wall thickness of <6 mm.

CT: computed tomography.

Graphic 83460 Version 3.0

CT acute appendicitis

Acute appendicitis. Images of the pelvis (A and B) from a CT with intravenous and oral contrast shows a
thickened appendix (arrow) containing an appendicolith and surrounding fluid indicating inflammation.

CT: computed tomography.

Graphic 83459 Version 4.0

Normal appendix by ultrasound imaging

The gray scale ultrasound (A, and magnified in B) and Doppler image (C) of the appendix are projected in the
transverse plane. Images A and B show a normal appendix measuring almost 6 mm in maximum transverse
dimension (arrow). The appendix was compressible and no hyperemia was demonstrated (arrow) on the Doppler
image (C). These findings are consistent with a normal appendix by ultrasound.

Graphic 83557 Version 1.0

Acute appendicitis ultrasound

The patient is a 19-year-old female who presented to the emergency department with right lower quadrant pain.
The gray scale ultrasound of the appendix is projected in the longitudinal (A) and transverse planes (B). A
noncompressible appendix measures almost 20 mm in diameter, consistent with a diagnosis of acute appendicitis.
The echogenic mucosal and submucosal portions of the wall have become discontinuous (arrows) suggesting
disruption as a result of sloughing. Luminal air (arrowheads) results in posterior shadowing.

Graphic 83556 Version 2.0

Appendicolith on abdominal films

This plain film of the abdomen reveals a 1.2 cm calcific density, an appendicolith. The
patient presented with right lower quadrant pain and was diagnosed with acute
appendicitis.

Graphic 83461 Version 1.0

Magnetic resonance image of appendicitis in pregnancy

T2-weighted magnetic resonance image of a woman with appendicitis at 9 weeks of

gestation. The appendix was fluid-filled and measured 7 mm (arrow). The gestational
sac (gs) is seen lower in the pelvis.

Courtesy of Deborah Levine, MD.

Graphic 66666 Version 3.0

Tubo-ovarian abscess

Gross intraoperative photograph of a left tubo-ovarian abscess in a patient with pelvic

inflammatory disease.

Courtesy of Mitchel Hoffman, MD.

Graphic 60914 Version 2.0

Ruptured ovarian cyst

Computed tomography. Arrows indicate free blood within peritoneal cavity surrounding
liver and spleen.

Courtesy of William J Mann, Jr, MD.

Graphic 75150 Version 2.0

Adnexal mass

Computed tomography. Arrow indicates poorly defined adnexal mass, which at exploration was
ruptured corpus luteum cyst and clot.

Courtesy of William J Mann, Jr, MD.

Graphic 72345 Version 2.0

Ovarian and tubal torsion demonstrating marked vascular
engorgement as well as increased size and distension

Anatomy was restored, and both structures were salvaged despite nonviable
appearance.

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6th ed, Emans SJ, Laufer
MR, Goldstein DP (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. Copyright © 2012
Lippincott Williams & Wilkins. www.lww.com.

Graphic 72645 Version 16.0

Tubal torsion demonstrating severe distension of the distal tube

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6th ed, Emans SJ, Laufer MR,
Goldstein DP (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. Copyright © 2012 Lippincott
Williams & Wilkins. www.lww.com.

Graphic 82480 Version 13.0

Enlarged left ovary found torsed upon laparotomy
demonstrating a dark, dusky appearance secondary to venous
lymphatic congestion in the setting of continued arterial
perfusion

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6th ed, Emans SJ, Laufer
MR, Goldstein DP (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. Copyright © 2012
Lippincott Williams & Wilkins. www.lww.com.

Graphic 61891 Version 15.0

Peritoneal endometriosis

The peritoneum in this woman with endometriosis is studded with reddish, irregularly
shaped implants.

Reprinted with permission. Copyright 1990 Syntex Laboratories, Inc. All rights reserved.

Graphic 61500 Version 1.0

Contributor Disclosures
Ronald F Martin, MD Nothing to disclose Martin Weiser, MD Nothing to disclose Wenliang Chen,
MD, PhD Nothing to disclose

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