Appendicitis

Appendicitis is the acute inflammation of the vermiform appendix and the most
common abdominal surgical emergency globally. The condition has a lifetime risk of
8%. Characteristic features include periumbilical abdominal pain that migrates to the
right lower quadrant, fever, anorexia, nausea, and vomiting. The diagnosis can
frequently be established clinically, but imaging is used in uncertain cases. Computed
tomography (CT) scan provides the highest diagnostic accuracy. Perforation occurs in
13%–20% of cases and can present as localized (abscess/phlegmon) or free perforation
with generalized peritonitis. The standard treatment is appendectomy, but localized
perforations are frequently managed non-operatively with antibiotics.

Last updated: May 17, 2024

CONTENTS

Overview
Pathophysiology and Clinical Presentation
Diagnosis
Management
Differential Diagnosis
References

Overview
Definition
Appendicitis is the inflammation of the vermiform appendix.

Epidemiology
Lifetime risk: approximately 8%
6% of the population gets appendicitis.
Peak incidence: 10–19 years of age
Males > females
The most common acute surgical problem in the pediatric population

Etiology
 Obstruction of appendiceal orifice (implicated, but not often proven)
Cause of obstruction varies with age.
Children and young adults: lymphoid follicular hyperplasia secondary to
infection
Older adults:
Fecaliths
Calculi
Fibrosis
Tumors (benign or malignant)
Rare: parasites (usually in endemic areas)

Pathophysiology and Clinical Presentation

Pathophysiology
Obstruction of appendiceal orifice is the 1st step (presumed).
Mucus accumulation and luminal distention:
Bacterial overgrowth (mixed; aerobes and anaerobes):
Escherichia coli
Peptostreptococcus
Pseudomonas
Bacteroides fragilis
→
Increase in transmural pressure thrombosis and occlusion of small vessels
Ischemia and necrosis (gangrene)
Eventual perforation

Time course
Early:
Usually first 24 hours
Distention of the appendix stimulates T8–10 afferent nerves.
Vague periumbilical pain develops.
Late:
Usually after 24 hours
Invasion of appendiceal wall by bacteria + ischemia
→
Propagation of neutrophilic exudate fibropurulent reaction involving serosal
surface
→
Peritoneal irritation localized pain and tenderness
Perforation:
Affects 13%–20% of cases
In 65% of cases, symptoms last longer than 48 hours.
In 20% of cases, symptoms last less than 24 hours.
More likely with calculus as the obstructing culprit:
Walled-off perforation: abscess formation
Free perforation: generalized peritonitis
 Acute appendicitis
Image (https://de.wikipedia.org/wiki/Datei:Acute_Appendicitis.jpg#/media/File:Acute_Appendicitis.jpg): “Acute
Appendicitis” by Ed Uthman. License: CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)

Clinical presentation
Classic:
Periumbilical pain that later migrates to the right lower quadrant (RLQ)
Anorexia
Nausea/vomiting
Fever
Atypical:
Indigestion
Diarrhea
Generalized malaise
Anatomic factors:
Anterior appendix (most common): pronounced localized RLQ pain
Retrocecal: dull abdominal pain
Pelvic: dysuria, diarrhea, tenesmus (from bladder and rectal irritation)

Diagnosis
History
 Duration of symptoms: typically 24–48 hours
Abdominal pain:
Sudden onset
Constant, becoming progressively worse
Exacerbated by movement
Anorexia, nausea, diarrhea/constipation may or may not be present.
Symptoms may be vague/atypical in the elderly.
Adults (eliminate other causes):
History of inflammatory bowel disease
History of colorectal cancer/previous colonoscopy
Reproductive/sexually transmitted diseases in women (rule out
pelvic inflammatory disease (PID), ectopic pregnancy)
Children:
Most common in 5–12-year-olds
Very rare in neonates
Rule out viral illness:
History of concurrent or preceding respiratory symptoms
History of sick contacts with similar symptoms

Physical exam
General:
Low-grade fever (up to 38.3°C (101°F))
High fever may indicate late appendicitis/necrosis/perforation.
Desire to lie still, with difficulty ambulating (common in children)
Signs of dehydration if prolonged vomiting/anorexia:
Tachycardia
Orthostatic hypotension
Decreased urinary output
Abdominal exam:
RLQ tenderness
Localized rebound tenderness (peritoneal irritation)
Signs:
McBurney’s point tenderness: maximal tenderness at 3.8–5.0 cm (1.5–2 in)
from anterior iliac spine on a straight line to the umbilicus
Rovsing’s sign: pain in the RLQ with palpation of the left lower quadrant
Psoas sign: RLQ pain with passive hip extension (characteristic of retrocecal
appendix)
Obturator sign: RLQ pain with internal hip rotation with a flexed knee (pelvic
appendix)
Generalized peritonitis suggests perforation.
Rectal exam:
Not helpful for establishing appendicitis diagnosis
May be helpful if an alternative diagnosis is suspected
Pelvic exam:
May be needed in a female if PID is suspected
Appendicitis (especially pelvic) may also produce tenderness on pelvic exam.

Laboratory studies
 Complete blood count (CBC): leukocytosis with a left shift
↑
Inflammatory markers: erythrocyte sedimentation rate (ESR), C-reactive protein
(CRP)
Chemistry may show dehydration pattern: low K (potassium), low Na (sodium),
metabolic alkalosis
Urinalysis: may show mild pyuria due to proximity of the right ureter
Pregnancy test: Perform on all females of reproductive age.

Alvarado score
A numerical scale for predicting the likelihood of appendicitis based on clinical and
laboratory findings
Facilitates decision making
Mnemonic: MANTRELS

Table: Alvarado score

Symptoms Migratory pain in the right iliac fossa 1

Anorexia 1

Nausea and vomiting 1

Signs Tenderness in the right iliac fossa 2

Rebound tenderness 1

Elevated temperature 1

Laboratory findings Leukocytosis 2

Shift to left 1

Total 10

Interpretation:
0–4: Appendicitis is less likely.
5–6: Appendicitis is possible; imaging evaluation needed
7–8: Appendicitis is probable → surgical consultation
9–10: Appendicitis is highly likely → surgical consultation

Imaging
Imaging is not required for diagnosis if the Alvarado score is very low (< 3) or high
(> 7).
Computed tomography (CT) scan:
Highest diagnostic accuracy
Should be performed with intravenous contrast unless contraindicated (
renal failure, allergy)
Findings of appendicitis:
Appendiceal diameter > 6 mm (0.24 in) with occluded lumen
Appendiceal wall thickening > 2 mm (0.08 in)
Appendiceal wall enhancement
Periappendiceal fat stranding
Appendicolith (in about 25% of cases)
Ultrasound (US):
Lower diagnostic accuracy than CT
Operator dependent
Preferred test in children and pregnant women as it avoids radiation
Signs of appendicitis:
Non-compressible appendix
Appendix diameter > 6 cm (2.4 in)
Focal pain with pressure from US probe
Increased echogenicity of surrounding fat
Fluid in RLQ
“Target sign”:
Hypoechoic (fluid-filled lumen)
Hyperechoic (mucosa/submucosa)
Hypoechoic (muscularis layer)
Magnetic resonance imaging (MRI):
Inferior to CT scan
An alternative when CT is contraindicated
Management
Initial management
Intravenous fluid resuscitation (hydrate and replace electrolytes)
NPO (nothing by mouth)
Analgesia
Nausea control

Uncomplicated appendicitis
Definition: acute appendicitis without clinical or radiographic signs of perforation

Non-operative management (NOM):

Growing evidence that non-perforated appendicitis can be managed with
antibiotics alone
90% will initially respond to antibiotics.
Adult antibiotic regimens:
Single-agent regimen:
Cefoxitin
Ertapenem
Moxifloxacin
Piperacillin–tazobactam (for high-severity infection)
Or metronidazole PLUS 1 of the following:
Cefazolin
Cefuroxime
Ceftriaxone
Cefotaxime
Ciprofloxacin
Levofloxacin
Recurrence rate of 20%–30% in the 1st year, up to 39% in 5 years
Appendectomy:
 Preoperative antibiotics are indicated and should be given within 60 min of the
start of the procedure.
Approach:
Laparoscopic:
Lower rate of wound infections
Less pain on postoperative day 1
Shorter hospital stay
Open:
Lower rate of intra-abdominal infections
Shorter operative time

Laparoscopic appendectomy
Image (https://commons.wikimedia.org/wiki/File:Appendix-Entfernung.jpg): “Appendix-Entfernung” by Life-of-
hannes.de. License: Public Domain (https://creativecommons.org/licenses/publicdomain/)

Complicated appendicitis
Definition: appendiceal rupture with or without phlegmon or abscess formation

Initial non-operative management:

Preferred approach as immediate surgery has high risk of complications:
More extensive surgery (ileocecectomy) may be required
Risk of postoperative abscess, fistula
Indicated for contained perforation:
Cecal phlegmon or abscess > 3 cm (1.18 in) on CT scan
Stable patient without diffuse peritonitis
Components of management:
Radiologically guided drainage of an abscess
IV antibiotics: broad-spectrum enteric coverage
IV fluids and bowel rest
Successful (patient is discharged home with 7–10-day course of oral antibiotics):
↓Pain
↓Fever
↓Leukocytosis
Unsuccessful: rescue appendectomy during the same admission
Interval appendectomy:
 Generally performed 6–8 weeks after successful nonoperative management
If not performed, proponents of interval appendectomy cite the following risks:
Up to 30% risk of recurrence during the 1st year
10%–29% risk of neoplasm in perforated appendix
Colonoscopy should also be considered for patients > 40.
Immediate appendectomy:
Always indicated for unstable patient with generalized peritonitis/free perforation
May require more extensive resection (ileocecectomy)
Requires washout and drainage of peritoneal cavity
Can also be performed for contained perforation with small phlegmon or abscess
(< 3 cm (1.18 in))

Prognosis
Mortality is low: 0.09%–4%
Complications of appendectomy:
Wound infection: 3.3%–10.3%
Pelvic/abdominal abscess: 9.4%
Stump appendicitis: if appendix was not completely removed, leaving more
than 0.5 cm (0.2 in) stump

Differential Diagnosis
Gastrointestinal
Gastroenteritis: acute self-limited viral illness presenting with abdominal pain,
vomiting, and diarrhea. Imaging and labs may be largely normal. Condition is
treated supportively with bowel rest and intravenous hydration.
Mesenteric lymphadenitis: inflammation of mesenteric lymph nodes associated
with acute or chronic abdominal pain. Mesenteric lymphadenitis commonly
localizes to RLQ because of a large number of lymph nodes in that area.
Computed tomography scan/US will show lymphadenopathy.
Epiploic appendagitis: ischemia/infarction of the colonic fatty
appendages. Epiploic appendagitis presents with acute or subacute lower
abdominal pain. Computed tomography scan can confirm the diagnosis. Usually,
this self-limited illness is treated with oral anti-inflammatory medications.
Meckel's diverticulitis: inflammation of Meckel’s diverticulum. The condition may
be impossible to clinically distinguish from acute appendicitis as the pain is similar;
however, it may be more central or left-sided. Occasionally, there is a history of
intermittent lower gastrointestinal bleeding. Computed tomography scan may or
may not be diagnostic. Sometimes, diagnosis is made during surgery.
Right-sided diverticulitis: inflammation of colonic diverticula. Usually left-sided,
but right-sided presentation can also occur, especially in young patients and in
Asian populations. Patients present with RLQ pain, fever, and change in bowel
habits. Diagnosis is made by CT scan.
Terminal ileitis: inflammation of the terminal ileum that can have an antecedent
history of abdominal cramping, weight loss, and diarrhea. The ileitis may be non-
specific, due to Crohn’s disease or Yersinia infection. Diagnosis is made acutely by
CT scan. Colonoscopy (Crohn’s) and serum antibody titers (Yersinia) can help
establish the etiology.

Genitourinary
 Right ureteric colic: obstructive stone in the right ureter that presents as
intermittent (colicky) pain of the right flank/groin. Urinalysis will show the presence
of red blood cells. Diagnosis is established by non-contrast CT scan.
Urinary tract infection: bacterial infection of the urinary tract in the form of cystitis
(bladder infection) or right-sided acute pyelonephritis (kidney
involvement). Presents with suprapubic pain and dysuria (cystitis) or right
costovertebral angle tenderness and fever (pyelonephritis). Diagnosis is made by
urinalysis and CT scan.

Gynecologic
Right-sided ectopic pregnancy: pregnancy in the right fallopian tube. Presents
with right-sided abdominal pain. When ruptured, can present with fever, sepsis,
and peritonitis. Usually, there is a history of a missed menstrual period. Findings
include a positive pregnancy test and pain with cervical manipulation (pelvic
exam). Diagnosis is confirmed with pelvic US.
PID: sexually transmitted infection involving internal reproductive organs, usually
in a young adult woman. Pelvic inflammatory disease presents with lower
abdominal pain (mostly bilateral), fever, and vaginal discharge. Diagnosis is
established with pelvic exam and US.
Ovarian and fallopian tube torsion: causes acute ischemia of the ovary/
fallopian tube. Torsion presents with abdominal pain (RLQ if on the right), fever,
and nausea/vomiting. When suspected, a Doppler pelvic US (looking at the
blood flow) should be performed. The condition can affect females of both adult
and pediatric age.
Ruptured ovarian cyst (right): fluid or blood released from the cyst causes
peritoneal irritation and acute onset of RLQ abdominal pain. Diagnosis is made by
pelvic US.

References
1. Martin, R.F. (2020). Acute appendicitis in adults: Clinical manifestations and differential diagnosis.
Retrieved 11 December 2020, from https://www.uptodate.com/contents/acute-appendicitis-in-adults-
clinical-manifestations-and-differential-diagnosis?
_ ~ _
search=appendicitis&source=search result&selectedTitle=2 150&usage type=default&display rank _
=2 (https://www.uptodate.com/contents/acute-appendicitis-in-adults-clinical-manifestations-and-
differential-diagnosis?
_ ~ _
search=appendicitis&source=search result&selectedTitle=2 150&usage type=default&display rank _
=2)
2. Pisano M., Capponi M.G., Ansaloni L. (2014). Acute Appendicitis: An Open Issue. Current Trends in
Diagnostic and Therapeutic Options. Retrieved 11 December 2020, from
https://www.sciencedirect.com/topics/medicine-and-dentistry/alvarado-score
(https://www.sciencedirect.com/topics/medicine-and-dentistry/alvarado-score)
3. Smink D., Soybel D.I. (2020). Management of acute appendicitis in adults. Retrieved 11 December
2020, from https://www.uptodate.com/contents/management-of-acute-appendicitis-in-adults?
_ ~ _
search=appendicitis&source=search result&selectedTitle=1 150&usage type=default&display rank= _
1 (https://www.uptodate.com/contents/management-of-acute-appendicitis-in-adults?
_ ~ _
search=appendicitis&source=search result&selectedTitle=1 150&usage type=default&display rank= _
1)
4. Wesson D.E., Brandt M.L. (2019). Acute appendicitis in children: Clinical manifestations and
diagnosis. Retrieved 11 December 2020, from https://www.uptodate.com/contents/acute-
appendicitis-in-children-clinical-manifestations-and-diagnosis?
_ ~ _
search=appendicitis&source=search result&selectedTitle=3 150&usage type=default&display rank _
=3 (https://www.uptodate.com/contents/acute-appendicitis-in-children-clinical-manifestations-and-
diagnosis?
_ ~ _
search=appendicitis&source=search result&selectedTitle=3 150&usage type=default&display rank _
=3)