Appendicitis

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Appendicitis

Classification and external resources

An acutely inflamed and

enlarged appendix, sliced lengthwise.
ICD -10
K 35 - K 37
ICD -9
540 -543
DiseasesDB 885
MedlinePlus 000256
eMedicine
med/3430 emerg/41 ped/127 ped/2925
MeSH
C06.405.205.099
Appendicitis (also called epityphlitis[1]) is inflammation of the
appendix and is a surgical emergency . Many cases of appendicitis require
removal of the inflamed appendix by laparotomy or laparoscopy due to the
high mortality associated with rupture of the appendix, which may lead
to severe complications such as peritonitis and sepsis .[2] Appendicitis
was first described by Reginald Fitz in 1886,[3] and is today recognized
as one of the most common and significant causes of severe acute
abdominal pain worldwide.

Contents
1 Signs and symptoms
2 Causes
3 Diagnosis
o 3.1 Clinical
o 3.2 Blood and urine test
o 3.3 Imaging
o 3.4 Scoring systems
o 3.5 Pathology
o 3.6 Differential diagnosis
4 Management
o 4.1 Pain
o 4.2 Surgery
5 Prognosis
6 Epidemiology
7 Society and culture
o 7.1 Cost

o 7.2 Length of stay

8 References
9 External links

Signs and symptoms

Location of the
appendix in the
digestive system
Pain first, vomiting
next and fever last
has been described as
the classic
presentation of acute
appendicitis. Since
the innervation of the
appendix enters the
spinal cord at the same
level as the umbilicus (belly button), the pain begins stomach-high.
Later, as the appendix becomes more swollen and irritates the adjoining
abdominal wall, it tends to localize over several hours into the right
lower quadrant , except in children under three years. This pain can be
elicited through various signs and can be severe. Signs include
localized findings in the right iliac fossa . The abdominal wall becomes
very sensitive to gentle pressure (palpation ). Also, there is severe
pain on sudden release of deep pressure in the lower abdomen (rebound
tenderness ). In case of a retrocecal appendix (appendix localized behind
the cecum ), however, even deep pressure in the right lower quadrant
may fail to elicit tenderness (silent appendix) because the cecum ,
distended with gas, protects the inflamed appendix from pressure.
Similarly, if the appendix lies entirely within the pelvis, there is
usually complete absence of abdominal rigidity. In such cases, a digital
rectal examination elicits tenderness in the rectovesical pouch. Coughing
causes point tenderness in this area (McBurney's point ).

Causes
On the basis of experimental evidence, acute appendicitis seems to be
the end result of a primary obstruction of the appendix lumen (the
inside space of a tubular structure).[4][5] Once this obstruction occurs,
the appendix subsequently becomes filled with mucus and swells,
increasing pressures within the lumen and the walls of the appendix,
resulting in thrombosis and occlusion of the small vessels, and stasis
of lymphatic flow . Rarely, spontaneous recovery can occur at this point.
As the former progresses, the appendix becomes ischemic and then necrotic
. As bacteria begin to leak out through the dying walls, pus forms

within and around the appendix (suppuration). The end result of this
cascade is appendiceal rupture (a 'burst appendix') causing peritonitis ,
which may lead to septicemia and eventually death .
The causative agents include bezoars, foreign bodies, trauma , intestinal
worms , lymphadenitis , and, most commonly, calcified fecal deposits
known as appendicoliths or fecaliths.[6] The occurrence of obstructing
fecaliths has attracted attention since their presence in patients with
appendicitis is significantly higher in developed than in developing
countries,[7] and an appendiceal fecalith is commonly associated with
complicated appendicitis.[8] Also, fecal stasis and arrest may play a
role, as demonstrated by a significantly lower number of bowel movements
per week in patients with acute appendicitis compared with healthy
controls.[9][10] The occurrence of a fecalith in the appendix was thought
to be attributed to a right-sided fecal retention reservoir in the colon
and a prolonged transit time, although a prolonged transit time was not
observed in subsequent studies.[11] From epidemiological data, it has
been stated that diverticular disease and adenomatous polyps were
unknown and colon cancer exceedingly rare in communities exempt from
appendicitis.[12][13] Also, acute appendicitis has been shown to occur
antecedent to cancer in the colon and rectum.[14] Several studies offer
evidence that a low fiber intake is involved in the pathogenesis of
appendicitis.[15][16][17] This is in accordance with the occurrence of a
right-sided fecal reservoir and the fact that dietary fiber reduces
transit time.[18]

Diagnosis
Diagnosis is based on patient history (symptoms) and physical
examination backed by an elevation of neutrophilic white blood cells.
(Neutrophils are the primary white blood cells that respond to a
bacterial infection.) 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 (or the left lower quadrant in patients with situs inversus
totalis ), where tenderness develops. The combination of pain, anorexia,
leukocytosis, and fever is classic. 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.[19]
Clinical
Aure-Rozanova sign

Increased pain on palpation with finger in right Petit triangle (can be a

positive Shchetkin-Bloomberg's)
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.
Dunphy's sign

Increased pain in the right lower quadrant with coughing.[20]

Kocher's (Kosher's) sign

From the history given, 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.
Massouh sign

Main article: Massouh sign

This sign, developed in and popular in southwest England, describes a
firm swish of the examiners index and middle finger across the
patients abdomen from xiphoid process of the sternum to first the left and
then the right iliac fossa. A positive Massouh sign is a grimace of the
patient upon a right sided (and not left) sweep, because initial stage
appendicitis usually causes localised irritation of the well-innervated
peritoneum.
Obturator sign

Main article: Obturator sign

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

Main article: Psoas sign

Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is
produced with either the passive extension of the patient's right hip
(patient lying on left side, with knee in flexion) or by the patient's
active flexion of the right hip while supine. The pain elicited is due
to inflammation of the peritoneum overlying the iliopsoas muscles and
inflammation of the psoas muscles themselves. Straightening out the leg
causes pain because it stretches these muscles, while flexing the hip
activates the iliopsoas and therefore also causes pain.
Rovsing's sign

Main article: Rovsing's sign

Continuous deep palpation starting from the left iliac fossa upwards
(counterclockwise 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.[21]
Sitkovskiy (Rosenstein)'s sign

Increased pain in the right iliac region as patient lies on his/her left
side.
Blood and urine test
While there is no laboratory test specific for appendicitis, a complete
blood count (CBC) is done to check for signs of infection. Although 7090 percent of people with appendicitis may have an elevated white blood
cell count, there are also many other abdominal and pelvic conditions
that can cause the white cell count to elevate.[22]
A urinalysis generally does not show infection but it is important for
determining the pregnancy status, especially the possibility of an
ectopic pregnancy in childbearing females, and for ruling out urinary
tract infection. However, there is a possibility of a microscopic pyuria
, the condition of urine containing pus, or hematuria , urine
containing red blood cells, caused by the proximity of the appendix to
the ureter and bladder in acute appendicitis. The presence of more than
20 WBC per high-power field in the urine is more suggestive of a urinary
tract disorder.[22]
Imaging
Appendicitis in children is common enough to merit special attention.
Because of the health risks of exposing children to radiation, many
medical societies recommend that in confirming a diagnosis with children
the ultrasound is a preferred first choice with x-rays being a
legitimate follow-up when warranted.[23][24][25] 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%.
Ultrasonography had an overall sensitivity of 86%, a specificity of 81%.[26]
XRay

In general, plain abdominal radiography (PAR) is not useful in making

the diagnosis of appendicitis. Plain abdominal films may be useful for
the detection of ureteral calculi , small bowel obstruction , or perforated
ulcer , but these conditions are rarely confused with appendicitis.[27]
An opaque fecalith can be identified in the right lower quadrant in less
than 5% of patients.[22] A barium enema has proven to be a poor
diagnostic tool because, while failure of the appendix to fill during a
barium enema has been associated with appendicitis, this finding lacks
both sensitivity and specificity because up to 20% of normal appendices
also do not fill.[27]
A study done in 1999 concluded that "plain abdominal radiographs in

patients with suspected appendicitis are neither sensitive nor specific,

are frequently misleading, are costly per specific and correct
diagnosis, and should not be routinely obtained on patients with
suspected appendicitis."[28] Another study came to the same conclusion,
but said they may be useful in a small number of people with suspected
small bowel obstruction or urinary symptoms.[29]
Ultrasound

Ultrasound image of an
acute appendicitis
Ultrasonography and
Doppler sonography
provide useful means
to detect
appendicitis,
especially in
children, and shows
free fluid collection in the right iliac fossa, along with a visible
appendix without blood flow in color Doppler. 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, sonographic imaging in experienced hands 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.
CT/CAT/Computed tomography Scan

A CT 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.
Where it is readily available, CT scan has become frequently used,
especially in adults whose diagnosis is not obvious on history and
physical examination. 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.
Scoring systems
Alvarado score

Alvarado score
Migratory right iliac fossa pain
1 point
Anorexia
1 point
Nausea and vomiting
1 point
Right iliac fossa tenderness
2 points
Rebound tenderness
1 point
Fever
1 point
Leukocytosis
2 points
Shift to left (segmented neutrophils ) 1 point
Total score
10 points
A number of clinical and laboratory-based scoring systems have been
devised to assist diagnosis. The most widely used is Alvarado score . A
score below 5 is strongly against a diagnosis of appendicitis,[30] while
a score of 7 or more is strongly predictive of acute appendicitis. In
patients with an equivocal score of 5 or 6, a CT scan is used to further
reduce the rate of negative appendicectomy.
Tzanakis scoring

Tzanakis scoring: Tzanakis and colleagues, in 2005 published a

simplified system, now called the Tzanakis scoring system for
appendicitis, to aid the diagnosis of appendicitis. It incorporates the
presence of four variables made up of specific signs and symptoms

(presence of right lower abdominal tenderness = 4 points and rebound

tenderness = 3), laboratory findings (presence of white blood cells
greater than 12,000 in the blood = 2), as well as ultrasound findings
(presence of positive ultrasound scan findings of appendicitis = 6), to
which scores are allocated, in the computing of a scoring to predict the
presence of appendicitis.
The maximum score is a total score of 15; where a patient scores 8 or
more points, there is greater than 96% chance that appendicitis exists.
Pathology

Micrograph of
appendicitis and
periappendicitis.
H&E stain .

Micrograph of
appendicitis
showing
neutrophils in the
muscularis propria. H&E
stain .
The definitive diagnosis is
based on pathology . The
histologic finding of
appendicitis is neutrophilic
infiltrate of the muscularis propria .
Periappendicits, inflammation of tissues around the appendix, is often
found in conjunction with other abdominal pathology.[31]
Differential diagnosis
In children: Gastroenteritis , mesenteric adenitis , Meckel's diverticulitis ,
intussusception , Henoch-Schnlein purpura , lobar pneumonia , urinary tract
infection (abdominal pain in the absence of other symptoms can occur in
children with UTI), new-onset Crohn's disease or ulcerative colitis ,
pancreatitis , and abdominal trauma from child abuse ; distal intestinal
obstruction syndrome in children with cystic fibrosis; typhlitis in
children with leukemia.
In women: A pregnancy test is important in all women of child bearing
age, as ectopic pregnancies and appendicitis present similar symptoms.
Other causes ovarian torsion , menarche , dysmenorrhea, pelvic inflammatory
disease , endometriosis , Mittelschmerz (the passing of an egg in the
ovaries approximately two weeks before an expected menstruation cycle).
In men: testicular torsion ;
In adults: new-onset Crohn's disease , ulcerative colitis , regional

enteritis, renal colic , perforated peptic ulcer , pancreatitis , rectus sheath

hematoma ;
In elderly: diverticulitis , intestinal obstruction, colonic carcinoma ,
mesenteric ischemia , leaking aortic aneurysm .
The term "pseudoappendicitis" is used to describe a condition mimicking
appendicitis.[32] It can be associated with Yersinia enterocolitica .[33]

Management
Acute appendicitis is typically managed by surgery however in
uncomplicated cases antibiotics are both effective and safe.[34] While
antibiotics are effective for treating uncomplicated appendicitis 20% of
people had a recurrence within a year and required eventual
appendectomy.[34]
Pain
Pain medications (such as morphine ) do not appear to affect the
accuracy of the clinical diagnosis of appendicitis and therefore should
be given early in the persons care.[35] Historically there were concerns
among some general surgeons that analgesics would affect the clinical
exam in children and thus some recommended that they not be given until
the surgeon in question was able to examine the person for themselves.
[35]
Surgery
See also: Appendectomy

Inflamed appendix
removal by open
surgery

Laparoscopic
appendectomy.
The surgical
procedure for the
removal of the
appendix is
called an appendicectomy . Laparoscopic removal (via three small
incisions with a camera to visualize the area of interest in the
abdomen) seem to have some advantages over an open procedures especially
in young females and the obese.[36]
Laparotomy

Laparotomy is the traditional type of surgery used for treating

appendicitis. This procedure consists in the removal of the infected

appendix through a single larger incision in the lower right area of the
abdomen.[37] The incision in a laparotomy is usually 2 to 3 inches (51
to 76 mm) long. This type of surgery is used also for visualizing and
examining structures inside the abdominal cavity and it is called
exploratory laparotomy.
During a traditional appendectomy procedure, the patient is placed under
general anesthesia to keep the muscles completely relaxed and to keep
the patient unconscious. The incision is two to three inches (76 mm)
long and it is made in the right lower abdomen, several inches above the
hip bone .[38] Once the incision opens the abdomen cavity and the
appendix is identified, the surgeon removes the infected tissue and
cuts the appendix from the surrounding tissue. After careful and close
inspection of the infected area, and ensuring there are no signs that
surrounding tissues are damaged or infected, the surgeon will start
closing the incision. This means sewing the muscles and using surgical
staples or stitches to close the skin up. In order to prevent infections
the incision is covered with a sterile bandage .
The entire procedure does not last longer than an hour if complications
do not occur.
Laparoscopic surgery

The newer method to treat appendicitis is the laparoscopic surgery . This

surgical procedure consists of making three to four incisions in the
abdomen, each 0.25 to 0.5 inches (6.4 to 12.7 mm) long. This type of
appendectomy is made by inserting a special surgical tool called
laparoscope into one of the incisions. The laparoscope is connected to a
monitor outside the patient's body and it is designed to help the
surgeon to inspect the infected area in the abdomen. The other two
incisions are made for the specific removal of the appendix by using
surgical instruments . Laparoscopic surgery also requires general anesthesia
and it can last up to two hours. The latest methods are NOTES
appendectomy pioneered in Coimbatore, India where there is no incision
on the external skin[39] and SILS (Single incision laparoscopic Surgery)
where a single 2.5 cm incision is made to perform the surgery. .
Pre surgery

The treatment begins by keeping the patient away from eating or drinking in
preparation for surgery. An intravenous drip is used to hydrate the
patient. Antibiotics given intravenously such as cefuroxime and
metronidazole may be administered early to help kill bacteria and thus
reduce the spread of infection in the abdomen and postoperative
complications in the abdomen or wound. Equivocal cases may become more
difficult to assess with antibiotic treatment and benefit from serial
examinations. If the stomach is empty (no food in the past six hours)
general anaesthesia is usually used. Otherwise, spinal anaesthesia may be
used.
Once the decision to perform an appendectomy has been made, the

preparation procedure takes approximately one to two hours. Meanwhile,

the surgeon will explain the surgery procedure and will present the
risks that must be considered when performing an appendectomy. With all
surgeries there are certain risks that must be evaluated before
performing the procedures. However, the risks are different depending on
the state of the appendix. If the appendix has not ruptured, the
complication rate is only about 3% but if the appendix has ruptured, the
complication rate rises to almost 59%.[40] The most usual complications
that can occur are pneumonia, hernia of the incision, thrombophlebitis ,
bleeding or adhesions . Recent evidence indicates that a delay in
obtaining surgery after admission results in no measurable difference in
patient outcomes.[41]
The surgeon will also explain how long the recovery process should take.
Abdomen hair is usually removed in order to avoid complications that may
appear regarding the incision. In most of the cases patients experience
nausea or vomiting which requires specific medication before surgery.
Antibiotics along with pain medication may also be administrated prior
to appendectomies.
After surgery

The stitches the

day after having
the appendix
removed by
laparoscopic
surgery
Hospital lengths
of stay typically
range from a few
hours to a few
days, but can be
a few weeks if complications occur. The recovery process may vary
depending on the severity of the condition, if the appendix had ruptured
or not before surgery. Appendix surgery recovery is generally a lot
faster if the appendix did not rupture.[42] It is important that
patients respect their doctor's advice and limit their physical activity
so the tissues can heal faster. Recovery after an appendectomy may not
require diet changes or a lifestyle change.
After surgery occurs, the patient will be transferred to a postanesthesia
care unit so his or her vital signs can be closely monitored to detect
anesthesia- and/or surgery-related complications. Pain medication may
also be administered if necessary. After patients are completely awake,
they are moved into a hospital room to recover. Most individuals will be
offered clear liquids the day after the surgery, then progress to a
regular diet when the intestines start to function properly. Patients
are recommended to sit up on the edge of the bed and walk short
distances for several times a day. Moving is mandatory and pain

medication may be given if necessary. Full recovery from appendectomies

takes about four to six weeks, but can be prolonged to up to eight weeks
if the appendix had ruptured.

Prognosis
Most appendicitis patients recover easily with surgical treatment, but
complications can occur if treatment is delayed or if peritonitis occurs.
Recovery time depends on age, condition, complications, and other
circumstances, including the amount of alcohol consumption, but usually
is between 10 and 28 days. For young children (around 10 years old), the
recovery takes three weeks.
The real possibility of life-threatening peritonitis is the reason why
acute appendicitis warrants speedy evaluation and treatment. The patient
may have to undergo a medical evacuation . Appendectomies have
occasionally been performed in emergency conditions (i.e., outside of a
proper hospital), when a timely medical evaluation was impossible.
Typical acute appendicitis responds quickly to appendectomy and
occasionally will resolve spontaneously. If appendicitis resolves
spontaneously, it remains controversial whether an elective interval
appendectomy should be performed to prevent a recurrent episode of
appendicitis. Atypical appendicitis (associated with suppurative
appendicitis) is more difficult to diagnose and is more apt to be
complicated even when operated early. In either condition, prompt
diagnosis and appendectomy yield the best results with full recovery in
two to four weeks usually. Mortality and severe complications are
unusual but do occur, especially if peritonitis persists and is
untreated. Another entity known as appendicular lump is talked about
quite often. It happens when appendix is not removed early during
infection and omentum and intestine get adherent to it forming a
palpable lump. During this period, operation is risky unless there is
pus formation evident by fever and toxicity or by USG. Medical
management treats the condition.
An unusual complication of an appendectomy is "stump appendicitis":
inflammation occurs in the remnant appendiceal stump left after a prior
incomplete appendectomy.[43]

Epidemiology

Disability-adjusted life
year for appendicitis
per 100,000
inhabitants in 2004.
[44]
no data
less than 2.5
2.5-5
5-7.5
7.5-10

10-12.5
12.5-15
15-17.5
17.5-20
20-22.5
22.5-25
25-27.5
more than 27.5
Appendicitis is most common between the ages of 5 and 40;[45] the median
age is 28. It tends to affect males, those in lower income groups, and,
for unknown reasons, people living in rural areas.[46]
In the United States, there were nearly 293,000 hospitalizations
involving appendicitis in 2010.[47] Appendicitis is one of the most
frequent diagnoses for emergency department visits resulting in
hospitalization among children aged 517 years in the United States.
[48]
Globally, as of 2010 (during one year or during decades[clarification
needed]), it resulted in about 35,000 deaths.[49]

Society and culture

Cost
While appendectomy is a standard surgical procedure, its cost has been
found to vary considerably, particularly in the United States. A 2012
study from the University of California, San Francisco published in the
Archives of Internal Medicine analyzed 2009 data from nearly 20,000 adult
patients treated for appendicitis in California hospitals. Researchers
examined only uncomplicated episodes of acute appendicitis that
involved visits for patients 18 to 59 years old with hospitalization
that lasted fewer than four days with routine discharges to home. The
lowest charge for removal of an appendix was $1,529 and the highest
$182,955, almost 120 times greater. The median charge was $33,611.[50]
[51]
Another study found that the average cost for an appendicitis stay in
the United States in 2010 was $7,800. Severity of the appendicitis
increased the cost: for stays where the patient had a perforated
(ruptured) appendix, the average cost was $12,800.[47]
Length of stay
Length of hospital stays for appendicitis varies on the severity of the
condition. A study from the United States found that in 2010, the
average appendicitis hospital stay was 1.8 days. For stays where the
patient's appendix had ruptured, the average length of stay was 5.2
days.[47]

References

MerriamWebster definition