Thissiteisintendedforhealthcareprofessionals

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

WORKUP

ApproachConsiderations
Patientswithappendicitismaynothavethereportedclassicclinicalpicture3745%ofthetime,
especiallywhentheappendixislocatedinanunusualplace(seeAnatomy).Insuchcases,imaging
studiesmaybeimportantbutnotalwaysavailable.However,patientswithappendicitisusuallyhave
accessorysignsthatmaybehelpfulfordiagnosis(seePhysicalExamination).Forexample,the
obturatorsignispresentwhentheinternalrotationofthethighelicitspain(ie,pelvicappendicitis),and
thepsoassignispresentwhentheextensionoftherightthighelicitspain(ie,retroperitonealor
retrocecalappendicitis).
Laboratorytestsarenotspecificforappendicitis,buttheymaybehelpfultoconfirmdiagnosisin
patientswithanatypicalpresentation.Forexample,liverandpancreaticfunctiontests(eg,
transaminases,bilirubin,alkalinephosphatase,serumlipase,amylase)maybehelpfultodetermine
thediagnosisinpatientswithanunclearpresentation.Forwomenofchildbearingage,thelevelof
urinarybetahumanchorionicgonadotropin(betahCG)isusefulindifferentiatingappendicitisfrom
earlyectopicpregnancy.

CBCCount
Studiesconsistentlyshowthat8085%ofadultswithappendicitishaveawhitebloodcell(WBC)
countgreaterthan10,500cells/L.Neutrophiliagreaterthan75%occursin78%ofpatients.Less
than4%ofpatientswithappendicitishaveaWBCcountlessthan10,500cells/Landneutrophilia
lessthan75%.
DueholmetalfurtherdelineatedtherelationshipbetweentheWBCcountandthelikelihoodof
appendicitisbycalculatinglikelihoodratiosfordefinedintervalsoftheWBCcount.[24]
Table2.WBCCountandLikelihoodofAppendicitis(OpenTableinanewwindow)
WBC(10,000)

LikelihoodRatio(95%CI)

47

0.10(00.39)

79

0.52(01.57)

911

0.29(00.62)

1113

2.8(1.24.4)

1315

1.7(03.6)

1517

2.8(06.0)

1719

3.5(010)

1922

Source:Dueholmetal.[24]
CI=confidenceintervalWBC=whitebloodcell.
CBCtestsareinexpensive,rapid,andwidelyavailablehowever,thefindingsarenonspecific.In
infantsandelderlypatients,aWBCcountisespeciallyunreliablebecausethesepatientsmaynot
mountanormalresponsetoinfection.Inpregnantwomen,thephysiologicleukocytosisrendersthe
CBCcountuselessforthediagnosisofappendicitis.

CReactiveProtein
Creactiveprotein(CRP)isanacutephasereactantsynthesizedbytheliverinresponsetoinfection
orinflammationandrapidlyincreaseswithinthefirst12hours.CRPhasbeenreportedtobeusefulin
thediagnosisofappendicitishowever,itlacksspecificityandcannotbeusedtodistinguishbetween
sitesofinfection.
CRPlevelsofgreaterthan1mg/dLarecommonlyreportedinpatientswithappendicitis,butveryhigh
levelsofCRPinpatientswithappendicitisindicategangrenousevolutionofthedisease,especiallyifit
isassociatedwithleukocytosisandneutrophilia.However,CRPnormalizationoccurs12hoursafter
onsetofsymptoms.Severalprospectivestudieshaveshownthat,inadultswhohavehadsymptoms
forlongerthan24hours,anormalCRPlevelhasanegativepredictivevalueof97100%for
appendicitis.[5,6,7]ThimsenetalnotedthatanormalCRPlevelafter12hoursofsymptomswas
100%predictiveofbenign,selflimitedillness.[5]

CRPsensitivity
MultiplestudieshaveexaminedthesensitivityofCRPlevelaloneforthediagnosisofappendicitisin
patientsselectedtoundergoappendectomy.GurleyiketalnotedaCRPsensitivityof96.6%in87of
90patientswithhistologicallyprovendisease.[25]Similarly,ShakhetrahfoundaCRPsensitivityof
95.5%in85of89patientswithhistologicallyprovenappendicitis.[26]AsfaretalreportedaCRP
sensitivityof93.6%in78patientsundergoingappendectomy,[27]andErkasapetalfoundaCRP
sensitivityof96%inagroupof102adultpatientswithRLQpain,55ofwhomproceededto
appendectomy.[28]

SensitivityofWBCcountandCRPlevelincombination
InvestigatorshavealsostudiedtheabilityofcombinationsofWBCcountandCRPtoreliablyruleout
thediagnosisofappendicitis.GronroosandGronroosfoundthattheWBCcountorCRPlevelwas
abnormalinall200patientswithappendicitisintheircohortof300patientsoperatedforsuspected

appendicitis.[29]OrtegaDeballonetalfoundthatanormalWBCcountandCRPlevelhadanegative
predictivevalueof92.3%forthepresenceofappendicitisinprospectivelystudiedpatientsreferredto
asurgeonforRLQpain.[30]
SomestudieshaveexaminedthesensitivityofacombinedWBCcountandCRPlevelinthe
subpopulationofpatientsolderthan60years.Gronroosstudied83patientsolderthan60yearswho
underwentappendectomy(73foundtohaveappendicitis)andfoundthatnopatientwithappendicitis
hadbothanormalWBCcountandCRPlevel.[31]Yangetalretrospectivelystudied77patientsolder
than60yearswithhistologicallyprovenappendicitisandfoundthatonly2hadanormal"triplescreen"
(seebelow).[32]
SeveralstudiesalsoexaminedtheaccuracyoftheWBCcountandCRPlevelinthesubpopulationof
pediatricpatientswithsuspectedappendicitis.Gronroosevaluated100childrenwithpathologyproven
appendicitisandfoundthatboththeWBCcountandCRPlevelwerenormalin7of100patients.[33]
Stefanuttietalprospectivelystudiedmorethan100childrenundergoingsurgeryforsuspected
appendicitisandfoundthateithertheWBCcountorCRPlevelwaselevatedin98%ofthosewith
pathologyprovenappendicitis.[34]

TriplescreenofWBCcount,CRPlevel,andneutrophilia
Mohammedetalprospectivelystudied216childrenadmittedforsuspectedappendicitisandfounda
triplescreensensitivityof86%andanegativepredictivevalueof81.[35]However,Yangetalfound
thatonly6of740patientswithappendicitishadaWBCcountlessthan10,500cells/LAND
neutrophiliathatwaslessthan75%,ANDanormalCRPlevel,yieldingasensitivityof99.2%forthe
"triplescreen."[36]

Urinalysis
Urinalysismaybeusefulindifferentiatingappendicitisfromurinarytractconditions.Mildpyuriamay
occurinpatientswithappendicitisbecauseoftherelationshipoftheappendixwiththerightureter.
Severepyuriaisamorecommonfindinginurinarytractinfections(UTIs).Proteinuriaandhematuria
suggestgenitourinarydiseasesorhemocoagulativedisorders.
Onestudyof500patientswithacuteappendicitisrevealedthatapproximatelyonethirdreported
urinarysymptoms,mostcommonlydysuriaorrightflankpain.[37]Onein7patientshadpyuriagreater
than10WBCsperhighpowerfield(hpf),and1in6patientshadgreaterthan3redbloodcells
(RBCs)perhpf.Thus,thediagnosisofappendicitisshouldnotbedismissedduetothepresenceof
urologicsymptomsorabnormalurinalysis.[37]

Urinary5HIAA
AccordingtoareportbyBolandparvazetal,measurementoftheurinary5hydroxyindoleaceticacid
(U5HIAA)levelscouldbeanearlymarkerofappendicitis.[8]Therationaleofsuchmeasurementis
relatedtothelargeamountofserotoninsecretingcellsintheappendix.Theinvestigatorsnotedthat
U5HIAAlevelsincreasedsignificantlyinacuteappendicitis,decreasingwhentheinflammation
shiftedtonecrosisoftheappendix.[8]Therefore,suchdecreasecouldbeanearlywarningsignof
perforationoftheappendix.

CTScanning

Computedtomography(CT)scanningwithoralcontrastmediumorrectalGastrografinenemahas
becomethemostimportantimagingstudyintheevaluationofpatientswithatypicalpresentationsof
appendicitis.Intravenouscontrastisusuallynotnecessary.
Studieshavefoundadecreaseinnegativelaparotomyrateandappendicealperforationratewhen
pelvicCTimagingwasusedinselectedpatientswithsuspectedappendicitis.[38,39,40,41]An
enlargedappendixisshownintheCTbelow.

CTscanrevealsanenlargedappendixwiththickenedwalls,whichdonotfillwithcoloniccontrastagent,lying
adjacenttotherightpsoasmuscle.

ViewMediaGallery
TheuseofCThasdramaticallyincreasedsincetheintroductionofmultidetectorCT(MDCT)
scanners.Alarge,singlecenterstudyfoundthatMDCThasahighrateofsensitivityandspecificity
(98.5%and98%,respectively)fordiagnosingacuteappendicitis.[42]
Inadultswithappendicitis,thediagnosticperformanceofCTscanswithintravenouscontrastaloneis
comparabletothatofscanswithbothintravenousandoralcontrast,andpatientswhoreceiveCT
scanswithintravenouscontrastalonearedischargedmorequicklyfromtheemergencydepartment.
[43]

Concernshavegrownoverthepossibleadverseeffectsonpatientsfromexposuretoradiationfrom
CTscanning.LowdoseabdominalCTallowsfora78%reductioninradiationexposurecomparedto
traditionalabdominopelvicCTandmaybepreferablefordiagnosingchildrenandyoungadultsin
whomexposuretoCTradiationisofparticularconcern.[9]Ultrasonographymayofferasafer
alternativeasaprimarydiagnostictoolforappendicitis,withCTscanningusedinthosecasesin
whichultrasonogramsarenegativeorinconclusive.
GotoImagingofAppendicitisformoreinformationonthistopic.

Ultrasonography
BecauseofconcernsaboutpatientexposuretoradiationduringCTscans,ultrasonographyhasbeen
suggestedasasaferprimarydiagnosticmodalityforappendicitis,withCTscanningusedsecondarily
whenultrasonogramsarenegativeorinconclusive.[44,45,46]
Ahealthyappendixusuallycannotbeviewedwithultrasonography.Whenappendicitisoccurs,the
ultrasonogramtypicallydemonstratesanoncompressibletubularstructureof79mmindiameter(see

theimagesbelow).

Sagittalgradedcompressiontransabdominalsonogramshowsanacutelyinflamedappendix.Thetubular
structureisnoncompressible,lacksperistalsis,andmeasuresgreaterthan6mmindiameter.Athinrimof
periappendicealfluidispresent.

ViewMediaGallery

Transversegradedcompressiontransabdominalsonogramofanacutelyinflamedappendix.Notethetargetlike
appearanceduetothickenedwallandsurroundingloculatedfluidcollection.

ViewMediaGallery

Inpediatricpatients,theACEP2010clinicalpolicyupdaterecommendsusingultrasonographyfor
confirmation,butnotexclusion,ofacuteappendicitis.Todefinitivelyexcludeacuteappendicitis,CTis
recommended.[10,11]
Ultrasonographyfollowedbymagneticresonanceimaging(MRI)appearstobeaneffective
combinationforaccuratelydiagnosingappendicitisinchildren.[47,48]Inaretrospectivestudyof662
patientsyoungerthanage18yearspresentingtotheemergencydepartmentwithabdominalpain,
ultrasonography/MRIwasperformedin397patientsandCTscanningwasusedin265.Inthe
ultrasonography/MRIgroup,ultrasoundwaspositiveforappendicitisin19.7%ofpatients,andMRI
identifiedanadditional62cases,ofwhich7(11.3%)werecomplicated.IntheCTgroup,55.4%of
patientspositiveforappendicitis,ofwhich19.4%werecomplicated.[47,48]
Thefalsepositiveratewassimilarinthetwogroups(1.4%intheultrasonography/MRIgroupand
2.5%intheCTgroup),andtherewerenofalsenegativesineithergroup.[47,48]Nosignificant
differencesbetweengroupswereobservedinmeanoveralllengthofhospitalstay,timetoantibiotic
administration,timetoappendectomy,orperforationrate.[47,48]
Vaginalultrasonographyaloneorincombinationwithtransabdominalscanmaybeusefulto
determinethediagnosisinwomenofchildbearingage.Onestudyof22pregnantwomeninthefirst
andsecondtrimestersshowedthatgradedcompressionultrasonographyhadasensitivityof66%and
specificityof95%.[12]
GotoImagingofAppendicitisformoreinformationonthistopic.

AbdominalRadiography
Thekidneysuretersbladder(KUB)radiographicviewistypicallyusedtovisualizeanappendicolithin
apatientwithsymptomsconsistentwithappendicitis.Thisfindingishighlysuggestiveofappendicitis,
butappendicolithsalsooccurinfewerthan10%ofcases.Theconsensusintheliteratureisthatplain
radiographsareinsensitive,nonspecific,andnotcosteffective.
GotoImagingofAppendicitisformoreinformationonthistopic.

BariumEnemaStudy
Inthepast,bariumenemaexaminationwasusedtodiagnoseappendicitisintheeraof
ultrasonographyandCTscanning,bariumenemastudyhasessentiallynoroleinthediagnosisof
acuteappendicitis.
Asinglecontraststudycanbeperformedonanunpreparedbowel.Absentorincompletefillingofthe
appendixcoupledwithpressureeffectorspasminthececumsuggestsappendicitis.Thetypical
radiologicsignofappendicitisisthe"reverse3,"whichtypicallymanifestsasanindentationofthe
cecum.However,theappendixcannotbevisualizedin50%ofhealthyindividualstherefore,barium
enemalacksreliability.
GotoImagingofAppendicitisformoreinformationonthistopic.

RadionuclideScanning
Wholebloodiswithdrawnforradionuclidescanning.Neutrophilsandmacrophagesarelabeledwith
technetiumTc99m(99mTc)albuminandadministeredintravenously.Then,imagesoftheabdomen

andpelvisareobtainedseriallyover4hours.LocalizeduptakeoftracerintheRLQsuggests
appendicealinflammationthisisshownintheimagebelow.

Technetium99mradionuclidescanoftheabdomenshowsfocaluptakeoflabeledWBCsintherightlower
quadrantconsistentwithacuteappendicitis.

ViewMediaGallery
GotoImagingofAppendicitisformoreinformationonthistopic.

MRI
Traditionally,magneticresonanceimaging(MRI)hasplayedarelativelylimitedroleintheevaluation
ofappendicitisbecauseofitshighcost,longscantimes,andlimitedavailability.However,thelackof
ionizingradiationmakesitanattractivemodalityinpregnantpatients.Infact,Cobbenetalshowed
thatMRIisfarsuperiortotransabdominalultrasonographyinevaluatingpregnantpatientswith
suspectedappendicitis.[49]Moreover,thesensitivityandspecificityofMRIforappendicitisappearsto
besimilartothoseofcomputedtomography(CT)scanning.[50]
Nonetheless,whenevaluatingpregnantpatientswithsuspectedappendicitis,gradedcompression
ultrasonographyshouldbetheimagingtestofchoice.Ifultrasonographydemonstratesaninflamed
appendix,thepatientshouldundergoappendectomy.Ifgradedcompressionultrasonographyis
nondiagnostic,thepatientshouldundergoMRIoftheabdomenandpelvis.
Whenusedforevaluatingpediatricpatients,MRIhasahighersensitivitythanultrasound.Ina
prospectivecomparisonofultrasoundandMRIin104childrenwithsuspectedappendicitis,
researchersfoundthatMRIhadasensitivityof100%comparedtoultrasoundwhichhadasensitivity
of76%.ToleranceofMRIwascomparabletothatoftoleranceforultrasound.[51]
Aretrospectivestudyof662patientsyoungerthatage18yearswhopresentedtotheemergency
departmentwithabdominalpainfoundthatultrasoundfollowedselectivelybyMRIaccurately
diagnosedpediatricappendicitis.[47,48]

GotoImagingofAppendicitisformoreinformationonthistopic.

GrossandMicroscopicEvaluation
Intheearlystagesofappendicitis,theappendixgrosslyappearsedematouswithdilationofthe
serosalvessels.Microscopydemonstratesneutrophilinfiltrateofthemucosalandmuscularislayers
extendingintothelumen.Astimepasses,theappendicealwallgrosslyappearsthickened,thelumen
appearsdilated,andaserosalexudate(fibrinousorfibrinopurulent)maybeobservedasgranular
roughening.Atthisstage,mucosalnecrosismaybeobservedmicroscopically.
Atthelaterstagesofappendicitis,theappendixgrosslyshowsmarkedsignsofmucosalnecrosis
extendingintotheexternallayersoftheappendicealwallthatcanbecomegangrenous.Sometimes,
theappendixmaybefoundinacollectionofpus.Atthisstageofappendicitis,microscopymay
demonstratemultiplemicroabscessesoftheappendicealwallandseverenecrosisofalllayers.
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