2017526 Appendicitis:PracticeEssentials,Background,Anatomy

Thissiteisintendedforhealthcareprofessionals

Appendicitis
Updated:Jan19,2017
Author:SandyCraig,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...

OVERVIEW

PracticeEssentials
Appendicitisisdefinedasaninflammationoftheinnerliningofthevermiformappendixthat
spreadstoitsotherparts.Despitediagnosticandtherapeuticadvancementinmedicine,
appendicitisremainsaclinicalemergencyandisoneofthemorecommoncausesofacute
abdominalpain.Seetheimagebelow.

Transversegradedcompressiontransabdominalsonogramofanacutelyinflamedappendix.Notethe
targetlikeappearanceduetothickenedwallandsurroundingloculatedfluidcollection.
ViewMediaGallery

SeeAppendicitis:AvoidingPitfallsinDiagnosis,aCriticalImagesslideshow,tohelpmakean
accuratediagnosis.

Also,seetheCan'tMissGastrointestinalDiagnosesslideshowtohelpdiagnosethepotentiallylife
threateningconditionsthatpresentwithgastrointestinalsymptoms.

Signsandsymptoms
Theclinicalpresentationofappendicitisisnotoriouslyinconsistent.Theclassichistoryofanorexia
andperiumbilicalpainfollowedbynausea,rightlowerquadrant(RLQ)pain,andvomitingoccursin
only50%ofcases.Featuresincludethefollowing:

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Abdominalpain:Mostcommonsymptom
Nausea:6192%ofpatients
Anorexia:7478%ofpatients
Vomiting:Nearlyalwaysfollowstheonsetofpainvomitingthatprecedespainsuggests
intestinalobstruction
Diarrheaorconstipation:Asmanyas18%ofpatients

Featuresoftheabdominalpainareasfollows:

Typicallybeginsasperiumbilicalorepigastricpain,thenmigratestotheRLQ[1]
Patientsusuallyliedown,flextheirhips,anddrawtheirkneesuptoreducemovementsand
toavoidworseningtheirpain
Thedurationofsymptomsislessthan48hoursinapproximately80%ofadultsbuttendsto
belongerinelderlypersonsandinthosewithperforation.

Physicalexaminationfindingsincludethefollowing:

Reboundtenderness,painonpercussion,rigidity,andguarding:Mostspecificfinding
RLQtenderness:Presentin96%ofpatients,butnonspecific
Leftlowerquadrant(LLQ)tenderness:Maybethemajormanifestationinpatientswithsitus
inversusorinpatientswithalengthyappendixthatextendsintotheLLQ
Maleinfantsandchildrenoccasionallypresentwithaninflamedhemiscrotum
Inpregnantwomen,RLQpainandtendernessdominateinthefirsttrimester,butinthelatter
halfofpregnancy,rightupperquadrant(RUQ)orrightflankpainmayoccur

Thefollowingaccessorysignsmaybepresentinaminorityofpatients:

Rovsingsign(RLQpainwithpalpationoftheLLQ):Suggestsperitonealirritation
Obturatorsign(RLQpainwithinternalandexternalrotationoftheflexedrighthip):Suggests
theinflamedappendixislocateddeepintherighthemipelvis
Psoassign(RLQpainwithextensionoftherighthiporwithflexionoftherighthipagainst
resistance):Suggeststhataninflamedappendixislocatedalongthecourseoftheright
psoasmuscle
Dunphysign(sharppainintheRLQelicitedbyavoluntarycough):Suggestslocalized
peritonitis
RLQpaininresponsetopercussionofaremotequadrantoftheabdomenortofirm
percussionofthepatient'sheel:Suggestsperitonealinflammation
Marklesign(painelicitedinacertainareaoftheabdomenwhenthestandingpatientdrops
fromstandingontoestotheheelswithajarringlanding):Hasasensitivityof74%[2]

SeeClinicalPresentationformoredetail.

Diagnosis
Thefollowinglaboratorytestsdonothavefindingsspecificforappendicitis,buttheymaybehelpful
toconfirmdiagnosisinpatientswithanatypicalpresentation:

CBC
Creactiveprotein(CRP)
Liverandpancreaticfunctiontests
Urinalysis(fordifferentiatingappendicitisfromurinarytractconditions)
UrinarybetahCG(fordifferentiatingappendicitisfromearlyectopicpregnancyinwomenof
childbearingage)
Urinary5hydroxyindoleaceticacid(5HIAA)

CBC

WBC>10,500cells/L:8085%ofadultswithappendicitis
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Neutrophilia>7578%ofpatients
Lessthan4%ofpatientswithappendicitishaveaWBCcountlessthan10,500cells/Land
neutrophilialessthan75%

Ininfantsandelderlypatients,aWBCcountisespeciallyunreliablebecausethesepatientsmay
notmountanormalresponsetoinfection.Inpregnantwomen,thephysiologicleukocytosisrenders
theCBCcountuselessforthediagnosisofappendicitis.

Creactiveprotein

CRPlevels>1mg/dLarecommoninpatientswithappendicitis
VeryhighlevelsofCRPinpatientswithappendicitisindicategangrenousevolutionofthe
disease,especiallyifitisassociatedwithleukocytosisandneutrophilia
Inadultswhohavehadsymptomsforlongerthan24hours,anormalCRPlevelhasa
negativepredictivevalueof97100%forappendicitis[3,4,5]

Urinary5HIAA

HIAAlevelsincreasesignificantlyinacuteappendicitisanddecreasewhentheinflammationshifts
tonecrosisoftheappendix.[6]Therefore,suchdecreasecouldbeanearlywarningsignof
perforationoftheappendix.

CTscanning

CTscanningwithoralcontrastmediumorrectalGastrografinenemahasbecomethemost
importantimagingstudyintheevaluationofpatientswithatypicalpresentationsof
appendicitis
LowdoseabdominalCTmaybepreferablefordiagnosingchildrenandyoungadultsin
whomexposuretoCTradiationisofparticularconcern[7]

Ultrasonography

Ultrasonographymayofferasaferalternativeasaprimarydiagnostictoolforappendicitis,
withCTscanningusedinthosecasesinwhichultrasonogramsarenegativeorinconclusive
Inpediatricpatients,AmericanCollegeofEmergencyPhysicians(ACEP)clinicalpolicy
recommendsultrasonographyforconfirmation,butnotexclusion,ofacuteappendicitisto
definitivelyexcludeacuteappendicitis,theACEPrecommendsCT[8,9]
Ahealthyappendixusuallycannotbeviewedwithultrasonographywhenappendicitis
occurs,theultrasonogramtypicallydemonstratesanoncompressibletubularstructureof79
mmindiameter
Vaginalultrasonographyaloneorincombinationwithtransabdominalscanmaybeusefulto
determinethediagnosisinwomenofchildbearingage[10]

Otherimagingstudies

Kidneysuretersbladderradiographs:Insensitive,nonspecific,andnotcosteffective
Bariumenemastudy:Hasessentiallynoroleinthediagnosisofacuteappendicitis
Radionuclidescanning:LocalizeduptakeoftracerintheRLQsuggestsappendiceal
inflammation
MRI:Usefulinpregnantpatientsifgradedcompressionultrasonographyisnondiagnostic

SeeWorkupformoredetail.

Management
Emergencydepartmentcareisasfollows:

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2017526 Appendicitis:PracticeEssentials,Background,Anatomy

EstablishIVaccessandadministeraggressivecrystalloidtherapytopatientswithclinical
signsofdehydrationorsepticemia
KeeppatientswithsuspectedappendicitisNPO
Administerparenteralanalgesicandantiemeticasneededforpatientcomfortnostudyhas
shownthatanalgesicsadverselyaffecttheaccuracyofphysicalexamination[11]

Appendectomyremainstheonlycurativetreatmentofappendicitis,butmanagementofpatients
withanappendicealmasscanusuallybedividedintothefollowing3treatmentcategories:

Phlegmonorasmallabscess:AfterIVantibiotictherapy,anintervalappendectomycanbe
performed46weekslater
Largerwelldefinedabscess:AfterpercutaneousdrainagewithIVantibioticsisperformed,
thepatientcanbedischargedwiththecatheterinplaceintervalappendectomycanbe
performedafterthefistulaisclosed
Multicompartmentalabscess:Thesepatientsrequireearlysurgicaldrainage

Antibiotics

Antibioticprophylaxisshouldbeadministeredbeforeeveryappendectomy
Preoperativeantibioticsshouldbeadministeredinconjunctionwiththesurgicalconsultant
Broadspectrumgramnegativeandanaerobiccoverageisindicated
Cefotetanandcefoxitinseemtobethebestchoicesofantibiotics
Inpenicillinallergicpatients,carbapenemsareagoodoption
PregnantpatientsshouldreceivepregnancycategoryAorBantibiotics
AntibiotictreatmentmaybestoppedwhenthepatientbecomesafebrileandtheWBCcount
normalizes

SeeTreatmentandMedicationformoredetail.

Background
Appendicitisisdefinedasaninflammationoftheinnerliningofthevermiformappendixthat
spreadstoitsotherparts.Thisconditionisacommonandurgentsurgicalillnesswithprotean
manifestations,generousoverlapwithotherclinicalsyndromes,andsignificantmorbidity,which
increaseswithdiagnosticdelay(seePresentation).Infact,despitediagnosticandtherapeutic
advancementinmedicine,appendicitisremainsaclinicalemergencyandisoneofthemore
commoncausesofacuteabdominalpain.

Nosinglesign,symptom,ordiagnostictestaccuratelyconfirmsthediagnosisofappendiceal
inflammationinallcases,andtheclassichistoryofanorexiaandperiumbilicalpainfollowedby
nausea,rightlowerquadrant(RLQ)pain,andvomitingoccursinonly50%ofcases(see
Presentation).

Appendicitismayoccurforseveralreasons,suchasaninfectionoftheappendix,butthemost
importantfactoristheobstructionoftheappendiceallumen(seePathophysiologyandEtiology).
Leftuntreated,appendicitishasthepotentialforseverecomplications,includingperforationor
sepsis,andmayevencausedeath(seePrognosis).However,thedifferentialdiagnosisof
appendicitisisoftenaclinicalchallengebecauseappendicitiscanmimicseveralabdominal
conditions(seeDiagnosticConsiderations.[12]

Appendectomyremainstheonlycurativetreatmentofappendicitis(seeTreatment).Thesurgeon's
goalsaretoevaluatearelativelysmallpopulationofpatientsreferredforsuspectedappendicitis
andtominimizethenegativeappendectomyratewithoutincreasingtheincidenceofperforation.
Theemergencydepartment(ED)clinicianmustevaluatethelargergroupofpatientswhopresent
totheEDwithabdominalpainofalletiologieswiththegoalofapproaching100%sensitivityforthe
diagnosisinatime,cost,andconsultationefficientmanner.

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2017526 Appendicitis:PracticeEssentials,Background,Anatomy

GotoPediatricAppendicitisformoreinformationonthistopic.

Forpatienteducationinformation,seetheDigestiveDisordersCenteraswell
asAppendicitisandAbdominalPaininAdults.

Anatomy
Theappendixisawormlikeextensionofthececumand,forthisreason,hasbeencalledthe
vermiformappendix.Theaveragelengthoftheappendixis810cm(rangingfrom220cm).The
appendixappearsduringthefifthmonthofgestation,andseverallymphoidfolliclesarescatteredin
itsmucosa.Suchfolliclesincreaseinnumberwhenindividualsareaged820years.Anormal
appendixisseenbelow.

Normalappendixbariumenemaradiographicexamination.Acompletecontrastfilledappendixisobserved
(arrows),whicheffectivelyexcludesthediagnosisofappendicitis.
ViewMediaGallery

Theappendixiscontainedwithinthevisceralperitoneumthatformstheserosa,anditsexterior
layerislongitudinalandderivedfromthetaeniacolithedeeper,interiormusclelayeriscircular.
Beneaththeselayersliesthesubmucosallayer,whichcontainslymphoepithelialtissue.The
mucosaconsistsofcolumnarepitheliumwithfewglandularelementsandneuroendocrine
argentaffincells.

Taeniacoliconvergeontheposteromedialareaofthececum,whichisthesiteoftheappendiceal
base.Theappendixrunsintoaserosalsheetoftheperitoneumcalledthemesoappendix,within
whichcoursestheappendicularartery,whichisderivedfromtheileocolicartery.Sometimes,an
accessoryappendicularartery(derivingfromtheposteriorcecalartery)maybefound.

Appendicealvasculature
Thevasculatureoftheappendixmustbeaddressedtoavoidintraoperativehemorrhages.The
appendiculararteryiscontainedwithinthemesentericfoldthatarisesfromaperitonealextension
fromtheterminalileumtothemedialaspectofthececumandappendixitisaterminalbranchof
theileocolicarteryandrunsadjacenttotheappendicularwall.Venousdrainageisviatheileocolic
veinsandtherightcolicveinintotheportalveinlymphaticdrainageoccursviatheileocolicnodes
alongthecourseofthesuperiormesentericarterytotheceliacnodesandcisternachyli.

Appendiceallocation

Theappendixhasnofixedposition.Itoriginates1.72.5cmbelowtheterminalileum,eitherina
dorsomediallocation(mostcommon)fromthececalfundus,directlybesidetheilealorifice,orasa
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2017526 Appendicitis:PracticeEssentials,Background,Anatomy

funnelshapedopening(23%ofpatients).Theappendixhasaretroperitoneallocationin65%of
patientsandmaydescendintotheiliacfossain31%.Infact,manyindividualsmayhavean
appendixlocatedintheretroperitonealspaceinthepelvisorbehindtheterminalileum,cecum,
ascendingcolon,orliver.Thus,thecourseoftheappendix,thepositionofitstip,andthedifference
inappendicealpositionconsiderablychangesclinicalfindings,accountingforthenonspecificsigns
andsymptomsofappendicitis.

Congenitalappendicealdisorders
Appendicealcongenitaldisordersareextremelyrarebutoccasionallyreported(eg,agenesis,
duplication,triplication).

Pathophysiology
Reportedly,appendicitisiscausedbyobstructionoftheappendiceallumenfromavarietyof
causes(seeEtiology).Independentoftheetiology,obstructionisbelievedtocauseanincreasein
pressurewithinthelumen.Suchanincreaseisrelatedtocontinuoussecretionoffluidsandmucus
fromthemucosaandthestagnationofthismaterial.Atthesametime,intestinalbacteriawithinthe
appendixmultiply,leadingtotherecruitmentofwhitebloodcells(seetheimagebelow)andthe
formationofpusandsubsequenthigherintraluminalpressure.

Technetium99mradionuclidescanoftheabdomenshowsfocaluptakeoflabeledWBCsintherightlower
quadrantconsistentwithacuteappendicitis.
ViewMediaGallery

Ifappendicealobstructionpersists,intraluminalpressurerisesultimatelyabovethatofthe
appendicealveins,leadingtovenousoutflowobstruction.Asaconsequence,appendicealwall
ischemiabegins,resultinginalossofepithelialintegrityandallowingbacterialinvasionofthe
appendicealwall.

Withinafewhours,thislocalizedconditionmayworsenbecauseofthrombosisoftheappendicular
arteryandveins,leadingtoperforationandgangreneoftheappendix.Asthisprocesscontinues,a
periappendicularabscessorperitonitismayoccur.

Etiology
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Appendicitisiscausedbyobstructionoftheappendiceallumen.Themostcommoncausesof
luminalobstructionincludelymphoidhyperplasiasecondarytoinflammatoryboweldisease(IBD)
orinfections(morecommonduringchildhoodandinyoungadults),fecalstasisandfecaliths(more
commoninelderlypatients),parasites(especiallyinEasterncountries),or,morerarely,foreign
bodiesandneoplasms.

Fecalithsformwhencalciumsaltsandfecaldebrisbecomelayeredaroundanidusofinspissated
fecalmateriallocatedwithintheappendix.Lymphoidhyperplasiaisassociatedwithvarious
inflammatoryandinfectiousdisordersincludingCrohndisease,gastroenteritis,amebiasis,
respiratoryinfections,measles,andmononucleosis.

Obstructionoftheappendiceallumenhaslesscommonlybeenassociatedwithbacteria(Yersinia
species,adenovirus,cytomegalovirus,actinomycosis,Mycobacteriaspecies,Histoplasma
species),parasites(eg,Schistosomesspecies,pinworms,Strongyloidesstercoralis),foreign
material(eg,shotgunpellet,intrauterinedevice,tonguestud,activatedcharcoal),tuberculosis,and
tumors.

Epidemiology
Appendicitisisoneofthemorecommonsurgicalemergencies,anditisoneofthemostcommon
causesofabdominalpain.IntheUnitedStates,250,000casesofappendicitisarereported
annually,representing1millionpatientdaysofadmission.Theincidenceofacuteappendicitishas
beendecliningsteadilysincethelate1940s,andthecurrentannualincidenceis10casesper
100,000population.Appendicitisoccursin7%oftheUSpopulation,withanincidenceof1.1cases
per1000peopleperyear.Somefamilialpredispositionexists.

InAsianandAfricancountries,theincidenceofacuteappendicitisisprobablylowerbecauseofthe
dietaryhabitsoftheinhabitantsofthesegeographicareas.Theincidenceofappendicitisislower
incultureswithahigherintakeofdietaryfiber.Dietaryfiberisthoughttodecreasetheviscosityof
feces,decreaseboweltransittime,anddiscourageformationoffecaliths,whichpredispose
individualstoobstructionsoftheappendiceallumen.

Inthelastfewyears,adecreaseinfrequencyofappendicitisinWesterncountrieshasbeen
reported,whichmayberelatedtochangesindietaryfiberintake.Infact,thehigherincidenceof
appendicitisisbelievedtoberelatedtopoorfiberintakeinsuchcountries.

Thereisaslightmalepreponderanceof3:2inteenagersandyoungadultsinadults,theincidence
ofappendicitisisapproximately1.4timesgreaterinmenthaninwomen.Theincidenceofprimary
appendectomyisapproximatelyequalinbothsexes.

Theincidenceofappendicitisgraduallyrisesfrombirth,peaksinthelateteenyears,andgradually
declinesinthegeriatricyears.Themeanagewhenappendicitisoccursinthepediatricpopulation
is610years.Lymphoidhyperplasiaisobservedmoreoftenamonginfantsandadultsandis
responsiblefortheincreasedincidenceofappendicitisintheseagegroups.Youngerchildrenhave
ahigherrateofperforation,withreportedratesof5085%.Themedianageatappendectomyis22
years.Althoughrare,neonatalandevenprenatalappendicitishavebeenreported.Cliniciansmust
maintainahighindexofsuspicioninallagegroups.

GotoPediatricAppendicitisformoreinformationonthistopic.

Prognosis
Acuteappendicitisisthemostcommonreasonforemergencyabdominalsurgery.Appendectomy
carriesacomplicationrateof415%,aswellasassociatedcostsandthediscomfortof
hospitalizationandsurgery.Therefore,thegoalofthesurgeonistomakeanaccuratediagnosisas
earlyaspossible.Delayeddiagnosisandtreatmentaccountformuchofthemortalityandmorbidity
associatedwithappendicitis.
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2017526 Appendicitis:PracticeEssentials,Background,Anatomy

Theoverallmortalityrateof0.20.8%isattributabletocomplicationsofthediseaseratherthanto
surgicalintervention.Themortalityrateinchildrenrangesfrom0.1%to1%inpatientsolderthan
70years,theraterisesabove20%,primarilybecauseofdiagnosticandtherapeuticdelay.

Appendicealperforationisassociatedwithincreasedmorbidityandmortalitycomparedwith
nonperforatingappendicitis.Themortalityriskofacutebutnotgangrenousappendicitisislessthan
0.1%,buttheriskrisesto0.6%ingangrenousappendicitis.Therateofperforationvariesfrom
16%to40%,withahigherfrequencyoccurringinyoungeragegroups(4057%)andinpatients
olderthan50years(5570%),inwhommisdiagnosisanddelayeddiagnosisarecommon.
Complicationsoccurin15%ofpatientswithappendicitis,andpostoperativewoundinfections
accountforalmostonethirdoftheassociatedmorbidity.

Inamultivariableanalysis,independentfactorspredictiveofcomplicatedappendicitisinchildren
wereasfollows[13]:

Ageyoungerthan5years
Symptomdurationlongerthan24hours
Hyponatremia
Leukocytosis

ClinicalPresentation

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MediaGallery

CTscanrevealsanenlargedappendixwiththickenedwalls,whichdonotfillwithcolonic
contrastagent,lyingadjacenttotherightpsoasmuscle.
Sagittalgradedcompressiontransabdominalsonogramshowsanacutelyinflamedappendix.
Thetubularstructureisnoncompressible,lacksperistalsis,andmeasuresgreaterthan6mm
indiameter.Athinrimofperiappendicealfluidispresent.
Transversegradedcompressiontransabdominalsonogramofanacutelyinflamedappendix.
Notethetargetlikeappearanceduetothickenedwallandsurroundingloculatedfluid
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2017526 Appendicitis:PracticeEssentials,Background,Anatomy

collection.
Technetium99mradionuclidescanoftheabdomenshowsfocaluptakeoflabeledWBCsin
therightlowerquadrantconsistentwithacuteappendicitis.
Perforatedappendicitis.
Normalappendixbariumenemaradiographicexamination.Acompletecontrastfilled
appendixisobserved(arrows),whicheffectivelyexcludesthediagnosisofappendicitis.

of6

Tables

Table1.MANTRELSScore
Table2.WBCCountandLikelihoodofAppendicitis

Table1.MANTRELSScore

Characteristic Score

M=MigrationofpaintotheRLQ 1

A=Anorexia 1

N=Nauseaandvomiting 1

T=TendernessinRLQ 2

R=Reboundpain 1

E=Elevatedtemperature 1

L=Leukocytosis 2

S=ShiftofWBCstotheleft 1

Total 10

Source:Alvarado.[18]

RLQ=rightlowerquadrantWBCs=whitebloodcells

Table2.WBCCountandLikelihoodofAppendicitis

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)
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2017526 Appendicitis:PracticeEssentials,Background,Anatomy

1315 1.7(03.6)

1517 2.8(06.0)

1719 3.5(010)

1922

Source:Dueholmetal.[23]

CI=confidenceintervalWBC=whitebloodcell.

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ContributorInformationandDisclosures

Author

SandyCraig,MDResidencyProgramDirector,CarolinasMedicalCenterAssociateProfessor,
DepartmentofEmergencyMedicine,UniversityofNorthCarolinaatChapelHillSchoolofMedicine

SandyCraig,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,Societyfor
AcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

ChiefEditor

BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternal
Medicine,ProgramDirectorforEmergencyMedicine,UHClevelandMedicalCenter,University
Hospitals,CaseWesternReserveUniversitySchoolofMedicine

BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmega
Alpha,AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,
AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeart
Association,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

Acknowledgements

EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,Departmentof
EmergencyMedicine,CharlesDrewUniversityofMedicineandScienceFormerChair,
DepartmentofEmergencyMedicine,MartinLutherKingJr/DrewMedicalCenter

Disclosure:Nothingtodisclose.

WilliamLober,MD,MSAssociateProfessor,HealthInformaticsandGlobalHealth,Schoolsof
Medicine,Nursing,andPublicHealth,UniversityofWashington

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2017526 Appendicitis:PracticeEssentials,Background,Anatomy

Disclosure:Nothingtodisclose.

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedical
CenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:MedscapeSalaryEmployment

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