QUICK RECERTIFICATION SERIES
Acute appendicitis
Timothy M. Hirsch, MS, PA-C
GENERAL FEATURES
• Appendicitis is the most common surgical abdominal
emergency, with a lifetime incidence of 7% to 9%.
• Appendicitis most commonly presents in patients ages
10 to 29 years, with highest incidence among patients
ages 10 to 19 years.
• Appendicitis is caused by obstruction of the appendiceal
lumen that leads to increasing lumen pressure, vascular
compromise, bacterial invasion, inflammation, and tissue
necrosis.
• Mortality is less than 1%, but increases to 3% if the
appendix is ruptured and approaches 15% in older adults.
• Delayed diagnosis and rupture is more common in the
extremely young and older adults, leading to higher
mortality in these populations.
• Appendicitis is the most common extrauterine surgical
emergency in pregnant women.
CLINICAL ASSESSMENT
• Right lower quadrant (RLQ) abdominal pain is the most
reliable symptom in the diagnosis of acute appendicitis.
This pain is reported in nearly all confirmed cases and is
81% sensitive and 53% specific.
• Migration of periumbilical pain to the RLQ is 64%
sensitive and 82% specific for the diagnosis and occurs
in 50% to 60% of confirmed cases.
• The classic triad of symptoms is abdominal pain, anorexia,
and nausea and vomiting, with 60% of patients present-
ing with some combination of these symptoms. Alone,
these symptoms are neither sensitive nor specific for
appendicitis.
• Many atypical presentations can occur due to anatomic
variability in appendix location. Atypical symptoms often
include indigestion, flatulence, bowel changes, diarrhea,
and malaise.
• Examination commonly reveals generalized abdominal
tenderness, RLQ tenderness, McBurney point tender-
ness, Rovsing sign, psoas sign, obturator sign, digital
rectal examination tenderness, and abdominal rebound
tenderness.
Timothy M. Hirsch practices emergency medicine for US Acute
Care Solutions in Denver, Colo. The author has disclosed no potential
conflicts of interest, financial or otherwise.
Dawn Colomb-Lippa, MHS, PA-C, department editor
DOI:10.1097/01.JAA.0000516357.34621.aa
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Copyright © 2017 American Academy of Physician Assistants
° In children, rebound tenderness is the most reliable
sign on physical examination.
• Fever typically is a late finding and rarely exceeds 39° C
(102.2° F) unless rupture or other complications occur.
Fever is unreliable as an indicator for appendicitis.
DIAGNOSIS
• Diagnosis is primarily clinical. In addition to a proper
history and physical examination, consider a complete
blood cell (CBC) count, urinalysis, pregnancy test, and
imaging if the diagnosis is not clear.
° On CBC count, leukocytosis is sensitive but nonspecific
for appendicitis.
° Urinalysis is important to rule out other diagnoses,
including urolithiasis and urinary tract infection.
° Pyuria and hematuria can occur when an inflamed
appendix overlies a ureter.
• Plain radiographs of the abdomen often show nonspecific
abnormalities including appendiceal fecalith, appendiceal
gas, localized paralytic ileus, free air, and blurred right
psoas muscle.
• Ultrasound is operator-dependent and is significantly
better in institutions where it is routinely used.
° Ultrasonography evaluation of appendicitis is limited
by a ruptured appendix, abnormally located appendix,
and in obese patients.
° To limit radiation exposure, ultrasound should be
considered as an initial study for women of reproduc-
tive age and children.
QUESTIONS
1. Appendicitis most commonly occurs in patients of what
age?
a. under age 10 years
b. age 10 to 19 years
c. age 20 to 30 years
d. over age 30 years
2. The classic triad of appendicitis consists of abdominal
pain and which other findings?
a. indigestion and nausea and vomiting
b. anorexia and bowel changes
c. nausea and vomiting and anorexia
d. diarrhea and nausea and vomiting
Volume 30 • Number 6 • June 2017

• CT is 98% sensitive and 95% specific for appendicitis.
° Focused appendiceal CT is uncommon; however, debate
exists whether focused appendiceal CT or traditional
nonfocused CT is the better choice.
° CT findings suggesting acute appendicitis include
pericecal inflammation, abscess, periappendiceal phleg-
mon, or fluid collections.
• MRI is useful for pregnant patients but is more costly
and time-consuming and availability is limited in many
institutions.
TREATMENT
• Prompt surgical intervention is considered the most
appropriate therapy for early appendicitis.
• Ruptured appendicitis with localized abscess may be
treated with antibiotics and percutaneous drainage, fol-
lowed by delayed appendectomy.
• While awaiting surgery, patients should have nothing by
mouth and should have IV access, antibiotics, and analgesia.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2017 American Academy of Physician Assistants
Acute appendicitis
° Antibiotics should cover anaerobes, enterococci, and
Gram-negative intestinal flora. Preoperative treatment
decreases the incidence of postoperative wound infec-
tion and abscess formation.
° Recommended antibiotic regimens include piperacil-
lin/tazobactam 3.375 g IV or ampicillin/sulbactam
3 g IV. JAAPA
malaise.
indigestion, flatulence, bowel changes, diarrhea, and
nausea and vomiting. Atypical symptoms include
2. C. The classic triad is abdominal pain, anorexia, and
presents in patients ages 10 to 29 years.
ages 10 to 19 years. The condition most commonly
1. B. The highest incidence of appendicitis is in patients
Answers
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