History

Fact Explanation
Colicky abdominal pain Colicky pain arises due to the inflammation and obstruction of the appendix. During the initial stages patient complains of peri-umbilical pain which later localizes to the right iliac fossa. [2] The embryological origin of the appendix is the mid-gut. So the initial visceral pain is referred to the peri-umbilical region. Once the inflammation progresses and involves the parietal peritoneum pain becomes more localized to the right iliac fossa. Coughing and sneezing exacerbates the pain. However in elders pain may rarely be localized to the right iliac fossa. [2] When the inflamed appendix perforates it causes peritonitis. The patient lies still on the bed because even a slight movement aggravates the pain. [1,3]
Anorexia [2] This occurs prior to the onset of abdominal pain and relatively constant symptom. [2]
Nausea and or vomiting [2] Nausea and vomiting results due to the sympathetic activation secondary to visceral pain. [7]
Fever [4,5,6] Fever occurs after the first 6 hours. [2] Fever occurs due to the inflammation and release of pyrogens.
Diarrhea In pelvic appendix this is a relatively early feature. [2] Diarrhea also occurs in post ileal appendix as well. Inflamed appendix irritates the adjacent bowel loops and causes diarrhea.
Increased frequency of micturition In pelvic appendix which lies over the bladder causes irritation of the bladder and results in increased frequency of micturition. [2]
Excessive retching This occurs with post ileal appendix. [2]
References
  1. NIWA H, HIRAMATSU T. A rare presentation of appendiceal diverticulitis associated with pelvic pseudocyst. World J Gastroenterol. [online] Feb 28 2008;14(8):1293-5. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690682/
  2. BAILEY, LOVE. ed. Norman S. Williams, Christopher J.K. Bulstrode, P. Ronan O’connell. Bailey & Love’s SHORT PRACTICE of SURGERY. 25th ed. London. Hodder Arnold. 2008
  3. ABDELKARIM H. O., MUHAMMAD R. K., GHAZI R. Q., AHMAD K. S., MOHAMMAD K. B. Y., SAHEL K. H. Acute appendicitis in the elderly: risk factors for perforation. World Journal of Emergency Surgery [online] 2014, 9:6 [viewed 1 April 2014] Available from:doi:10.1186/1749-7922-9-6
  4. HORATTAS M, GUYTON D, DIANE W: A reappraisal of appendicitis in theelderly. Am J Surg [online] 1990, 160:291-293. [viewed 1 April 2014] Available from:http://www.ncbi.nlm.nih.gov/pubmed/2393058?dopt=Abstract&holding=f1000,f1000m,isrctn
  5. STORM-DICKERSON TL, HORATTAS MC: What we have learned over the past 20 years about appendicitis in the elderly? Am J Surg [online] 2003, 185:198-201. [viewed 1 April 2014] Available from:http://www.ncbi.nlm.nih.gov/pubmed/12620555?dopt=Abstract&holding=f1000,f1000m,isrctn
  6. SHEU BF, CHIU TF, CHEN JC, TUNG MS, CHANG MW, YOUNG YR: Risk factors associated with perforated appendicitis in elderly patients presenting with signs and symptoms of acute appendicitis. ANZ J Surg [online] 2007, 77:662-666. [viewed 1 April 2014] Available from:http://www.ncbi.nlm.nih.gov/pubmed/17635280?dopt=Abstract&holding=f1000,f1000m,isrctn
  7. MORRIS CE. Low Back Syndromes: Integrated Clinical Management. New York: McGraw-Hill; 2005. p. 267. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576917/

Examination

Fact Explanation
Fever Patient is febrile after the first 6 hours. This is usually a low-grade fever. [1,4,5,6]
Tachycardia Fever occurs with the onset of fever. [1]
Reduced respiratory movements in the lower abdomen. When the inflamed parietal peritoneum and the visceral peritoneum touches each other during the respiratory movements pain arises. This results in reduced respiratory movements in the lower abdomen. [1]
Abdominal tenderness [4,5,6] Tenderness is localized to the right iliac fossa. [1] There is associated muscle guarding and rebound tenderness. This is maximum over the McBurney’s point. Tenderness may be absent even with deep palpation if the appendix is retro cecal (silent appendix) or pelvic in location. It is due to the poor transmission of the pressure due to the gas filled cecum. [1] Retrocecal appendix causes spasm of the psoas muscle and the patient may keep the muscle in a flexed position. The hyper-extension of the hip joint may elicit abdominal pain in retrocecal appendix. Pelvic appendix often produces tenderness on palpation of the suprapubic area slightly more towards to the right side.
Pointing sign When the patient is asked to point the place where the maximum pain is felt, patient points to the right iliac fossa. [1]
Rovsing’s sign Deep palpation of the left iliac fossa causes pain in the right iliac fossa. [1]
Psoas sign When the inflamed appendix lies over the psoas muscle flexion of the thigh elicits pain.
Obturator test When the hip is flexed and internally rotated it causes spasm of the obturator muscle. [1]
Cutaneous hyperaesthesia over the right iliac fossa [1] Occurs due to the underlying inflammation in the right iliac fossa.
Tenderness over the pouch of Douglas On digital rectal examination a pelvic appendix causes pain in the pouch of Douglas. [3] Obturator spasm may also be felt.
Markle sign Patient is asked to stand on toes and to shift the weight to the heels quickly. This will elicit abdominal pain. [2]
References
  1. BAILEY, LOVE. ed. Norman S. Williams, Christopher J.K. Bulstrode, P. Ronan O’connell. Bailey & Love’s SHORT PRACTICE of SURGERY. 25th ed. London. Hodder Arnold. 2008
  2. MARKLE GB 4th. Heel-drop jarring test for appendicitis. Arch Surg. [online] Feb 1985;120(2):243. [viewed 1 April 2014]
  3. SEDLAK M, WAGNER OJ, WILD B, PAPAGRIGORIADES S, EXADAKTYLOS AK. Is there still a role for rectal examination in suspected appendicitis in adults?. Am J Emerg Med. [online] Mar 2008;26(3):359-60. [viewed 1 April 2014]
  4. STORM-DICKERSON TL, HORATTAS MC: What we have learned over the past 20 years about appendicitis in the elderly? Am J Surg [online] 2003, 185:198-201. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12620555?dopt=Abstract&holding=f1000,f1000m,isrctn
  5. PARANJAPE C, DALIA S, PAN J, HORATTAS M: Appendicitis in the elderly: a change in the laparoscopic era. SurgEndosc [online] 2007, 21:777-781. [viewed 1 April 2014]
  6. POOLER BD, LAWRENCE EM, PICKHARDT PJ: MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome. Emerg Radio [online] 2012, 19:27-33. [viewed 1 April 2014] Available from: http://link.springer.com/article/10.1007%2Fs10140-011-1002-3
  7. HENRY ROBINSON. The clinical bearing of cutaneous tenderness on various acuteabdominal disorders, especially appendicitis. QJM[online] (1908) os1 (4): 387-415. [viewed 1 April 2014]

Differential Diagnoses

Fact Explanation
Appendiceal diverticulitis This is more common than appendicitis. [1] Appendiceal diverticula can be either congenital or acquired. [2] Acquired ones are more prone to perforation and rupture. [3]
Mesenteric adenitis This is common in children. If the child is having high fever (more than 38.5°C) mesenteric adenitis is more likely than appendicitis. [4] Child presents with colicky abdominal pain and palpable cervical lymph nodes. [4]
Subacute intestinal obstruction [4,5] Peri appendicular inflammation causes adhesions and results in intestinal obstruction. [6]
Acute gastroenteritis Viral gastroenteritis is more common than appendicitis especially in children. Diarrhea may also occur in both pelvic and post-ileal appendicitis. [4]
Meckel’s diverticulitis Causes pain in the peri umbilical region, similar to appendicitis. [4]
Intussusception Intussusception is common in children less than 2 years of age. [4] Presents with a sausage shaped mass in the right iliac fossa, and characteristic 'red current jelly' stools.
Henoch–Schönlein purpura This is associated with ecchymotic skin lesions over the extensor surfaces of the body and diffuse abdominal pain. [4] There is a preceding history of sore throat.
Urinary tract infection (UTI) The symptoms of increased frequency of micturition may mimic a UTI. Urinalysis will help to diagnose UTI but it has limited value in excluding the diagnosis of appendicitis. [8]
Perforated peptic ulcer [4] Patients have a history of dyspepsia and very sudden onset of pain in the epigastrium. Erect chest X ray film may show gas under the diaphragm.
Torsion of testis [4] Testicular torsion may produce referred pain in the right iliac fossa in young patients.
Pancreatitis [4] Elevated serum amylase levels may favor the diagnosis of pancreatitis.
Mittelschmerz [4] Mid cycle rupture of a follicular cyst causes lower abdominal pain in menstruating females. A menstrual history will provide clues to the diagnosis.
Pelvic inflammatory disease Especially in adult females. A history of unprotected sexual intercourse is usually present. [4] Patient may have a history of vaginal discharge or dysmenorrhea.
Ectopic pregnancy [4] Positive urine hCG test with absent intra-uterine pregnancy should raise the suspicion of an ectopic pregnancy.
Torsion/rupture of ovarian cyst [4] Ultrasound examination will detect the cyst.
Endometriosis [4] Endometriosis of the appendicular lumen may result in luminal obstruction. [7]
Diverticulitis [4] This is common in elders with a history of longstanding constipation.
Colonic carcinoma [4] Carcinoma of the cecum should be suspected in adults presenting with appendicitis.
References
  1. NIWA H, HIRAMATSU T. A rare presentation of appendiceal diverticulitis associated with pelvic pseudocyst. World J Gastroenterol. [online] Feb 28 2008;14(8):1293-5. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690682/
  2. PLACE RJ, SIMMANG CL, HUBER PJ JR. Appendiceal diverticulitis. South Med J. [online] 2000;93:76–79. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10653074
  3. COLLINS DC. A study of 50,000 specimens of the human vermiform appendix. Surg Gynecol Obstet. [online] 1955;101:437–445. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13256319
  4. BAILEY, LOVE. ed. Norman S. Williams, Christopher J.K. Bulstrode, P. Ronan O’connell. Bailey & Love’s SHORT PRACTICE of SURGERY. 25th ed. London. Hodder Arnold. 2008
  5. SANJAY H., KAMAL M., DOUGAL B., LESLIE B., PETER S. Acute appendicitis presenting as small bowel obstruction: two case reports. Cases Journal [online] 2009, 2:9106 [viewed 1 April 2014] Available from: doi:10.1186/1757-1626-2-9106
  6. ASSENZA M, RICCI G, BARTOLUCCI P, MODINI C: Mechanical small bowel obstruction due to an inflamed appendix wrapping around the last loop of ileum. G Chir. [online] 2005 Jun-Jul;26(6-7):261-6. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16329768?dopt=Abstract&holding=f1000,f1000m,isrctn
  7. IJAZ S, LIDDER S, MOHAMID W, CARTER M, THOMPSON H: Intussusception of the appendix secondary to endometriosis: a case report. J Med Case Reports 2008, 2:12. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18211674?dopt=Abstract&holding=f1000,f1000m,isrctn
  8. TUNDIDOR BERMÚDEZ AM1, AMADO DIÉGUEZ JA, MONTES DE OCA MASTRAPA JL. Urological manifestations of acute appendicitis. Arch Esp Urol. 2005 Apr;58(3):207-12. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15906614

Investigations - for Diagnosis

Fact Explanation
None Appendicitis is usually a clinical diagnosis. [1,7]
Full blood count [1,8] Leukocytosis [2,3,4] and left shift favor the diagnosis of appendicitis according to the Alvarado score. (score of 7 or more is strongly suggestive of acute appendicitis)
Contrast-enhanced CT [4,5,6] This aids in diagnosis and reduces the incidence of unnecessary appendectomy. It is considered the best investigation to confirm or to exclude the diagnosis of appendicitis. [9,10]
MRI MRI is useful imaging modality in diagnosing appendicitis if the clinical diagnosis is uncertain. [11,12]
Abdominal X-ray This will help in excluding intestinal obstruction and also may find clues to the etiology of appendicitis (Eg: Fecolith) [13] An erect abdominal X-ray will help in excluding perforated peptic ulcer.
Diagnostic laparoscopy This is not routinely done and useful when the diagnosis is uncertain.
Abdominal ultrasound [4,5,6] Not routinely used. When the diagnosis is in doubt ultrasound investigation will help in the diagnosis. [1]
C-Reactive Protein [8] (CRP) CRP is an inflammatory marker and elevated in appendicitis. [8]
Urinalysis [1] Urinalysis has limited value in excluding the diagnosis of appendicitis. [14]
Urine pregnancy test Excludes pregnancy and makes the ruptured ectopic less likely.
References
  1. BAILEY, LOVE. ed. Norman S. Williams, Christopher J.K. Bulstrode, P. Ronan O’connell. Bailey & Love’s SHORT PRACTICE of SURGERY. 25th ed. London. Hodder Arnold. 2008
  2. STORM-DICKERSON TL, HORATTAS MC: What we have learned over the past 20 years about appendicitis in the elderly? Am J Surg [online] 2003, 185:198-201. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12620555?dopt=Abstract&holding=f1000,f1000m,isrctn
  3. PARANJAPE C, DALIA S, PAN J, HORATTAS M: Appendicitis in the elderly: a change in the laparoscopic era. SurgEndosc [online] 2007, 21:777-781. [viewed 1 April 2014]
  4. POOLER BD, LAWRENCE EM, PICKHARDT PJ: MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome. Emerg Radio [online] 2012, 19:27-33. [viewed 1 April 2014] Available from: http://link.springer.com/article/10.1007%2Fs10140-011-1002-3
  5. KORNER H, SONDENAA K, SOREIDE JA, ANDERSEN E, NYSTED A, LENDE TH, KIELLEVOLD KH: Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg[online] 1997, 21:313-317. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9015177?dopt=Abstract&holding=f1000,f1000m,isrctn
  6. ILVES I, PAAJANEN HE, HERZIG KH, FAGERSTROM A, MIETTINEN PJ: Changing incidence of acute appendicitis and nonspecific abdominal pain between 1987 and 2007 in Finland. World J Surg [online] 2011, 35:731-738. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21327601?dopt=Abstract&holding=f1000,f1000m,isrctn
  7. RICHARD N, DEIRDRÉ K, THIFHELI EL. Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital. International Journal of Emergency Medicine [online] 2014, 7:12 [viewed 1 April 2014] Available from: doi:10.1186/1865-1380-7-12
  8. AHMAD QA, MUNEERA MJ, RASOOL MI: Predictive value of TLC and CRP in the diagnosis of acute appendicitis. Ann [online] 2010, 16:116-119. [viewed 1 April 2014]
  9. TERASAWA T, BLACKMORE CC, BENT S, KOHLWES RJ: Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med [online] 2004, 141(7):537-546. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15466771?dopt=Abstract&holding=f1000,f1000m,isrctn
  10. DORIA AS, MOINEDDIN R, KELLENBURGER CJ, EPELMEN M, BEYENE J, SCHUH S, BABYN PS, DICK PT: US or CT for diagnosis of appendicitis in children and adults.Radiology [online] 2006, 241:84-94. [viewed 1 April 2014]
  11. OLSEN JB, MYREN CJ, HAAHR PE: Randomized study of the value of laparoscopy before appendicectomy. Br J Surg [online] 1993, 80:822-923. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6639177?dopt=Abstract&holding=f1000,f1000m,isrctn
  12. TEICHER I, LANDA B, COHEN M, CABNICK LS, WISE L: Scoring system to aid in the diagnosis of appendicitis. Ann Surg [online] 1983, 198:753-759. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6639177?dopt=Abstract&holding=f1000,f1000m,isrctn
  13. ALAEDEEN DI, COOK M, CHWALS WJ. Appendiceal fecalith is associated with early perforation in pediatric patients. J Pediatr Surg. [online] 2008 May;43(5):889-92. [viewed 1 April 2014] Available from: doi: 10.1016/j.jpedsurg.2007.12.034.
  14. TUNDIDOR BERMÚDEZ AM1, AMADO DIÉGUEZ JA, MONTES DE OCA MASTRAPA JL. Urological manifestations of acute appendicitis. Arch Esp Urol. [online] 2005 Apr;58(3):207-12. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15906614

Investigations - Fitness for Management

Fact Explanation
Urea and electrolytes [1] Asses the renal function before the induction of general anesthesia.
Chest X-ray It is indicated if there is a history of lung disease. [2]
ECG Asses the cardiovascular fitness of the patient. [1]
References
  1. Practice advisory for preanesthesia evaluation. An updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. [viewed 1 April 2014] Available from: http://www.guideline.gov/content.aspx?id=36197
  2. RUCKER L, FRYE EB, STATEN MA. Usefulness of screening chest roentgenograms in preoperative patients. JAMA [online]250(23):3209-11. [viewed 1 April 2014]

Management - General Measures

Fact Explanation
Intravenous fluids [1] Patient might be dehydrated due to recurrent vomiting and poor oral intake.
Antibiotics [1] Single dose of intravenous antibiotics at the time of induction will reduce the risk of wound infection. Third-generation cephalosporin is the drug of choice. [3] However if peritonitis is present antibiotics should cover gram negative and anerobic organisms as well.
Anelgesics [2] Pain may relieve with diclofenac sodium suppository.
References
  1. BAILEY, LOVE. ed. Norman S. Williams, Christopher J.K. Bulstrode, P. Ronan O’connell. Bailey & Love’s SHORT PRACTICE of SURGERY. 25th ed. London. Hodder Arnold. 2008
  2. MANTEROLA C, VIAL M, MORAGA J, ASTUDILLO P. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. [online] Jan 19 2011;1:CD005660. [viewed 1 April 2014]
  3. WOJCIECHOWICZ KH, HOFFKAMP HJ, VAN HULST RA. Conservative treatment of acute appendicitis: an overview. Int Marit Health. [online] 2010;62(4):265-72. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21348022

Management - Specific Treatments

Fact Explanation
Open appendectomy Open appendectomy and laparoscopic appendectomy both are considered as equally beneficial and have fewer complications. [3] If an appendicular mass is felt the conservative approach is practiced and interval appendectomy is performed. [5] However if the conservative management is successful surgery may not be indicated since appendicitis has low risk of recurrences. [6,7,8]
Laparoscopic appendectomy This is the suitable mode of treatment in pregnant females [2], children and in uncomplicated appendicitis and it is preferred in perforated appendicitis, in obese and in elderly patients. [1] Recurrent appendicitis is treated with interval appendectomy and laparoscopic approach is preferred. [4]
References
  1. KORNDORFFER JR JR, FELLINGER E, REED W. SAGES guideline for laparoscopic appendectomy. Surg Endosc. [online] Apr 2010;24(4):757-61. [viewed 1 April 2014] Available from: http://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-appendectomy/
  2. WILASRUSMEE C, SUKRAT B, MCEVOY M, ATTIA J, THAKKINSTIAN A. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. [online] Nov 2012;99(11):1470-8. [viewed 1 April 2014]
  3. WRAY CJ, KAO LS, MILLAS SG, TSAO K, KO TC: Acute appendicitis: controversies in diagnosis and management. CurrProblSurg [online] 2013, 50:54-86. [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21327601?dopt=Abstract&holding=f1000,f1000m,isrctn
  4. ABDUL-WAHED N. M., Appendiceal mass: Is interval appendicectomy “something of the past”? World J Gastroenterol. [online] Jul 7, 2011; 17(25): 2977–2980. [viewed 1 April 2014] Available from: doi: 10.3748/wjg.v17.i25.2977
  5. BAILEY, LOVE. ed. Norman S. Williams, Christopher J.K. Bulstrode, P. Ronan O’connell. Bailey & Love’s SHORT PRACTICE of SURGERY. 25th ed. London. Hodder Arnold. 2008
  6. BENJAMIN Q., Interval appendectomy in adults: A necessary evil? J Emerg Trauma Shock. [online] 2012 Jul-Sep; 5(3): 213–216. [viewed 1 April 2014] Available from: doi: 10.4103/0974-2700.99683
  7. WILLEMSEN PJ, HOORNTJE LE, EDDES EH, PLOEG RJ. The need for interval appendectomy after resolution of an appendiceal mass questioned. Dig Surg. [online] 2002;19(3):216-20; [viewed 1 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12119525
  8. HAMAD AL-QAHTANI, MOHAMMED KHURSHID ALAM, MOHAMMAD. H. AL-AKEELY, SALEH M. AL-SALAMAH. Routine or Selective Interval Appendectomy for Non-Surgically Treated Appendiceal Mass. Journal of Taibah University Medical Sciences. [online] 2010, 5 (2), 105–109. [viewed 1 April 2014] Available from: http://dx.doi.org/10.1016/S1658-3612(10)70139-6