| 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] |
| 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] |
| 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. |
| 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. |
| 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] |
| 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. |
| 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] |