eMedicine Specialties > General Surgery > Abdomen

Appendicitis: Workup

Author: Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Coauthor(s): Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh
Contributor Information and Disclosures

Updated: May 1, 2009

Workup

Laboratory Studies

  • Laboratory tests are not specific for appendicitis but may be helpful to confirm diagnosis in patients with an atypical presentation.
  • CBC count
    • A mild elevation of WBCs (ie, >12,000/µL) is a common finding in patients with acute appendicitis. In these patients, leukocytosis occurs. Otherwise, the WBC count has low specificity for appendicitis, and a number of bacterial and viral diseases may also lead to leukocytosis.
    • In infants and elderly patients, a WBC count is especially unreliable because these patients may not mount a normal response to infection.
    • In pregnant women, the physiologic leukocytosis renders the CBC count useless for the diagnosis of appendicitis.
  • Urinalysis
    • Urinalysis may be useful in differentiating appendicitis from urinary tract conditions.
    • Mild pyuria may occur in patients with appendicitis because of the relationship of the appendix with the right ureter. Severe pyuria is a more common finding in UTI.
    • Proteinuria and hematuria suggest genitourinary diseases or hemocoagulative disorders.
  • C-reactive protein
    • C-reactive protein (CRP) has been reported to be useful in the diagnosis of appendicitis. This protein is physiologically produced by the liver when bacterial infections occur and rapidly increases within the first 12 hours.
    • CRP lacks specificity and cannot be used to distinguish between sites of infection.
    • CRP levels of greater than 1 mg/dL are commonly reported in patients with appendicitis. Very high levels of CRP in patients with appendicitis indicate gangrenous evolution of the disease, especially if it is associated with leukocytosis and neutrophilia. However, CRP normalization occurs 12 hours after onset of symptoms.
  • Liver and pancreatic function tests (eg, transaminases, bilirubin, alkaline phosphatase, serum lipase, amylase) may be helpful to determine the diagnosis in patients with an unclear presentation.
  • For women of childbearing age, the level of urinary beta–human chorionic gonadotropic (beta-hCG) is useful in differentiating appendicitis from early ectopic pregnancy.
  • Urinary 5-hydroxyindoleacetic acid
    • According to a report, measurement of the urinary 5-hydroxyindoleacetic acid (U-5-HIAA) levels could be an early marker of appendicitis.2 The rationale of such measurement is related to the large amount of serotonin-secreting cells in the appendix.
    • In the cited report, U-5-HIAA levels increase significantly in acute appendicitis, decreasing when the inflammation shifts to necrosis of the appendix.2 Therefore, such decrease could be an early warning sign of perforation of the appendix.

Imaging Studies

  • Abdomen plain film: Occasionally, a plain film of the abdomen may demonstrate fecalith within the appendix, but this study is rarely indicated.
  • Barium enema
    • Although barium enema is performed only rarely, in the past this examination was used to diagnose appendicitis. (See image below and Image 1.)
Normal appendix; barium enema radiographic examin...

Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.

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Normal appendix; barium enema radiographic examin...

Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.


    • When barium enema is performed, the typical radiologic sign of appendicitis is the "reverse 3." This sign typically manifests as an indentation of the cecum. In addition, the appendix does not fill with barium.
    • The appendix cannot be visualized in 50% of healthy individuals; therefore, barium enema lacks reliability.
  • Ultrasonography
    • A healthy appendix usually cannot be viewed with ultrasonography. When appendicitis occurs, the ultrasonogram typically demonstrates a noncompressible tubular structure of 7-9 mm in diameter.
    • Vaginal ultrasonography alone or in combination with transabdominal scan may be useful to determine the diagnosis in women of childbearing age.
    • False-positive results may occur in patients with Crohn disease. False-negative results are frequent in patients with retrocecal appendix.
    • The main limitation of an ultrasonogram is that its reliability is completely user-dependent
    • One study indicated that in cases of appendicitis, ultrasonography has a sensitivity and specificity of 77% and 86%, respectively (although other studies have reported higher figures for these3 ), as compared with 100% sensitivity and specificity for CT scanning.4
    • Similarly, a literature review from the Netherlands found CT scanning to be superior to graded-compression ultrasonography for the diagnosis of acute appendicitis.5
    • However, owing to concerns about patient exposure to radiation during CT scans, ultrasonography has been suggested as a safer primary diagnostic modality for appendicitis, with CT scanning used secondarily when ultrasonograms are negative or inconclusive.4,6,7,8 (See images below and Images 4, 6, 7.)
Suppurative appendicitis; transverse view, color ...

Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis.

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Suppurative appendicitis; transverse view, color ...

Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis.


Sagittal graded compression transabdominal ultras...

Sagittal graded compression transabdominal ultrasonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.

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Sagittal graded compression transabdominal ultras...

Sagittal graded compression transabdominal ultrasonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.


Transverse graded compression transabdominal ultr...

Transverse graded compression transabdominal ultrasonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection.

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Transverse graded compression transabdominal ultr...

Transverse graded compression transabdominal ultrasonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection.


  • CT scan
    • CT scan with oral contrast medium or rectal Gastrografin enema may help in diagnosis of appendicitis. Intravenous contrast is not usually necessary. It may help differentiate between appendicitis and other pelvic pathologies.
    • The typical findings are a nonfilling appendix with distention and thickened walls of the appendix and the cecum, enlarged mesenteric nodes, and periappendiceal inflammation or fluid.9 (See image below and Image 2.)
Computed tomography scan reveals an enlarged appe...

Computed tomography scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.

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Computed tomography scan reveals an enlarged appe...

Computed tomography scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.


    • Because of its cost, CT scanning has generally been reserved for patients with an uncertain diagnosis or severe obesity. However, advances in CT scanning have led to its increased use in the diagnosis of appendicitis.6 This is partially related to a reduction in the time necessary to perform a scan, which has to a great extent eliminated the need to administer anesthesia to children to prevent them from moving during the procedure.
    • Helical CT scanning has demonstrated high sensitivity and specificity in differentiating appendicitis from other conditions, and it may be cost efficient with regard to limiting the number of unnecessary operations.
    • As mentioned above, however, concerns have grown over the possible adverse effects on patients from exposure to radiation from CT scanning. Ultrasonography may offer a safer alternative as a primary diagnostic tool for appendicitis, with CT scanning used in those cases in which ultrasonograms are negative or inconclusive.3,4,6,7,8
  • Another diagnostic tool for acute appendicitis is radionuclide scanning using WBCs labeled with technetium-99m (99m Tc). Despite its reported high specificity and sensitivity, the procedure is time consuming and not useful in emergency situations. It is cost effective; however, it is not widely available. (See image below and Image 5.)
Technetium-99m radionuclide scan of the abdomen s...

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled white blood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.

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Technetium-99m radionuclide scan of the abdomen s...

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled white blood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.


Diagnostic Procedures

  • Diagnostic laparoscopy may be useful in selected cases (eg, infants, elderly patients, female patients) to confirm the diagnosis of appendicitis. If findings are positive, such procedures should be followed by definitive surgical treatment at the time of laparoscopy.

Histologic Findings

In the early stages of appendicitis, the appendix grossly appears edematous with dilation of the serosal vessels. Microscopy demonstrates neutrophil infiltrate of the mucosal and muscularis layers extending into the lumen. As time passes, the appendiceal wall grossly appears thickened, the lumen appears dilated, and a serosal exudate (fibrinous or fibrinopurulent) may be observed as granular roughening. At this stage, mucosal necrosis may be observed microscopically.

At the later stages of appendicitis, the appendix grossly shows marked signs of mucosal necrosis extending into the external layers of the appendiceal wall that can become gangrenous. Sometimes, the appendix may be found in a collection of pus. At this stage of appendicitis, microscopy may demonstrate multiple microabscesses of the appendiceal wall and severe necrosis of all layers.

Staging

Appendicitis usually has 3 stages.

  • Edematous stage
    • Appendicitis may have spontaneous regression or may evolve to the second stage.
    • The mesoappendix is commonly involved with inflammation.
  • Purulent (phlegmonous) stage
    • Spontaneous regression rarely occurs.
    • Appendicitis usually evolves beyond perforation and rupture.
    • Peritonitis may be possible.
  • Gangrenous stage
    • Spontaneous regression never occurs.
    • Peritonitis is present.

More on Appendicitis

Overview: Appendicitis
Workup: Appendicitis
Treatment: Appendicitis
Follow-up: Appendicitis
Multimedia: Appendicitis
References
Further Reading
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References

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Keywords

appendicitis, appendix, appendectomy, appendix pain, symptoms of appendicitis, appendix symptoms, appendicitis signs, appendix side, human appendix, abdominal pain, appendicitis children, appendix surgery, after appendectomy, acute appendicitis, acute abdominal pain, perforated appendix, peritonitis, appendix inflammation, acute inflammation of the appendix, appendiceal lumen, vermiform appendix, typhlitis, lymphoid hyperplasia, irritable bowel disease, IBD, fecal stasis, fecaliths, lymphoid hyperplasia of the appendix, obstruction of the appendiceal lumen, periappendicular abscess

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Contributor Information and Disclosures

Author

Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Disclosure: Nothing to disclose.

Coauthor(s)

Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh
Disclosure: Nothing to disclose.

Medical Editor

Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine
Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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