eMedicine Specialties > Emergency Medicine > Gastrointestinal

Appendicitis, Acute

Author: Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Carolinas Medical Center
Contributor Information and Disclosures

Updated: Jun 1, 2009

Introduction

Background

Appendicitis is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay. No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases.

The surgeon's goals are to evaluate a relatively small population of patients referred for suspected appendicitis and to minimize the negative appendectomy rate without increasing the incidence of perforation. The emergency department clinician must evaluate the larger group of patients who present to the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the diagnosis in a time-, cost-, and consultation-efficient manner.

See Medscape's Gastroenterology Specialty page for more information.

Pathophysiology

Obstruction of the appendiceal lumen is the primary cause of appendicitis. An anatomic blind pouch, obstruction of the appendiceal lumen leads to distension of the appendix due to accumulated intraluminal fluid. Ineffective lymphatic and venous drainage allows bacterial invasion of the appendiceal wall and, in advanced cases, perforation and spillage of pus into the peritoneal cavity.

Frequency

United States

Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000 people per year. Some familial predisposition exists.

International

Incidence of appendicitis is lower in cultures with a higher intake of dietary fiber. Dietary fiber is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose individuals to obstructions of the appendiceal lumen.

Mortality/Morbidity

  • The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to surgical intervention.
  • Mortality rate rises above 20% in patients older than 70 years, primarily because of diagnostic and therapeutic delay.
  • Perforation rate is higher among patients younger than 18 years and patients older than 50 years, possibly because of delays in diagnosis. Appendiceal perforation is associated with a sharp increase in morbidity and mortality rates.

Sex

The incidence of appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary appendectomy is approximately equal in both sexes.

Age

  • Incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years. The median age at appendectomy is 22 years.
  • Although rare, neonatal and even prenatal appendicitis have been reported.
  • The emergency department clinician must maintain a high index of suspicion in all age groups.

Clinical

History

  • Variations in the position of the appendix, age of the patient, and degree of inflammation make the clinical presentation of appendicitis notoriously inconsistent.
  • It is important to remember that the position of the appendix is variable. Of 100 patients undergoing 3-D multidetector CT, the base of the appendix was located at McBurney's point in only 4% of patients. In 36% of patients, the base was within 3 cm of McBurney's point; in 28%, it was 3-5 cm from McBurney's point; and, in 36% of patients, the base of the appendix was more than 5 cm from McBurney's point.
  • In addition, patients with many other disorders present with symptoms similar to those of appendicitis. Examples include the following:
  • The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
  • Migration of pain from the periumbilical area to the RLQ is the most discriminating feature of the patient's history. This finding has a sensitivity and specificity of approximately 80%.
  • When vomiting occurs, it nearly always follows the onset of pain. Vomiting that precedes pain is suggestive of intestinal obstruction, and the diagnosis of appendicitis should be reconsidered.
  • Nausea is present in 61-92% of patients; anorexia is present in 74-78% of patients. Neither finding is statistically different from findings in ED patients with other etiologies of abdominal pain.
  • Diarrhea or constipation is noted in as many as 18% of patients and should not be used to discard the possibility of appendicitis.
  • Duration of symptoms is less than 48 hours in approximately 80% of adults but tends to be longer in elderly persons and in those with perforation. Approximately 2% of patients report duration of pain in excess of 2 weeks.
  • A history of similar pain is reported in as many as 23% of cases. A history of similar pain, in and of itself, should not be used to rule out the possibility of appendicitis.
  • An inflamed appendix near the urinary bladder or ureter can cause irritative voiding symptoms and hematuria or pyuria. Cystitis in male patients is rare in the absence of instrumentation. Consider the possibility of an inflamed pelvic appendix in male patients with apparent cystitis.
  • Also consider the possibility of appendicitis in pediatric or adult patients who present with acute urinary retention.

Physical

  • Male infants and children occasionally present with an inflamed hemiscrotum due to migration of an inflamed appendix or pus through a patent processus vaginalis. This is often initially misdiagnosed as acute testicular torsion.
  • RLQ tenderness is present in 96% of patients, but this is a nonspecific finding. Rarely, left lower quadrant (LLQ) tenderness has been the major manifestation in patients with situs inversus or in patients with a lengthy appendix that extends into the LLQ.
  • The most specific physical findings are rebound tenderness, pain on percussion, rigidity, and guarding.
  • The Rovsing sign (RLQ pain with palpation of the LLQ) suggests peritoneal irritation in the right lower quadrant precipitated by palpation at a remote location.
  • The obturator sign (RLQ pain with internal or external rotation of the flexed right hip) suggests that the inflamed appendix is located deep in the right hemipelvis.
  • The psoas sign (RLQ pain with extension of the right hip) suggests that an inflamed appendix is located along the course of the right psoas muscle.
  • These signs are present in a minority of patients with acute appendicitis. Their absence never should be used to rule out appendiceal inflammation.
  • Dunphy's sign (sharp pain in the RLQ elicited by a voluntary cough) may be helpful in making the clinical diagnosis of localized peritonitis. Similarly, RLQ pain in response to percussion of a remote quadrant of the abdomen, or to firm percussion of the patient's heel, suggests peritoneal inflammation. The Markle sign, pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing, is stated in DeGowin's Diagnostic Examination to be very sensitive for localizing true peritonitis.1
  • There is no evidence in the medical literature that the digital rectal examination (DRE) provides useful information in the evaluation of patients with suspected appendicitis; however, failure to perform a rectal examination is frequently cited in successful malpractice claims. In 2008, Sedlak et al studied 577 patients who underwent DRE as part of an evaluation for suspected appendicitis and found no value as a means of distinguishing patients with and without appendicitis.2

Causes

  • Obstruction of the appendiceal lumen usually precipitates appendicitis.
  • The most common causes of luminal obstruction are fecaliths and lymphoid follicle hyperplasia.
    • Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix.
    • Lymphoid hyperplasia is associated with a variety of inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis.
    • Obstruction of the appendiceal lumen has less commonly been associated with parasites (eg, Schistosomes species, Strongyloides species), foreign material (eg, shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors.

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References
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Further Reading

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Keywords

appendicitis, acute appendicitis, appendectomy, acute inflammation of the appendix, abdominal pain, fecaliths, appendiceal perforation, right lower quadrant pain, vomiting, periumbilical pain, Rovsing sign, obturator sign, psoas sign, positive cough sign, burst appendix, luminal obstruction

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Contributor Information and Disclosures

Author

Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Carolinas Medical Center
Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William Lober, MD, Associate Professor, Department of Medical Education, Division of Biomedical and Health Informatics, University of Washington School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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