Diagnosis of Acute

Appendicitis
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, USA
Objectives
To review the pathophysiology and
clinical presentation of acute
appendicitis
To understand which patient groups are
at high risk of misdiagnosis
To discuss the use of laboratory and
imaging studies in the diagnosis of
acute appendicitis
Appendicitis Incidence &
Complications
6 % lifetime incidence
69 % are ages 10 to 30
Up to 30 % misdiagnosed initially
20 to 30 % ruptured at surgery
Mortality : 0.1 to 0.2 % unruptured, 3 to 5
% ruptured
Significant morbidity
Anatomic Aspects
Blind pouch off of cecum
Contains lymphoid tissue which peaks in
adolescence, atrophies with age
Function still unclear
Appendix can be anywhere within
peritoneal cavity
One study showed 65 % retrocecal, 31 %
pelvic
Review of 70,000 cases showed 4 % in
RUQ, 0.06 % LUQ, 0.04 % LLQ
Pathophysiology of Appendicitis
Lymphoid hyperplasia leads to luminal
obstruction
Often follows viral illness
Epithelial cells secrete mucus
Appendix distends, bacteria multiply
Visceral pain begins an average of 17 hours after
obstruction
Increased pressure compromises blood supply
Somatic pain develops
Average time to perforation = 34 hrs.
Classic Presentation
Seen in 60 %
Anorexia
Periumbilical pain, nausea, vomiting
RLQ pain developing over 24 hrs.
Anorexia and pain are most frequent
Usually nausea, sometimes vomiting
Diarrhea, esp. with pelvic location
Usually tender to palpation
Rebound is a later finding
Physical Exam
Tenderness at McBurney's point
Cutaneous hyperesthesia in T 10 to 12
dermatomes
Rovsing's sign
Psoas sign
Obturator sign
MANTRELS Score
Established in 1986
Migration of pain
Anorexia
Nausea / vomiting
Tenderness RLQ
Rebound
Elevated temp.
Leukocytosis
Shift to left
MANTRELS Score, cont'd.
RLQ tenderness and leukocytosis = 2
points each ; all others 1 point
Score of 5 to 6 = possible appendicitis
Score of 7 to 8 = probable appendicitis
Score of 9 to 10 = very probable
appendicitis
High Risk Patients
Ovulating women
PID, TOA, ovarian cyst rupture can mimic
appendicitis
Look for cervical motion tenderness,
adnexal tenderness, history of STDs
Can have CMT with pelvic appendix
High Risk Patients, cont'd.
Pregnancy
Most common surgical emergency in
pregnancy
Mortality rate if missed = 2 % for mother,
up to 35 % for fetus
WBC elevated in pregnancy
Appendix changes location
High Risk Patients, cont'd.
Pediatrics
Most common surgical disorder in kids
Accounts for 5 % of abd. pain visits
Up to 50 % initially misdiagnosed
< 2 yrs. : perforation rate approaches 100 %
3 to 5 yrs. = 71 %
6 to 10 yrs. = 40 %
Most common misdiagnosis is AGE
Sequence of pain and vomiting may be helpful
Localized tenderness not a feature of AGE
High Risk Patients, cont'd.
Elderly
Vital signs and exam may not reflect
severity
> age 60 : only 5 to 10 % diagnosed
without delay
Perforation rate = 46 to 83 %
RLQ tenderness absent in 23 %
N/V, anorexia less common
Leukocytosis less pronounced
Only 20 % classic presentation
High Risk Patients, cont'd.
Immunocompromised
HIV, chronic steroids, sickle cell,
chemotherapy, DM, dialysis
Increased risk of complications and
misdiagnosis
Inflammatory response decreased
Differential Diagnosis
Gastroenteritis
Mesenteric
lymphadenitis
PID
Mittelschmertz
Crohn's disease
Diverticulitis
Endometriosis
TOA
Ectopic pregnancy
UTI
Pyelonepritis
Other processes
involving appendix

" No single evaluation can
substitute for the diagnostic
accuracy of the experienced
physician."
Laboratory Studies
CBC
75 to 85 % have elevated WBC, but it is
nonspecific
WBC normal in 80 % in the first 24 hrs.
Can see elevated ANC in up to 89 %
WBC usually 12 to 18,000 in appendicitis
Chemistry panel
May help with diagnosis of dehydration
Laboratory Studies, cont'd.
Urinalysis
Specific gravity, ketones
Can see WBCs, RBCs, bacteria if
inflamed appendix close to ureter
> 30 WBCs = probable UTI
HCG
Essential in women of child-bearing age
CRP
Acute phase reactant
Imaging Studies
Plain films
Low sensitivity and specificity
Appendicolith specific, but seen in only 2 %
May see local air-fluid levels, psoas
obliteration, soft tissue mass, gas in
appendix : all nonspecific
Imaging Studies, cont'd.
Ultrasound
75 to 90 % sensitive, 86 to 100 % specific
Noninvasive, low cost, but operator-
dependent
Good for diagnosing GYN disorders
3 criteria for diagnosis
Tender, noncompressible appendix
No peristalsis of appendix
Overall diameter > 6 mm
Imaging Studies, cont'd.
Ultrasound (US)
Appendix may not be seen, due to obesity,
guarding, bowel gas, perforation,
retrocecal location
2.4 to 56 % of normal appendixes seen
One study of 736 pediatric patients
showed 36.6 % without preop US had
negative appendectomy vs. 9.8 % who had
US
Imaging Studies, cont'd.
Ultrasound
Study from Australia showed total WBC
and neutrophil count were more accurate
than US. They recommended pts. with
unequivocal presentation go to OR. If
equivocal, obtain CBC. If WBC > 15,000,
go to OR. If < 11,000, obtain CT (US only
in pregnancy).
Imaging Studies, cont'd.
CT
Early studies showed low yield, but helical
CT much more accurate
Sensitivity 97 to 100 %, specificity 95 %
(similar no matter what type or whether
contrast is used)
Often shows alternative diagnosis
More expensive, radiation exposure
Imaging Studies, cont'd.
CT
Criteria for appendicitis :
Diameter > 6 mm
Failure to completely fill with contrast or
air
Appendicolith
Wall thickening or enhancement
Other contributory signs include fat
stranding, fluid, inflammatory mass,
adenopathy
Imaging Studies, cont'd.
CT
One study showed negative laparotomy
rates of 4 % in men, 8 % in ovulating
women with CT (typical is 20 % and 45 %
respectively), but no change in perforation
rate
Another study showed increase in CT use
led to earlier diagnosis, less severe
pathologic findings, and decreased length
of stay
Imaging Studies, cont'd.
CT
Study from Dept. of Surgery, Stamford,
Connecticut : use of CT markedly
increased from 1994 to 2000, without
change in rate of negative appendectomy.
They concluded use of CT by
nonsurgeons leads to increased E.D. LOS
without improving accuracy. They
recommend mandatory surgical consult if
CT considered.
Do We Need Imaging Studies?
Literature conflicting
Pediatric Imaging -Evidence-Based
Guidelines
Imaging most useful in clinically equivocal
cases
Costs of imaging minor compared to cost
of unnecessary surgery or delayed
diagnosis
US and CT both specific enough to rule in
appendicitis, but only CT sensitive
enough to rule it out
Do We Need Imaging Studies?
Study from Austria
350 patients divided into low,
intermediate, and high probability
All had US
10 % of low prob., 24 % of intermediate
prob., and 65 % of high prob. had
appendicitis
Specificity and sensitivity of US = 98 %
Concluded imaging should be done even
in high probability patients
Do We Need Imaging Studies?
NEJM : Suspected Appendicitis Jan. 2003
Patients with classic presentation should go to
O.R. Diagnostic accuracy approaches 95 %
If equivocal or suspect perforation : CT
US reserved for pregnant women or high
suspicion of GYN disease
If study indeterminate, observe with repeated
exams or laparoscopy
Analgesia
Sir Zachary Cope's 1921 textbook of
surgery said no way
Prospective studies (both EM and
Surgery literature) now show
appropriate use of IV narcotics does not
decrease diagnostic accuracy, and may
improve exam
Analgesia, cont'd.
Journal of American College of Surgeons : Jan.
2003
Prospective, randomized, double blind study
Adults with abd. pain got up to 15 mg morphine
vs. placebo
Increased pain relief, with no change in diagnostic
accuracy
Not all surgeons read their own literature, so
give them a chance to come in a reasonable
time frame or give the meds
Risk Management
Misdiagnosis of appendicitis = 5th
leading cause of successful litigation
against EPs
7 features of misdiagnosed cases :
No nausea / vomiting
Lack of distress
No rebound
No guarding
No rectal exam (controversial)
Narcotic pain meds given
Diagnosis of acute gastroenteritis
Risk Management, cont'd.
When discharging, stress unclear
diagnosis, what to watch for
Follow up in 12 hours (PMD or E.D.)
Can always observe if unsure
"When in doubt, don't send them out."
Summary
Appendicitis is a common surgical
emergency with a varied clinical
presentation
Several patient groups are at high risk of
misdiagnosis
Lab and imaging studies are helpful, but
no single study is a substitute for good
clinical judgement