INTESTINAL SURGERY II

Acute appendicitis

the eastern countries, and more rarely, neoplasia and foreign

bodies can cause luminal obstruction. This obstruction leads to
congestion, inflammation and ischaemia of the appendix.

T V Chandrasekaran
Natalie Johnson

Epidemiology

Appendicitis is the inflammation of the vermiform appendix and is the

commonest clinical differential diagnosis made in young adults presenting with acute abdominal and right iliac fossa pain. The diagnosis is
largely clinical but ultrasound or CT may be helpful in some cases. Antibiotic treatment is used for uncomplicated appendicitis in some centres
based on the principle that other intra-abdominal infections, such as
diverticulitis are appropriately managed with antibiotics. The gold standard of treatment, however, is still appendicectomy with the more
frequent use of laparoscopic appendicectomy, particularly in the female
patient. The most common complication is that of wound infection.

Appendicitis is the most common cause of the acute abdomen in

the UK and about 10% of the population will develop acute
appendicitis. It occurs in about 7% of the US population. It is
suspected to be lower in incidence in African and Asian countries
due to the higher fibre content in the diet. Higher fibre decreases
the formation of faecoliths and hence reduces risk of obstruction.
It can occur at any age but tends to be highest in the 10 to 20 age
group.1 It is rare in infants under 3 years of age. In the paediatric
population the average age of occurrence is between 6 and 10
years. It is more common in males than females. Appendicitis in
pregnancy is associated with up to a 5% risk of fetal loss. This
increases to 20% if perforation occurs.

Keywords Alvarado score; appendicitis; laparoscopic appendicectomy;

Mc Burneys point; Rovsings sign

Pathology and pathogenesis

Abstract

Obstruction of the lumen of the appendix leads to congestion

within the appendix resulting in an increase in luminal pressure
due to the secretion of inflammatory exudate and mucous. This
obstructs lymphatic drainage leading to further oedema, ulceration, bacterial growth and formation of pus due to recruitment
of white blood cells leading to ischaemia of the appendix. The
loss of integrity leads to bacterial invasion of the submucosa
and muscularis propria resulting in acute appendicitis.
Thrombosis of the appendiceal artery and veins leads to
ischaemic necrosis resulting in perforation and gangrene. This
may lead to a phlegmon, appendix abscess or frank peritonitis.
On the rare occasion when the initial stages of infection resolves, the appendix gets distended with mucus resulting in a
mucocele.

Introduction
Appendicitis is the inflammation of the vermiform appendix. The
appendix originates 1.7e2.5 cm below the terminal ileum. The
base is fixed in position at the confluence of the three taeniae coli
of the caecum, which fuse to form the outer longitudinal muscle
of the appendix. During appendicectomy location of this landmark will help identify the base of the appendix. The tip of the
appendix is more varied in position and can affect clinical presentation when inflamed. The majority, 74%, are retrocaecal,
21% pelvic, 2% paracaecal, 1.5% subcaecal, 1% pre-ileal and
0.5% post-ileal. Patients may also have their appendix behind
the ascending colon and liver making clinical presentations more
variable. Congenital agenesis, duplication and triplication of the
appendix are extremely rare. Appendicitis was first described in
the 16th century as perityphlitis. McBurney described the clinical
findings in 1889 and appendicectomy is still the mainstay of
treatment. It is the current belief that appendicitis gets worse
with time and if left untreated will lead to perforation. About one
in five patients present with complicated appendicitis and a
perforation rate of 15e20% has been reported.

Diagnosis
The diagnosis of acute appendicitis is mainly clinical. There is no
single investigation that can specifically identify appendicitis and
therefore a combination of the history, clinical examination,
haematological investigations, radiological investigations and
diagnostic laparoscopy may be required for diagnosis.

History (Box 1)
Aetiology

A thorough history is essential given the vast differential of

right lower quadrant pain. It is important to enquire about
gastrointestinal, upper respiratory and genitourinary symptoms

The pathophysiology of appendicitis is not fully elucidated, but

obstruction of the appendiceal lumen is the most common
process leading to infection of the wall by gut flora. Faecoliths
and less frequently lymphoid hyperplasia secondary to gastroenteritis, amoebiasis or Crohns are responsible for luminal
obstruction leading to appendicitis. Parasites, more common in

Symptoms of appendicitis
C
C
C
C

T V Chandrasekaran MBBS FRCS (Edin) FRCS (Gen) is a Consultant Colorectal

Surgeon at Morriston and Singleton Hospital, Wales, UK. Conflicts of
interest: none declared.

C
C
C

Natalie Johnson MB.BS MRCS (Eng) PhD is an ST3 Surgical Trainee at Morriston Hospital, Wales, UK. Conflicts of interest: none declared.

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Peri-umbilical colicky abdominal pain

Loss of appetite
Nausea
Diarrhoea/constipation
Malaise
Abdominal swelling
Fever

Box 1

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Please cite this article in press as: Chandrasekaran T. V., Johnson N, Acute appendicitis, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.06.004

INTESTINAL SURGERY II

Children

in the patients history of abdominal pain. The patient may give

an initial history of acute onset poorly localised, colicky,
abdominal pain. This pain may initially be central due to
appendiceal inflammation and obstruction causing visceral
pain but as infection worsens it becomes more localized to the
right lower quadrant. There is associated nausea and sometimes vomiting (mostly in children). This vomiting comes after
the onset of pain. A persistent anorexia is almost always present. The pyrexia associated with appendicitis usually follows
the first 6 hours of the onset of symptoms. These symptoms
progress over several hours or days, and may not be apparent
during the early presentation but develop after a short period of
observation. Hence, repeated observations and re-assessment is
necessary.

In the paediatric age group, the most common disease mistaken

for appendicitis is gastroenteritis or mesenteric adenitis. Enlarged
cervical lymph nodes may indicate the latter. In Meckels diverticulitis, the only discerning factor may be central and left-sided
pain and possible lower gastrointestinal bleeding. Appendicitis is
unusual below the age of 3 and the average age for intussusception is 18 months. HenocheSchonlein purpura is preceded by
sore throat or previous respiratory infection and ecchymosis on
the extensor surfaces and buttocks with facial sparing. These
patients commonly have microscopic haematuria.

Adults
Terminal ileitis due to Crohns or Yersinia infection may produce
a palpable mass of inflamed ileum. These patients will give a
history of cramping abdominal pain, weight loss and diarrhoea.
Ureteric colic presents with loin to groin pain and a positive urine
dipstick. Pyrexia is not usually associated and a plain film
radiograph, ultrasound or CT may be diagnostic. Right-sided
pyelonephritis is associated with a high temperature, rigors and
urinary symptoms. The tenderness is maximal in the loin. A
perforated peptic ulcer leaks duodenal contents which track
along the paracolic gutter to the right iliac fossa. The history may
include dyspepsia and an acute onset of epigastric pain. An erect
chest film will elucidate free air under the diaphragm in 70% of
cases. The pain of testicular torsion can radiate to the right iliac
fossa. The scrotum should be examined in all cases, especially in
younger males. A rectus sheath haematoma although rare, can
present with acute pain, tenderness and a mass in the right iliac
fossa, particularly in patients on warfarin or other anti-platelet
agents. There may be a history of recent strenuous exercise
and there is no gastrointestinal upset.

Physical examination
As standard, the examination should begin with preliminary
markers such as pulse rate, temperature, rate of respiration
and blood pressure. Temperature ranges from 37.2 to 37.8 C
and is rarely above 38 C. In children such a high temperature
is suggestive of an alternative cause such as mesenteric
adenitis and examination of the ear, nose and throat should be
included. Tachycardia usually corresponds to the rise in
temperature.
A thorough examination of the abdomen is expected
including a digital rectal examination. This should take the form
of inspection, palpation, percussion and auscultation. There are
signs that are pathognomonic for appendicitis and these include
the Pointing sign in which the patient identifies the area of
maximal tenderness. Before touching the patient ask them to
cough which may elicit abdominal pain, Dunphys sign. In more
advanced appendicitis the abdomen may be firm as the patient
is guarding the abdominal wall muscles. Gentle superficial
palpation from left iliac fossa to right in an anticlockwise
fashion will highlight the point of maximal tenderness, that is,
McBurneys point. Deep palpation of the left iliac fossa may
elicit pain in the right iliac fossa, known as Rovsings sign. Pain
on percussion over the right iliac fossa will indicate localized
peritonitis. The psoas sign is right lower quadrant pain that is
produced on passive extension of the right hip or active flexion
when standing. The pain is due to inflammation in the peritoneum overlying the iliopsoas muscle. The patient may be lying
with the knee in flexion and straightening out the leg causes
pain because it stretches the muscles. When an inflamed appendix is in contact with the obturator internus, the obturator
test of flexion and internal rotation of the hip causes spasm of
the muscle and pain in the hypogastrium. It is important to note
that the location of the appendix can alter its presentation and
clinical signs. A retrocaecal appendix may only be tender on
deep palpation. A pelvic appendix may cause diarrhoea and the
patients tenderness is just supero-lateral to the symphysis
pubis. An inflamed appendix abutting the bladder may trigger
urinary symptoms.

Women
A thorough history should be taken in all female patients, especially those of childbearing age, to include their gynaecological
history. A history of the menstrual cycle, dysmenorrhoea,
vaginal discharge, hormonal contraception and pregnancy are
very useful in narrowing down the myriad of causes that can
present in a similar fashion to appendicitis. A urine pregnancy
test, blood b-human chorionic gonadotropin (b-HCG) and
abdominal or transvaginal ultrasound may be useful in
diagnosis.

Elderly
In the elderly age group a long sigmoid may lie to the right of the
midline making differentiation from appendicitis difficult. An
abdominal CT will be useful in this scenario. Colon cancer in the
elderly that has obstructed or perforated may mimic appendicitis.
The history may clarify the difference with anaemia, weight loss
and change in bowel habit but a CT is diagnostic.

Differential diagnosis (Table 1)

Investigations

Many other conditions may mimic appendicitis including chest

pathology and the differential for acute abdominal pain can be
age and gender specific.

Laboratory-based investigations help reduce the removal of the

normal appendix that happens in up to a third of patients. Haematological and bedside tests help to reduce the incidence of

SURGERY --:-

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Chandrasekaran T. V., Johnson N, Acute appendicitis, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.06.004

INTESTINAL SURGERY II

Differential diagnosis for acute appendicitis2

Paediatric

Adult

Female

Elderly

Gastroenteritis
Mesenteric adenitis
Meckels diverticulitis
Intussusception
Henoch Schonlein purpura
Lobar pneumonia

Ureteric colic
Perforated peptic ulcer
Testicular torsion
Pancreatitis
Rectus sheath haematoma
Crohns ileitis
Epiploic appendagitis

Mittleschmerz
Pelvic inflammatory disease
Pyelonephritis
Ectopic pregnancy
Torsion or rupture of ovarian cyst
Endometriosis

Diverticulitis
Intestinal obstruction
Colon cancer
Mesenteric infarct
Leaking aortic aneurysm
Torsion appendix epiplociae

Table 1

management includes keeping the patient nil by mouth, starting

IV fluids, analgesia and antibiotics. Antibiotics usually include
metronidazole and a third-generation cephalosporin. Recent
literature has suggested that the use of antibiotic treatment in
uncomplicated appendicitis is safe and effective.3 There is,
however, a recurrence rate of 15% within 1 year and of those
readmitted after successful treatment with antibiotics, one in five
present with complicated appendicitis.4 The conservative management may best suit patients with a high operative risk and
multiple co-morbidities. For open or conventional appendicectomy, the incision is made over McBurneys point. This is located
one-third of the way along an imaginary line from the anterior
superior iliac spine to the umbilicus and is said to identify the
base of the appendix as the tip may have multiple positions. The
incision, known as the McBurneys or Gridiron incision, is made
perpendicular to this point. More recently the transverse Lanz
incision has been favoured. This is made horizontally over
McBurneys point and is believed to give better cosmesis, exposure and room for extension. If in doubt or an appendix mass is
palpated in the anaesthetized patient a lower midline incision
can be made (Figure 1).

removal of a normal appendix particularly in the elderly and comorbid group. Investigations include a full blood count in which
the white cell count will be elevated. The acute inflammatory
markers such as C-reactive protein may also be elevated. This
may be low or normal at early presentation. b-HCG is mandatory
in women of childbearing age, including those on contraception
and urine dipstick and microscopy are helpful along with the full
clinical picture to rule out renal pathology.
There are several scoring systems but the most widely used is
the Alvarado score (Table 2). A score of 7 or greater is strongly
predictive of appendicitis. An equivocal score of 5e6 may warrant an abdominal ultrasound or contrast CT.

Imaging
An abdominal and pelvic ultrasound scan is performed mostly in
female patients when the history is unclear and clinical findings
are equivocal. In obese patients its use is limited due to their
habitus. A CT is less indicated in the young and female patients
due to its high level of irradiation and may be more useful in the
elderly age group but there is still a 10e20% negative appendicectomy rate despite the use of CT. Direct visualization at laparoscopy may be necessary to confirm the diagnosis.

Incisions for open appendicectomy

Management
The standard treatment of acute appendicitis is appendicectomy.
This is now more practised with minimal access approach with
the developments in laparoscopic surgery. Initial acute

Score
Symptoms

Signs

Laboratory tests
Total

Migratory RIF pain

Anorexia
Nausea and vomiting
Tenderness in RLQ
Rebound tenderness
Elevated temperature
Leucocytosis
Shift to left

Lanz
incision

1
1
1
2
1
1
2
1
10

Asis

Lower
midline

Figure 1 The standard incision was the Gridiron incision centred over
McBurneys point. This point is located one-third along an imaginary line
between the anterior superior iliac spine and the umbilicus. This incision
can be modified and made along the Langers lines in the same location.
The Lanz incision is made about 2 cm below the umbilicus, centred on the
mid-clavicular line. The lower midline incision can be used in the event of
a gangrenous appendix or appendix abscess.

Table 2

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Umbilicus

Gridiron
incision

The Alvarado (MANTRELS) scoring system

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Please cite this article in press as: Chandrasekaran T. V., Johnson N, Acute appendicitis, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.06.004

INTESTINAL SURGERY II

Procedure

Ports for laparoscopic appendicectomy

Following division of the skin and subcutaneous tissues, the

external oblique aponeurosis is exposed and divided in the line
of the fibres. The internal oblique and transverse abdominis are
split in the line of the fibres exposing the parietal peritoneum.
The peritoneum is opened taking care not to damage any underlying viscera. A swab for microbiology is taken if any
collection or pus is encountered. The caecum is identified by
the taeniae coli or by following the small bowel to the caecum.
Appendix is delivered through the wound and may be aided by
the use of Babcock forceps. Adhesions in a very inflamed appendix may be divided gently by finger sweeping to aid the
delivery of the appendix to the wound. The appendix is
controlled with Babcock forceps. The mesoappendix containing
the appendicular vessels are divided between ligatures. Once
the appendix is free, the base of the appendix is then crushed at
its junction to the caecum with a heavy clip and this is repeated
just distal to this. The base is then transfixed with an absorbable 2/0 ligature. The appendix can then be resected with a
scalpel. The appendix stump is buried using a purse string or Z
suture, which is applied through the serosa at about 1 cm from
the base. When the suture is tied the appendix base is invaginated. Not all surgeons believe invagination is necessary and in
circumstances where the caecal wall is inflammed the suture
may cut out. In the event of a retrocaecal and adherent appendix a retrograde appendicectomy is performed. In this case
the base is divided, the appendiceal vessels ligated and this
frees the body of the appendix to be delivered and removed
from base to tip. The caecum is returned to the peritoneal
cavity and the edges of the peritoneum closed with a continuous absorbable suture. Muscle fibres are loosely apposed with
interrupted sutures and the external oblique closed with a
continuous absorbable suture. The skin is closed with an
absorbable subcuticular suture. In the event of an appendix
mass or abscess found at operation, the abscess should be
drained and IV antibiotics administered.

Umbilical port
1012 mm
Supraumbilical
port 5 mm

Figure 2 The left iliac fossa port is used as the optical port in order to
triangulate and the assistant holds the camera through this port. Most
centres use a 30 , 5-mm camera. The umbilical port is used to retrieve the
appendix and the suprapubic port is used for traction and counter-traction
with the appropriate instruments.

Complications
Complications may be classified as early and late based on their
time of presentation postoperatively. Within the first week
postoperatively, the most common early complication following
appendicectomy is wound infection and occurs in 5e10% of
patients. The most common causative organisms are Gramnegative bacilli and anaerobes. Wound drainage may be indicated based on clinical findings and antibiotics given pre- and
intraoperatively can reduce the rate of wound infection. Intraabdominal abscesses present early. The most common sites for
this include between loops of small bowel (interloop), pelvic,
subphrenic and paracolic sites. This should be considered in a
patient presenting with postoperative pain, temperature and
anorexia within the first week and radiological imaging such as
ultrasound or CT may be used to identify and possibly guide
drainage of the collection. Postoperative ileus should be
managed conservatively by keeping the patient nil by mouth, IV
fluids and the insertion of a nasogastric tube. Port site haematoma can be avoided by removing ports under vision.
Late complications include adhesional obstruction,7 faecal
fistula, and incisional herniae. They are rare and may occur up to
a few months to years after surgery and more frequently occur in
females, diabetics and those with peritonitis at the time of surgery.8 Herniae following the open technique occurs in less than
0.12% of patients.9 Patients should be warned about the risk of
these types of herniae occurring during consent.

Laparoscopic appendicectomy
This is diagnostic as well as therapeutic. There are several
papers that have suggested that it improves diagnosis and reduces the risk of negative appendicectomy in fertile women.5
The operator is positioned on the patients left. Three ports
are inserted. A 10-mm umbilical port and two 5-mm ports
placed in the left lower quadrant and hypogastrium. The optical
port is triangulated in the left lower quadrant and the suprapubic and umbilical ports are working ports (Figure 2). The
appendix is located. This may be aided by a Trendelenberg tilt
to deliver loops of small bowel and improve visibility. The
appendix is elevated to expose the mesoappendix, which is
divided with diathermy. The base of the appendix is tied using
two absorbable loop sutures and the appendix is divided and
removed via the 10-mm port. If the appendix is normal,
examining the pelvis and immediate small bowel should identify alternative causes. Not all surgeons remove the appendix if
it appears normal, particularly if an alternative cause is found.
Of those removed, 3.2% show acute inflammation on
histology.6

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Left iliac fossa

5mm port

Neoplasms of the appendix

Neoplasms of the appendix are rare. Carcinoid tumour or argentaffinoma of the appendix is the most common accounting for up to
77% of tumours of the appendix. It is frequently found in the distal
third of the appendix and arises from the argentaffin tissue or the
hn. It rarely develops
Kulchitsky cells within the crypts of Lieberku
metastases and appendicectomy is sufficient management of this
tumour providing the tumour is less than 2 cm, there is no

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Chandrasekaran T. V., Johnson N, Acute appendicitis, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.06.004

INTESTINAL SURGERY II

2 Bailey and Love. Short practice of surgery. 26th edn.

3 Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E. Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence. Can J Surg 2011; 54:
307e14.
4 Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics
compared with appendicectomy for treatment of uncomplicated
acute appendicitis: meta-analysis of randomised controlled trials. Br
Med J 2012; 344: e2156.
5 Mishra RK, Hanna GB, Cushieri A. Laparoscopic vs. open appendicectomy for the treatment of acute appendicitis. World J Laparoscopic Surg 2008; 1: 19e28.
6 Walker SJ, West CR, Colmer MR. Acute appendicitis: does removal of
a normal appendix matter, what is the importance of diagnostic accuracy and is surgical delay important. Ann R Coll Surg Engl 1995;
77: 358e63.
7 Tingstedt B, Johansson J, Nehez L, Andersson R. Late abdominal
complaints after appendectomyereadmissions during long-term
follow-up. Dig Surg 2004; 21: 23e7.
8 Beltran MA, Cruces KS. Incisional hernia after McBurney incision:
retrospective case-control study of risk factors and surgical treatment. World J Surg 2008; 32: 596e601. discussion 602e3.
9 Konstantakos AK, Zollinger Jr RM. Repair of McBurney incisional
hernias after open appendectomy. Curr Surg 2000; 57: 79e80.
10 Andersen B, Nielsen TF. Appendicitis in pregnancy, diagnosis, management and complications. Acta Obstet Gynecol Scand 1999; 78:
758e62.
11 Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy:
new information that contradicts long-held clinical beliefs. Am J
Obstet Gynecol 2000; 182: 1027e9.

involvement of the caecal wall and no lymphadenopathy. The

Goblet cell carcinoid tumour is a more aggressive variant that requires hemicolectomy based on a size greater than 2 cm, lymphovascular invasion, marginal involvement and more than two
mitoses per high power field on microscopy. The mucinous cystadenoma of the appendix if ruptured requires radical resection of
all surfaces involved and aggressive chemotherapy. This is
necessary as the ruptured lesion seeds the peritoneum with its
mucus secreting cells. Adenocarcinomas are very rare.

Appendicitis in pregnancy
Appendicitis in pregnancy occurs in one in 2000 pregnancies and
can result in fetal loss in up to 5% of cases,10 which is reportedly
highest in the first and second trimesters.11 A high index of
suspicion is necessary as the usual signs and symptoms may be
masked as those of pregnancy. Intraoperative management is the
same keeping in mind the displacement of the appendix by the
gravid uterus.

Summary
In a patient presenting with acute appendicitis, perforation and
peritonitis are the greatest concerns to the surgeon. With a high
clinical suspicion, a thorough history, examination and the aid of
investigations, safe and appropriate management can be ensured
and can also reduce the incidence of a negative appendicectomy.A
REFERENCES
1 Lewis SR, Mahony PJ, Simpson J. Appendicitis. Br Med J 2011; 343:
d5976.

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2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Chandrasekaran T. V., Johnson N, Acute appendicitis, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.06.004