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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:
o

Pelvic inflammatory disease (PID) or tubo-ovarian abscess

o

Endometriosis

o

Ovarian cyst or torsion

o

Ureterolithiasis and renal colic

o

Degenerating uterine leiomyomata

o

Diverticulitis

o

Crohn disease

o

Colonic carcinoma

 Also consider the possibility of appendicitis in pediatric or adult patients who present with acute urinary retention. This finding has a sensitivity and specificity of approximately 80%.  An inflamed appendix near the urinary bladder or ureter can cause irritative voiding symptoms and hematuria or pyuria. and vomiting occurs in only 50% of cases. anorexia is present in 74-78% of patients. Consider the possibility of an inflamed pelvic appendix in male patients with apparent cystitis.o Rectus sheath hematoma o Cholecystitis o Bacterial enteritis o Mesenteric adenitis o Omental torsion  The classic history of anorexia and periumbilical pain followed by nausea. it nearly always follows the onset of pain. right lower quadrant (RLQ) pain. and the diagnosis of appendicitis should be reconsidered.  RLQ tenderness is present in 96% of patients. in and of itself. Rarely. Approximately 2% of patients report duration of pain in excess of 2 weeks. Cystitis in male patients is rare in the absence of instrumentation. Neither finding is statistically different from findings in ED patients with other etiologies of abdominal pain. should not be used to rule out the possibility of appendicitis. Vomiting that precedes pain is suggestive of intestinal obstruction. 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. 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.  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. but this is a nonspecific finding. .  Diarrhea or constipation is noted in as many as 18% of patients and should not be used to discard the possibility of appendicitis.  When vomiting occurs. This is often initially misdiagnosed as acute testicular torsion.  Migration of pain from the periumbilical area to the RLQ is the most discriminating feature of the patient's history. A history of similar pain.  A history of similar pain is reported in as many as 23% of cases.  Nausea is present in 61-92% of patients.

rigidity. foreign material (eg. measles. o Obstruction of the appendiceal lumen has less commonly been associated with parasites (eg. 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. Differential Diagnoses Abdominal Abscess Mesenteric Lymphadenitis Cholecystitis and Biliary Colic Omental Torsion .  The most common causes of luminal obstruction are fecaliths and lymphoid follicle hyperplasia. pain on percussion. amebiasis. The Markle sign. respiratory infections. and tumors. failure to perform a rectal examination is frequently cited in successful malpractice claims. activated charcoal). RLQ pain in response to percussion of a remote quadrant of the abdomen. o Lymphoid hyperplasia is associated with a variety of inflammatory and infectious disorders including Crohn disease. Their absence never should be used to rule out appendiceal inflammation.  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. 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. however. o Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix.  Dunphy's sign (sharp pain in the RLQ elicited by a voluntary cough) may be helpful in making the clinical diagnosis of localized peritonitis. or to firm percussion of the patient's heel. The most specific physical findings are rebound tenderness. 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. suggests peritoneal inflammation. and mononucleosis. gastroenteritis. tongue stud. Similarly. intrauterine device.  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.  These signs are present in a minority of patients with acute appendicitis. Schistosomes species.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. In 2008. 2 Causes  Obstruction of the appendiceal lumen usually precipitates appendicitis. Strongyloides species). shotgun pellet. is stated in DeGowin's Diagnostic Examination to be very sensitive for localizing true peritonitis. tuberculosis.

Widow Gastroenteritis. Fewer than 4% of patients with appendicitis have a WBC count less than 10.57) .Constipation Ovarian Cysts Crohn Disease Ovarian Torsion Diverticular Disease Pediatrics. in 1989. Bacterial Urinary Tract Infection.39) 7-9 0. Neutrophilia greater than 75% occurs in 78% of patients.500 cells/mm3 and neutrophilia less than 75%. Intussusception Ectopic Pregnancy Pelvic Inflammatory Disease Endometriosis Renal Calculi Gastroenteritis Spider Envenomations. Female Inflammatory Bowel Disease Urinary Tract Infection. Male Meckel Diverticulum Mesenteric Ischemia Other Problems to Be Considered Appendiceal stump appendicitis Typhilitis Epiploic appendagitis Psoas abscess Yersiniosis Workup Laboratory Studies Complete blood cell count Studies consistently show that 80-85% of adults with appendicitis have a WBC count greater than 10. Dueholm et al.500 cells/mm3. further delineated the relationship between WBC count and the likelihood of appendicitis by calculating likelihood ratios for defined intervals of the WBC count.52 (0-1.3 Table 1.10 (0-0. WBC Count and Likelihood of Appendicitis Open table in new window [ CLOSE WINDOW ] Table WBC (X 10.000) Likelihood Ratio (95% CI*) 4-7 0.

9-11 0. 4. a normal CRP level has a negative predictive value of 97-100% for appendicitis.39) 7-9 0.62) 11-13 2. Thimsen et al noted that a normal CRP level after 12 hours of symptoms was 100% predictive of benign.4) 13-15 1.62) 11-13 2.29 (0-0.5 (0-10) 19-22 ∞ *CI.0) 17-19 3. the findings are nonspecific. The literature is inconsistent with regard to WBC counts in children and elderly patients with appendicitis.5 (0-10) 19-22 ∞ WBC (X 10. Albu 1994. confidence interval.29 (0-0. in adults who have had symptoms for longer than 24 hours.0) 17-19 3.6) 15-17 2.2-4. rapid. self-limited illness.5 In a 1989 study of 70 patients.7 (0-3.6) 15-17 2.8 (1.10 (0-0. Several prospective studies (Thimsen 1989.8 (1. .8 (0-6.7 (0-3.57) 9-11 0.2-4.000) Likelihood Ratio (95% CI*) 4-7 0. however. and widely available. A rapid assay is widely available. CBC tests are inexpensive.52 (0-1.4) 13-15 1. de Carvalho 2003) have shown that. 4 Multiple studies have examined the sensitivity of CRP alone for the diagnosis of appendicitis in patients selected to undergo appendectomy.8 (0-6. C-reactive protein test C-reactive protein (CRP) is an acute-phase reactant synthesized by the liver in response to infection or inflammation.

in 2000. prospectively studied more than 100 children undergoing surgery for suspected appendicitis and found that either WBC or CRP was elevated in 98% of those with pathology-proven appendicitis (CI. retrospectively studied 77 patients older than 60 years with histologically proven appendicitis and found that only 2 had a normal "triple screen.3% for the presence of appendicitis.16  Stefanutti et al.7  Asfar et al. studied 100 children with pathology-proven appendicitis and found that both WBC and CRP were normal in 7 of the 100 patients. respectively. Gurleyik et al.5%. 12 Some studies have examined the sensitivity of combined WBC and CRP in the subpopulation of patients older than 60 years.2% for the "triple screen". 95. in 1999.3-100%).6%. In this group. found that 85 of 89 patients with histologically proven appendicitis had an elevated CRP. a sensitivity of 95. completed a prospective double blind study of 78 patients undergoing appendectomy and found that CRP had a sensitivity of 93. 8  Erkasap et al.10  Ortega-Deballon et al."14 Several studies have examined the accuracy of CRP and WBC in the subpopulation of pediatric patients with suspected appendicitis. in 2001.13  Yang et al. in 1999. prospectively studied patients referred to a surgeon for RLQ pain and found that normal WBC and CRP had a negative predictive value of 92. in 2000.6  Shakhetrah. 17 . 15  Mohammed. in 2006. in 2008.9 Investigators have also studied the ability of combinations of WBC and CRP to reliably rule out the diagnosis of appendicitis. AND a normal CRP. studied 300 patients operated for suspected appendicitis (200 positive. in 2000. prospectively studied 216 children admitted for suspected appendicitis and found triple screen sensitivity and negative predictive value of 86% and 81%. the sensitivity of CRP was 96%. prospectively studied the more relevant group of 102 adult patients with RLQ pain. 55 of whom proceeded to appendectomy.  Gronroos. in 2005. 100 negative) and found that WBC or CRP was abnormal in all 200 patients with appendicitis.6%. studied 83 patients older than 60 years who underwent appendectomy (73 found to have appendicitis) and found that no patient with appendicitis had both normal WBC and CRP. found that 87 of 90 patients with histologically proven appendicitis had an elevated CRP.500 cells/mm3 AND neutrophilia >75%. a sensitivity of 96. in 2004. retrospectively studied 897 patients who underwent appendectomy (740 with appendicitis. 157 without) and found that only 6 of 740 patients with appendicitis had WBC <10. in 2007. 11  Yang. in 1995.  Gronroos.  Gronroos. This yields a sensitivity of 99.

ready availability. lengthy acquisition time if oral contrast is used.7%. and negative predictive value of 90.21. Disadvantages include radiation exposure. most commonly dysuria or right flank pain. Thus.27. Hoecker and Bilman found that unenhanced CT achieved a sensitivity of 87. Kaiser et al found that nonenhanced CT was 66% sensitive. sequential CT with oral and intravenous contrast enhancement is highly accurate but time consuming and expensive. and 1 in 6 patients had greater than 3 RBC per high power field.19.26.31 Sensitivity increased to 90% with the use of intravenous contrast material. 18 Imaging Studies  Computed tomography o Abdominal CT has become the most important imaging study in the evaluation of patients with atypical presentations of appendicitis.8%. In a 2005 study of 112 pediatric patients. 32  In 1997.25 More recent studies of noncontrast helical CT in adults with suspected appendicitis showed a sensitivity of 91-96% and a specificity of 92-100%. 33 Focused helical .5%.28. it is best used for equivocal presentations when helical CT is not available. the diagnosis of appendicitis should not be dismissed due to the presence of urologic symptoms or abnormal urinalysis.23  Advantages of CT scanning include its superior sensitivity and accuracy compared with those of other imaging techniques.30  In a 2004 study of pediatric patients. In 1993.20.29. and potential to reveal alternative diagnoses.CRP is nonspecific and does not distinguish between various types of infection or inflammation. findings on CT must be correlated with the clinical scenario. positive predictive value of 91. Malone evaluated nonenhanced. Urinalysis One study of 500 patients with acute appendicitis revealed that approximately one third reported urinary symptoms.22  Note that one study of asymptomatic volunteers undergoing pelvic CT found that 42% had an "abnormal" appendiceal diameter of greater than 6 mm and 78% of appendices did not fill after oral contrast.  In 1997. and patient discomfort if rectal contrast is used. 24 The addition of intravenous and oral contrast agent increased sensitivity to 96-98%. One in 7 patients had pyuria greater than 10 WBC per high power field. sequential CT in 211 patients and reported a sensitivity of 87% and a specificity of 97%.  Initial studies evaluated sequential (nonhelical) CT in the diagnosis of appendicitis. potential for anaphylactic reaction if intravenous contrast agent is used. Thus. noninvasiveness. specificity of 98. Rao et al found that focused (lower abdominal and upper pelvic) helical CT with 3% Gastrografin instilled into the colon (without intravenous contrast agent) had a superior sensitivity of 98% and specificity of 98%.3%. Lane et al evaluated helical CT without contrast enhancement and found a sensitivity of 90% and specificity of 97%. Thus. Studies have found a decrease in negative laparotomy rate and appendiceal perforation rate when pelvic CT was used in selected patients with suspected appendicitis.

Scattered case reports endorse transvaginal sonography in women with low pelvic tenderness if the appendix is not visualized on transabdominal scans.  The literature suggests that limited helical CT with rectal contrast enhancement is a highly accurate. cost-effective way to evaluate adults with equivocal presentations for appendicitis. lack of peristalsis. time-efficient. A posterolateral approach is suggested to evaluate the retrocecal area.37 A 5-MHz transducer is used. positive predictive value of 97%. specificity of 87. One study found sensitivity of 35% and specificity of 98% in pediatric patients with perforated appendicitis. The tubular structure is noncompressible. and accuracy of 91%. and ischemia.  One recent retrospective study of 173 adults found that helical CT with intravenous contrast only has a sensitivity of 100%. Ultrasonography Sagittal graded compression transabdominal sonogram shows an acutely inflamed appendix. and negative predictive value of 96%.  Numerous studies have documented a sensitivity of 85-90% and a specificity of 92-96%. adnexal pathology.  Continued improvements in helical CT technology may allow nonenhanced helical CT to be the imaging test of choice for adults with suspected appendicitis. specificity of 97%. 36 Elimination of oral contrast reduces emergency department length of stay and delay to operative intervention. Acquisition time is less than 15 minutes.  In 1986. The normal appendix is not visualized in most cases. improving image quality. lacks peristalsis. and measures greater than 6 mm in diameter. Gentle but firm pressure is applied on the RLQ to displace intervening bowel gas and to decrease the distance between the transducer and the appendix. Puylaert described a graded compression technique for evaluating the appendix with transabdominal sonography. achieving sensitivity of 95%. and negative predictive value of 100%. An outer diameter of greater than 6 mm.5%. RLQ tumor. small-bowel hernias. Five studies of graded compression ultrasonography in children showed overall sensitivities of 85-95% and specificities ranging from 47-96%. Radiation exposure is less than that of a standard obstruction series. 34 An earlier study of 78 patients with appendicitis found sensitivity of 91. Transverse graded compression transabdominal sonogram of an acutely inflamed appendix. . Alternative diagnoses are revealed in up to 62% of patients and include diverticulitis. The cost is approximately $225. Anderson et al found that CT without oral contrast was at least as accurate as CT with oral contrast.9%. nephrolithiasis. A thin rim of periappendiceal fluid is present.scanning without intravenous contrast agent eliminates the risk of anaphylaxis and reduces the cost to about $230. Two studies of focused helical CT with rectal contrast in children suggest a sensitivity of 95-97%. Additional studies are needed to identify subgroups that derive the most benefit from diagnostic imaging. This is an excellent diagnostic approach in patients with equivocal presentations who are poor candidates for intravenous contrast. positive predictive value of 97%. noncompressibility.35 In a 2005 retrospective review of 23 published reports. specificity of 97%. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection. or periappendiceal fluid collection characterizes an inflamed appendix.

 Tzanakis and others proposed a clinical scoring system that assigns 6 points if appendiceal ultrasonogram is positive. Advantages of sonography include its noninvasiveness.4%. specificity.4%. and positive CT was confirmed in 21 patients. Kidneys-ureters-bladder (KUB) radiograph shows an appendicolith in the right lower quadrant. and potential for diagnosis of other causes of abdominal pain. .  One new study suggests that ultrasonography should be incorporated as a firstline imaging modality for the diagnosis of acute appendicitis in adults. o Poortman et al concluded that this diagnostic pathway using primary graded-compression ultrasonography and complementary multidetector CT yields a high diagnostic accuracy for acute appendicitis without adverse events from delay in treatment. respectively. Patients with negative CT findings were admitted for observation. when present. Positive ultrasonography was confirmed at surgery in 71 of 79 patients. 151 patients with suspected appendicitis underwent the designed protocol. 3 points for rebound tenderness. Patients with positive findings on CT also underwent surgery. but. lack of radiation exposure.000. Patients with positive results on graded-compression ultrasonography underwent surgery. it is essentially pathognomonic. appendectomy should be performed. it can be used as a primary imaging modality and avoids the disadvantages of CT. and 2 points for WBC count greater than 12. technical expertise and commitment to a thorough examination are essential in obtaining maximum sensitivity. they found sensitivity. The sensitivity and specificity of this protocol was 100% and 86%. and 96. Although ultrasonography is less accurate than CT. this finding is not sufficiently sensitive to rule out the possibility of appendicitis. If negative. short acquisition time. 97. Observation is safe for patients with negative findings on ultrasonography or CT. Graded-compression ultrasonography was performed first.5%. Because nonvisualization is interpreted as a noninflamed appendix. Consideration should be given to further observation and focused helical CT with rectal contrast enhancement.  If graded compression sonogram of the RLQ is positive for appendicitis. Abdominal radiography  The kidneys-ureters-bladder (KUB) view is typically used. and accuracy of 95. Visualization of an appendicolith in a patient with symptoms consistent with appendicitis is highly suggestive of appendicitis.39 These findings should be confirmed by additional studies before routine clinical use. An appendicolith is seen in fewer than 10% of patients with appendicitis. Thirty-nine patients with normal CT results recovered and did not require surgery. In their prospective study of 303 adults using a total score cut-off of 8 points or greater. particularly in the subset of women of childbearing age.  The principal disadvantage is that ultrasonography is operator dependent. Many authorities believe that ultrasonography should be the initial imaging test in pregnant women and in pediatric patients because radiation exposure is particularly undesirable in these groups. 38 o In this study. Those with inconclusive or negative results underwent contrast-enhanced multidetector CT. respectively. 4 points for RLQ tenderness. but this occurs in fewer than 10% of cases.

43 Two studies of newer labeling techniques achieved sensitivities of 98% for the presence of appendicitis. However. radiation exposure.42.  Advantages of barium enema study are its wide availability. long scan times.  Barium enema study  A single-contrast study can be performed on an unprepared bowel.41. Localized uptake of tracer in the RLQ suggests appendiceal inflammation. Neutrophils and macrophages are labeled with technetium-99m albumin and administered intravenously.45 o Although future studies may confirm sensitivity as high as 98%. ischemic colitis) that may mimic appendicitis. colon cancer. o A single retrospective study assessed the accuracy of MRI in 51 pregnant patients with suspected appendicitis in whom ultrasonography was . and potential for diagnosis of other diseases (eg. and limited availability.  Radionuclide scanning  Whole blood is withdrawn for radionuclide scanning. These disadvantages make barium enema study a poor screening examination for use by emergency departments. Crohn disease. The cost is approximately $420. and not cost-effective. and invasiveness.   o Four early studies in adults with suspected appendicitis showed a sensitivity of 80-90% and specificity of 92-100%. use of simple equipment. Absent or incomplete filling of the appendix coupled with pressure effect or spasm in the cecum suggests appendicitis. insufficient sensitivity. Images of the abdomen and pelvis are obtained serially over 4 hours. as many as 16% of studies in adults (22-39% in children) were technically unsuitable for interpretation and excluded from data analysis. Magnetic resonance imaging o MRI plays a relatively limited role in the evaluation because of high cost.The consensus in the literature is that plain radiographs are insensitive.  Multiple studies have found that the sensitivity of a barium enema study is in the range of 80-100%.  Disadvantages include its high incidence of nondiagnostic results. the acquisition time of 5 hours and the lack of availability are disadvantages to its use as a high-sensitivity ED screening test for appendicitis.  Barium enema study has essentially no role in the diagnosis of acute appendicitis in the era of ultrasonography and CT.44. nonspecific. Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled WBCs in the right lower quadrant consistent with acute appendicitis. though the lack of ionizing radiation makes it an attractive modality in pregnant patients.40.

4%. 91. tenderness in the RLQ. respectively. The best known of these is the MANTRELS score. Table 2. leukocytosis. rebound tenderness. The sum of these values is used to predict the likelihood of acute appendicitis. 93. graded compression ultrasound should be the imaging test of choice. and accuracy for MRI was 100%. and shift to the left (Table 2).0%. specificity. positive and negative predictive values. If graded compression ultrasonography is nondiagnostic. the patient should undergo MRI of the abdomen and pelvis. 100%. If ultrasonography demonstrates an inflamed appendix.46 o Cobben et al showed that MRI is far superior to transabdominal ultrasonography in evaluating pregnant patients with suspected appendicitis. nausea and/or vomiting.nondiagnostic. the patient should undergo appendectomy.47 o When evaluating pregnant patients with suspected appendicitis. which tabulates migration of pain. elevated temperature. anorexia. Sensitivity. Other Tests Clinical diagnostic scores Several investigators have created diagnostic scoring systems in which a finite number of clinical variables is elicited from the patient and each is given a numerical value. and 94. MANTRELS Score Open table in new window [ CLOSE WINDOW ] Table Characteristic Score M = Migration of pain to the RLQ 1 A = Anorexia 1 N = Nausea and vomiting 1 T = Tenderness in RLQ 2 R = Rebound pain 1 E = Elevated temperature 1 L = Leukocytosis 2 S = Shift of WBC to the left 1 Total 10 Characteristic M = Migration of pain to the RLQ Score 1 .6%.

patients with a MANTRELS score of 3 or lower had a 3. that those with scores of 7 or above receive surgical consultation. was based on a population of patients hospitalized for suspected appendicitis. however. The principle disadvantages are that each institution must generate its own database to reflect characteristics of its local population. none has been shown prospectively to improve on the clinician's judgment in the subset of patients evaluated in the ED for abdominal pain suggestive of appendicitis. These investigators suggested that patients with an Alvarado score of 0-3 could be discharged without imaging. 49 Schneider et al. It is then used in prospectively assessing the risk of appendicitis. patients with scores of 4-6 had a 32% incidence of appendicitis. and those with scores of 4-6 undergo computed tomography. and patients with scores of 7-10 had a 78% incidence of appendicitis. in fact.6% incidence of appendicitis. The MANTRELS score.A = Anorexia 1 N = Nausea and vomiting 1 T = Tenderness in RLQ 2 R = Rebound pain 1 E = Elevated temperature 1 L = Leukocytosis 2 S = Shift of WBC to the left 1 Total 10 Source. They concluded that the MANTRELS score was not sufficiently accurate to be used as the sole method for determining the need for appendectomy in the pediatric population.48 Clinical scoring systems are attractive because of their simplicity. Computer-aided diagnosis can achieve a sensitivity greater than 90% while reducing rates of perforation and negative laparotomy by as much as 50%. . which differs markedly from the population seen in the ED.50 Computer-aided diagnosis A retrospective database of clinical features of patients with appendicitis and other causes of abdominal pain is entered into a computer.—Alvarado. Specialized equipment and significant initiation time are required. McKay et al reviewed 150 emergency department patients who underwent abdominopelvic CT to rule out appendicitis. studied 588 patients aged 3-21 years and found that a MANTRELS score of 7 or greater had a positive predictive value of 65% and a negative predictive value of 85%. in 2007. In that series. 1986.

o Consider ectopic pregnancy in women of childbearing age. but 37% of these patients had recurrent appendicitis within 14 months. no study has shown that analgesics adversely affect the accuracy of physical examination. individuals on ships at sea). symptoms resolved in 95% of patients receiving antibiotics alone.Computer-aided diagnosis is not widely available in US EDs. o Preoperative antibiotics should be given in conjunction with the surgical consultant. o In one prospective study of 20 patients with sonography-proven appendicitis. o Broad-spectrum gram-negative and anaerobic coverage is indicated. o Administer parenteral analgesic and antiemetic as needed for patient comfort. o Administer intravenous antibiotics to those with signs of septicemia and to those who are to proceed to laparotomy. Nonsurgical treatment of appendicitis o Anecdotal reports describe the success of intravenous antibiotics in treating acute appendicitis in patients without access to surgical intervention (eg.51 o Nonsurgical treatment may be useful when appendectomy is not accessible or when it is temporarily a high-risk procedure. . submariners. The administration of analgesics to patients with acute undifferentiated abdominal pain has historically been discouraged and criticized because of concerns that they render the physical findings less reliable. At least 8 randomized controlled studies now demonstrate that administering opioid analgesic medications to adult and pediatric patients with acute undifferentiated abdominal pain is safe. and obtain a qualitative beta–human chorionic gonadotropin (beta-hCG) measurement in all cases. Preoperative antibiotics o Preoperative antibiotics have demonstrated efficacy in decreasing postoperative wound infection rates in numerous prospective controlled studies. o Patients with suspected appendicitis should not receive anything by mouth. Treatment Emergency Department Care    Treatment guidelines for patients with suspected acute appendicitis o Establish intravenous access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration or septicemia.

Appears to be absorbed into cells. The Surgical Infection Society recommends starting prophylactic antibiotics before surgery. Carbapenems are a good option in these patients. Regimens are of approximately equal efficacy. disulfiram reaction may occur with orally ingested ethanol Documented hypersensitivity Pregnancy B . monitor for seizures and peripheral neuropathy Gentamicin (Gentacidin. Medication The goals of therapy are to eradicate the infection and to prevent complications. and phenytoin.5 mg/kg IV before surgery Pediatric 15-30 mg/kg/d IV divided bid/tid for 7 d. cimetidine may increase toxicity. Antibiotics These agents are effective in decreasing the rate of postoperative wound infection and in improving outcome in patients with appendiceal abscess or septicemia. lithium. so consideration should be given to features such as medication allergy. or 40 mg/kg PO once. o Pregnant patients should receive pregnancy category A or B antibiotics.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Adjust dose in hepatic disease. gentamicin). pregnancy category (if applicable). Garamycin) . intermediate metabolized compounds bind DNA and inhibit protein synthesis. broad gram-negative and anaerobic coverage. Consultations  Consult a general surgeon. Metronidazole (Flagyl) Used in combination with aminoglycoside (eg. using appropriate spectrum agents for less than 24 hours for nonperforated appendicitis and for less than 5 days for perforated appendicitis. causing cell death. toxicity.o Penicillin-allergic patients should avoid beta-lactamase type antibiotics and cephalosporins. and cost. not to exceed 2 g/d May increase toxicity of anticoagulants. Adult 7.

Used in combination with agent against gram-positive organisms and one against anaerobes. adjust dose in renal impairment Cefotetan (Cefotan) Second-generation cephalosporin used as single-drug therapy for broad gram-negative and anaerobic coverage.5 h. Consider if penicillins or other less toxic drugs contraindicated.5 mg/kg/d IV divided tid Coadministration with other aminoglycosides. cephalosporins.Aminoglycoside antibiotic for gram-negative coverage. Numerous regimens. Give with cefoxitin to achieve effectiveness of single dose. 3-5 mg/kg/d divided tid/qid thereafter Pediatric Infants/neonates: 7.  Dosing  Interactions  Contraindications  Precautions Adult 2 mg/kg IV loading dose before surgery. which may cause irreversible hearing loss of varying degrees (monitor regularly) Documented hypersensitivity. may use if benefits outweigh risk to fetus Precautions Narrow therapeutic index (not intended for long-term therapy). non–dialysis-dependent renal insufficiency Pregnancy C . adjust dose for CrCl and changes in volume of distribution. aminoglycosides enhance effects of neuromuscular blocking agents. hypocalcemia.5 mg/kg/d IV divided tid Children: 6-7. Half-life is 3. myasthenia gravis. and amphotericin B may increase nephrotoxicity. May be given IV/IM. and conditions that depress neuromuscular transmission. coadministration with loop diuretics may increase ototoxicity of aminoglycosides. prolonged respiratory depression may occur. Adult 2 g IV once before surgery Pediatric 20-40 mg/kg IV/IM once before surgery . Not DOC. and in mixed infections caused by susceptible staphylococci and gram-negative organisms. caution in renal failure (not on dialysis).Fetal risk revealed in studies in animals but not established or not studied in humans. when clinically indicated. penicillins.

effective against most gram-positive and gram-negative bacteria. coadministration with potent diuretics (eg. Adult 2 g IV before surgery. may increase hypoprothrombinemic effects of anticoagulants.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment. loop diuretics) or aminoglycosides may increase nephrotoxicity Documented hypersensitivity Pregnancy B . followed by 3 doses of 2 g q4-6h for 24 h Probenecid may increase effects. followed by 3 doses of 2 g q4-6h for 24 h Pediatric <3 months: Not established >3 months: 30-40 mg/kg IV before surgery.Consumption of alcohol within 72 h may produce disulfiramlike reactions.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Reduce dose by half if CrCl 10-30 mL/min and by three quarters if <10 mL/min. Half-life is 0. caution in patients with previously diagnosed colitis Meropenem (Merrem) Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Adult 1 g IV q8h . coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function) Documented hypersensitivity Pregnancy B .8 h. bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy Cefoxitin (Mefoxin) Second-generation cephalosporin indicated as single agent for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Used as a single agent.

effects when administered concurrently with aminoglycosides are synergistic. Adult 3. perform urinalysis.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Pseudomembranous colitis and thrombocytopenia may occur (immediate discontinue) Piperacillin and tazobactam sodium (Zosyn) Drug combination of beta-lactamase inhibitor with piperacillin. monitor for liver function abnormalities by measuring AST and ALT during therapy. bacteremia. inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication. emphysema.375 g IV q6h Pediatric 300-400 mg piperacillin/kg/d IV divided q6-8h Tetracyclines may decrease effects of piperacillin. meningitis. increasing levels Documented hypersensitivity Pregnancy B . monitor blood levels to avoid possible neurotoxic reactions . and anaerobic bacteria. probenecid may increase penicillin levels. exercise caution in patients diagnosed with hepatic insufficiencies. Used as a single agent. and BUN and creatinine determinations during therapy and adjust dose if values become elevated. Activity against some gram-positive organisms. gram-negative organisms.Fetal risk revealed in studies in animals but not established or not studied in humans. and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage Pregnancy C . high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line. pericarditis. high dose parenteral penicillins may result in increased risk of bleeding Documented hypersensitivity. may use if benefits outweigh risk to fetus Precautions Perform CBCs prior to initiation of therapy and at least weekly during therapy.Pediatric 40 mg/kg IV q8h Probenecid may inhibit renal excretion. severe pneumonia.

may start at 0. Oramorph) DOC for analgesia because of reliable and predictable effects. not to exceed 4 g/d sulbactam or 8 g/d ampicillin Pediatric <3 months: Not established 3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h >12 years: Administer as in adults.2 mg/kg dose IV/IM/SC q2-4h prn. Adult 1. Adult Starting dose: 0. Morphine sulfate (Astramorph.05 mg/kg/dose Further Inpatient Care . not to exceed 15 mg/dose. and anaerobic bacteria.Ampicillin and sulbactam (Unasyn) Drug combination of beta-lactamase inhibitor with ampicillin. gram-negative organisms (nonpseudomonal species). Duramorph. allopurinol decreases ampicillin effects and has additive effects on ampicillin rash.1-0. Used as a single agent.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h. causing bactericidal activity against susceptible organisms. evaluate rash and differentiate from hypersensitivity reaction Analgesics These agents can be used to relieve acute undifferentiated abdominal pain in patients presenting to the ED. Activity against some gram-positive organisms. MSIR. Interferes with bacterial cell wall synthesis during active replication.5 (1 g ampicillin + 0. not to exceed 4 g/d sulbactam or 8 g/d ampicillin Probenecid and disulfiram elevate ampicillin levels. commonly titrated to desired effect. may decrease effects of oral contraceptives Documented hypersensitivity Pregnancy Precautions Adjust dose in renal failure. and ease of reversibility with naloxone. MS Contin.1 mg/kg IV/IM/SC Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h Relative hypovolemia: Start with 2 mg IV/IM/SC. safety profile. reassess hemodynamic effects of dose Pediatric Infants and children: 0. Various IV doses are used.

therapy can be changed to oral antibiotics and the patient can be discharged home. Recent experience has also demonstrated that laparoscopic appendectomy is successful in approximately 90% of cases of perforated appendicitis.   Open versus laparoscopic appendectomy o Initially performed in 1987. Immediate versus interval appendectomy for appendicitis with perforation o Historically. . WBC count. and fever satisfactorily resolve. o Further studies are necessary to identify the optimal treatment strategy in patients with perforated appendicitis. advanced stages of appendicitis. Emergent versus urgent appendectomy o One retrospective study suggests that the risk of appendiceal rupture is minimal in patients with less than 24-36 hours of untreated symptoms. laparoscopic appendectomy has been performed in thousands of patients and is successful in 90-94% of attempts. If the patient's symptoms. o Disadvantages of laparoscopic appendectomy are increased cost and an operating time approximately 20 minutes longer than that of open appendectomy. whether perforated or unperforated. The latter may resolve with increasing experience with laparoscopic technique. Delayed (interval) appendectomy can then be performed 4-8 weeks later. o Advantages of laparoscopic appendectomy include increased cosmetic satisfaction and a decrease in the postoperative wound-infection rate. This approach is successful in the vast majority of patients with perforated appendicitis and localized symptoms. Some studies show that laparoscopic appendectomy shortens the hospital stay and convalescent period compared with open appendectomy. immediate (emergent) appendectomy was recommended for all patients with appendicitis. Further studies are needed to clarify whether routine interval appendectomy is indicated. o Recent clinical experience suggests that patients with perforated appendicitis with mild symptoms and localized abscess or phlegmon on abdominopelvic CT scans can be initially treated with intravenous antibiotics and percutaneous or transrectal drainage of any localized abscess. Some have suggested that interval appendectomy is not necessary unless the patient presents with recurrent symptoms. or complications compared to appendectomy within 12 hours of presentation. operative time.53 o Additional studies are needed to demonstrate whether initiation of antibiotic therapy followed by urgent appendectomy is as effective as emergent appendectomy for patients with unperforated appendicitis. 52 Another recent retrospective study suggests that appendectomy within 1224 hours of presentation is not associated with an increase in hospital length of stay. o Laparoscopic appendectomy is contraindicated in patients with significant intra-abdominal adhesions.

o Nausea. . but their reappearance later in gestation should be viewed with suspicion. but in the latter half of pregnancy. the appendix migrates in a counterclockwise direction toward the right kidney. see eMedicine's patient education articles. rising above the iliac crest at about 4.Although rare. the condition is not diagnosed correctly on their first visit to the health care provider. Special Concerns  Pregnant women o The incidence of appendicitis is unchanged in pregnancy. o RLQ pain and tenderness dominate in the first trimester. o During pregnancy. approximately 36 reported cases of appendicitis in the surgical stump after prior appendectomy exist.5 months' gestation. Also.  Failure to diagnose appendicitis is the leading cause of successful malpractice claims and the fifth most expensive source of claims against emergency physicians. Appendicitis and Abdominal Pain in Adults. Miscellaneous Medicolegal Pitfalls  For approximately 10% of adults with appendicitis. Patient Education  For excellent patient education resources. Stomach.Complications  Wound infection  Dehiscence  Bowel obstruction  Abdominal/pelvic abscess  Stump appendicitis . vomiting. but the clinical presentation is more variable than at other times. visit eMedicine's Esophagus. right upper quadrant (RUQ) or right flank pain must be considered a possible sign of appendiceal inflammation. and Intestine Center. 54  Death (rare) Prognosis  The prognosis is excellent. and anorexia are common in uncomplicated first trimester pregnancies.

diagnostic delay with perforation does increase fetal and maternal morbidity. aggressive evaluation of the appendix is warranted in this group. dysuria. vaginal discharge. and ear. . and throat findings. The most frequent misdiagnoses are PID. o Children with misdiagnosed appendicitis are more likely than their counterparts to have vomiting before pain onset. and lethargy or irritability. nose. signs and symptoms of upper respiratory infection. o Physical findings less likely to be documented in children with a misdiagnosis than in others include bowel sounds. and the rate of initial misdiagnosis is inversely related to the age of the patient.   o Physiologic leukocytosis during pregnancy makes the WBC count less useful in the diagnosis than at other times. vaginal discharge. o The most common misdiagnosis is gastroenteritis. anorexia and onset of pain more than 14 days after menses suggests appendicitis. Children o Appendicitis is misdiagnosed in 25-30% of children. constipation. diarrhea. cervical motion tenderness. peritoneal signs. or urinary symptoms indicates PID. and no reliable distinguishing WBC parameters are cited in the literature. Elderly patients o Appendicitis in patients older than 60 years accounts for 10% of all appendectomies. Nonpregnant women of childbearing age o Appendicitis is misdiagnosed in 33% of nonpregnant women of childbearing age. tenderness outside the RLQ. Previous PID. followed by upper respiratory infection and lower respiratory infection. followed by gastroenteritis and urinary tract infection. o Although negative appendectomy does not appear to adversely affect maternal or fetal health. rectal findings. and positive urinalysis support the diagnosis of PID. o In distinguishing appendiceal pain from that of PID. o On physical examination.55 o Diagnostic laparoscopy has also been suggested for pregnant patients in the first trimester with suspected appendicitis. o The incidence of misdiagnosis is increased in elderly patients. Therefore. o One study of 22 pregnant women in the first and second trimesters showed that graded compression ultrasonography had a sensitivity of 66% and specificity of 95%.

a duration of symptoms in excess of 24-48 hours should not dissuade the clinician from the diagnosis.o In patients with comorbid conditions. therefore. . diagnostic delay is correlated with increased morbidity and mortality. o Older patients tend to seek medical attention later in the course of illness.