Corin 1

18/11/2015
Acuteappendicitisinadults:Clinicalmanifestationsanddifferentialdiagnosis
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Author
RonaldFMartin,MD
SectionEditor
MartinWeiser,MD
DeputyEditor
WenliangChen,MD,PhD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Oct2015.|Thistopiclastupdated:Jul09,2014.
INTRODUCTIONAppendicitis,aninflammationofthevestigialvermiformappendix,isoneofthemost
commoncausesoftheacuteabdomenandoneofthemostfrequentindicationsforanemergentabdominal
surgicalprocedureworldwide[1,2].
Theclinicalmanifestationsanddiagnosisofappendicitisinadultswillbereviewedhere.Themanagementof
appendicitisinadultsandappendicitisinpregnancyandchildrenarediscussedseparately.(See"Managementof
acuteappendicitisinadults"and"Acuteappendicitisinpregnancy"and"Acuteappendicitisinchildren:Clinical
manifestationsanddiagnosis".)
ANATOMYThevermiformappendixislocatedatthebaseofthececum,neartheileocecalvalvewherethe
taeniacoliconvergeonthececum(figure1)[3,4].Theappendixisatruediverticulumofthececum.Incontrastto
acquireddiverticulardisease,whichconsistsofaprotuberanceofasubsetoftheentericwalllayers,the
appendicealwallcontainsallofthelayersofthecolonicwall:mucosa,submucosa,muscularis(longitudinaland
circular),andtheserosalcovering[5].
Theappendicealorificeopensintothececum.Itsbloodsupply,theappendicealartery,isaterminalbranchofthe
ileocolicartery,whichtraversesthelengthofthemesoappendixandterminatesatthetipoftheorgan(figure2)[4].
Theattachmentoftheappendixtothebaseofthececumisconstant.However,thetipmaymigratetothe
retrocecal,subcecal,preileal,postileal,andpelvicpositions.Thesenormalanatomicvariationscancomplicatethe
diagnosisasthesiteofpainandfindingsontheclinicalexaminationwillreflecttheanatomicpositionofthe
appendix.
ThepresenceofBandTlymphoidcellsinthemucosaandsubmucosaofthelaminapropriamaketheappendix
histologicallydistinctfromthececum[5].Thesecellscreatealymphoidpulpthataidsimmunologicfunctionby
increasinglymphoidproductssuchasIgAandoperatingaspartofthegutassociatedlymphoidtissuesystem[3].
Lymphoidhyperplasiacancauseobstructionoftheappendixandleadtoappendicitis.Thelymphoidtissue
undergoesatrophywithage[6].
EPIDEMIOLOGYAppendicitisoccursmostfrequentlyinthesecondandthirddecadesoflife.Theincidenceis
approximately233/100,000populationandishighestinthe10to19yearoldagegroup[7].Itisalsohigheramong
men(maletofemaleratioof1.4:1),whohavealifetimeincidenceof8.6percentcomparedwith6.7percentfor
women[7].
PATHOGENESISThenaturalhistoryofappendicitisissimilartothatofotherinflammatoryprocesses
involvinghollowvisceralorgans.Initialinflammationoftheappendicealwallisfollowedbylocalizedischemia,
perforation,andthedevelopmentofacontainedabscessorgeneralizedperitonitis.
Appendicealobstructionhasbeenproposedastheprimarycauseofappendicitis[3,811].Obstructionisfrequently
implicatedbutnotalwaysidentified.Astudyofpatientswithappendicitisshowedthattherewaselevated
intraluminalpressureinonlyonethirdofthepatientswithnonperforatedappendicitis[12].
Appendicealobstructionmaybecausedbyfecaliths(hardfecalmasses),calculi,lymphoidhyperplasia,infectious
processes,andbenignormalignanttumors.However,somepatientswithafecalithhaveahistologicallynormal
appendixandthemajorityofpatientswithappendicitisdonothaveafecalith[13,14].
http://www.uptodate.com/contents/acuteappendicitisinadultsclinicalmanifestationsanddifferentialdiagnosis?topicKey=SURG%2F1386&elapsedTimeMs
1/27
18/11/2015
Whenobstructionoftheappendixisthecauseofappendicitis,theobstructionleadstoanincreaseinluminaland
intramuralpressure,resultinginthrombosisandocclusionofthesmallvesselsintheappendicealwall,andstasis
oflymphaticflow.Astheappendixbecomesengorged,thevisceralafferentnervefibersenteringthespinalcordat
T8T10arestimulated,leadingtovaguecentralorperiumbilicalabdominalpain[8].Welllocalizedpainoccurslater
inthecoursewheninflammationinvolvestheadjacentparietalperitoneum.
Themechanismofluminalobstructionvariesdependinguponthepatient'sage.Intheyoung,lymphoidfollicular
hyperplasiaduetoinfectionisthoughttobethemaincause.Inolderpatients,luminalobstructionismorelikelyto
becausedbyfibrosis,fecaliths,orneoplasia(carcinoid,adenocarcinoma,ormucocele).Inendemicareas,
parasitescancauseobstructioninanyagegroup.(See"Canceroftheappendixandpseudomyxomaperitonei".)
Onceobstructed,thelumenbecomesfilledwithmucusanddistends,increasingluminalandintramuralpressure.
Thisresultsinthrombosisandocclusionofthesmallvessels,andstasisoflymphaticflow.Aslymphaticand
vascularcompromiseprogress,thewalloftheappendixbecomesischemicandthennecrotic.
Bacterialovergrowthoccurswithinthediseasedappendix.Aerobicorganismspredominateearlyinthecourse,
whilemixedinfectionismorecommoninlateappendicitis[15].Commonorganismsinvolvedingangrenousand
perforatedappendicitisincludeEscherichiacoli,Peptostreptococcus,Bacteroidesfragilis,andPseudomonas
species[16].Intraluminalbacteriasubsequentlyinvadetheappendicealwallandfurtherpropagateaneutrophilic
exudate.Theinfluxofneutrophilscausesafibropurulentreactionontheserosalsurface,irritatingthesurrounding
parietalperitoneum[6].Thisresultsinstimulationofsomaticnerves,causingpainatthesiteofperitonealirritation
[5].
Duringthefirst24hoursaftersymptomsdevelop,approximately90percentofpatientsdevelopinflammationand
perhapsnecrosisoftheappendix,butnotperforation.Thetypeofluminalobstructionmaybeapredictorof
perforationofanacutelyinflamedappendix.Fecalithsweresixtimesmorecommonthantruecalculiinthe
appendix,butcalculiweremoreoftenassociatedwithperforatedappendicitisorperiappendicealabscess(45
percent)thanwerefecaliths(19percent).Thisispresumablyduetotherigidityoftruecalculiascomparedwith
thesofter,morecrushablefecaliths[13].
Oncesignificantinflammationandnecrosisoccur,theappendixisatriskofperforation,whichleadstolocalized
abscessformationordiffuseperitonitis.Thetimecoursetoperforationisvariable.Onestudyshowedthat20
percentofpatientsdevelopedperforationlessthan24hoursaftertheonsetofsymptoms[17].Sixtyfivepercentof
patientsinwhomtheappendixperforatedhadsymptomsforlongerthan48hours.
CLINICALFEATURES
Clinicalmanifestations
HistoryAbdominalpainisthemostcommonsymptom,andisreportedinnearlyallconfirmedcasesof
appendicitis[18,19].Theclinicalpresentationofacuteappendicitisisdescribedasaconstellationofthefollowing
classicsymptoms:
Rightlowerquadrant(rightanterioriliacfossa)abdominalpain
Anorexia
Nauseaandvomiting
Intheclassicpresentation,thepatientdescribestheonsetofabdominalpainasthefirstsymptom.Thepainis
typicallyperiumbilicalinnaturewithsubsequentmigrationtotherightlowerquadrantastheinflammation
progresses[18].Althoughconsideredaclassicsymptom,migratorypainoccursonlyin50to60percentof
patientswithappendicitis[8,20].Nauseaandvomiting,iftheyoccur,usuallyfollowtheonsetofpain.Fever
relatedsymptomsgenerallyoccurlaterinthecourseofillness.
Inmanypatients,initialfeaturesareatypicalornonspecific,andcaninclude:
Indigestion
2/27
18/11/2015
Flatulence
Bowelirregularity
Diarrhea
Generalizedmalaise
Becausetheearlysymptomsofappendicitisareoftensubtle,patientsandcliniciansmayminimizetheir
importance.Thesymptomsofappendicitisvarydependinguponthelocationofthetipoftheappendix(figure1)
(see'Anatomy'above).Forexample,aninflamedanteriorappendixproducesmarked,localizedpainintheright
lowerquadrant,whilearetrocecalappendixmaycauseadullabdominalache[21].Thelocationofthepainmay
alsobeatypicalinpatientswhohavethetipoftheappendixlocatedinthepelvis,whichcancausetenderness
belowMcBurney'spoint.Suchpatientsmaycomplainofurinaryfrequencyanddysuriaorrectalsymptoms,such
astenesmusanddiarrhea.
PhysicalexaminationTheearlysignsofappendicitisareoftensubtle.Lowgradefeverreaching101.0F
(38.3C)maybepresent.Thephysicalexaminationmaybeunrevealingintheveryearlystagesofappendicitis
sincethevisceralorgansarenotinnervatedwithsomaticpainfibers.
However,astheinflammationprogresses,involvementoftheoverlyingparietalperitoneumcauseslocalized
tendernessintherightlowerquadrantandcanbedetectedontheabdominalexamination.Rectalexamination,
althoughoftenadvocated,hasnotbeenshowntoprovideadditionaldiagnosticinformationincasesof
appendicitis.Inwomen,rightadnexalareatendernessmaybepresentonpelvicexamination,anddifferentiating
betweentendernessofpelvicoriginversusthatofappendicitismaybechallenging.Highgradefever
(>101.0F/38.3C)occursasinflammationprogresses.(See"Differentialdiagnosisofabdominalpaininadults".)
Patientswitharetrocecalappendixmaynotexhibitmarkedlocalizedtendernessintherightlowerquadrantsince
theappendixdoesnotcomeintocontactwiththeanteriorparietalperitoneum(figure1)[21].Therectaland/or
pelvicexaminationismorelikelytoelicitpositivesignsthantheabdominalexamination.Tendernessmaybemore
prominentonpelvicexamination,andmaybemistakenforadnexaltenderness.
Severalfindingsonphysicalexaminationhavebeendescribedtofacilitatediagnosis,butthesefindingspredated
definitiveimagingforappendicitis,andthewidevariationintheirsensitivityandspecificitysuggeststhattheybe
usedwithcautiontobroaden,ornarrow,adifferentialdiagnosis.Therearenophysicalfindings,takenaloneorin
concert,thatdefinitivelyconfirmadiagnosisofappendicitis.
Commonlydescribedphysicalsignsinclude:
McBurney'spointtendernessisdescribedasmaximaltendernessat1.5to2inchesfromtheanterior
superioriliacspine(ASIS)onastraightlinefromtheASIStotheumbilicus[22](sensitivity50to94percent
specificity75to86percent[2325]).
Rovsing'ssignreferstopainintherightlowerquadrantwithpalpationoftheleftlowerquadrant.Thissignis
alsocalledindirecttendernessandisindicativeofrightsidedlocalperitonealirritation[26](sensitivity22to
68percentspecificity58to96percent[24,2729]).
Thepsoassignisassociatedwitharetrocecalappendix.Thisismanifestedbyrightlowerquadrantpainwith
passiverighthipextension.Theinflamedappendixmaylieagainsttherightpsoasmuscle,causingthe
patienttoshortenthemusclebydrawinguptherightknee.Passiveextensionoftheiliopsoasmusclewith
hipextensioncausesrightlowerquadrantpain(sensitivity13to42percentspecificity79to97percent
[27,30,31]).
Theobturatorsignisassociatedwithapelvicappendix.Thistestisbasedontheprinciplethattheinflamed
appendixmaylayagainsttherightobturatorinternusmuscle.Whentheclinicianflexesthepatient'srighthip
andkneefollowedbyinternalrotationoftherighthip,thiselicitsrightlowerquadrantpain,(sensitivity8
percentspecificity94percent[30]).Thesensitivityislowenoughthatexperiencedcliniciansnolonger
performthisassessment.
3/27
18/11/2015
LaboratoryfindingsAmildleukocytosis(whitebloodcellcount>10,000cells/microL)ispresentinmost
patientswithacuteappendicitis[32].Approximately80percentofpatientshavealeukocytosisandaleftshift
(increaseintotalWBCcount,bands[immatureneutrophils],andneutrophils)inthedifferential[3335].The
sensitivityandspecificityofanelevatedwhitebloodcell(WBC)countinacuteappendicitisis80percentand55
percentrespectively.
AcuteappendicitisisunlikelywhentheWBCcountisnormal,exceptintheveryearlycourseoftheillness[35
37].Incomparison,meanWBCcountsarehigherinpatientswithagangrenous(necrotic)orperforatedappendix
[38]:
Acute14,5007,300cells/microL
Gangrenous17,1003,900cells/microL
Perforated17,9002,100cells/microL(see'Perforatedappendix'below)
Mildelevationsinserumbilirubin(totalbilirubin>1.0mg/dL)havebeennotedtobeamarkerforappendiceal
perforationwithasensitivityof70percentandaspecificityof86percent[39].Thiscomparesfavorablywitha
sensitivityandspecificityofanelevatedWBCof80percentand55percentrespectively.
Imagingstudies
ComputedtomographyfindingsThefollowingfindingssuggestacuteappendicitisonstandardabdominal
computedtomography(CT)scanningwithcontrastincluding(image1andimage2)[4042]:
Enlargedappendicealdiameter>6mmwithanoccludedlumen
Appendicealwallthickening(>2mm)
Periappendicealfatstranding
Appendicealwallenhancement
Appendicolith(seeninapproximately25percentofpatients)
UltrasoundfindingsThemostaccurateultrasoundfindingforacuteappendicitisisanappendiceal
diameterof>6mm(image3andimage4)[8,43,44].
PlainradiographfindingsPlainradiographsareusuallynothelpfulforestablishingthediagnosisof
appendicitis(image5).However,thefollowingradiographicfindingshavebeenassociatedwithacuteappendicitis:
Rightlowerquadrantappendicolith
Localizedrightlowerquadrantileus
Lossofthepsoasshadow
Freeair(occasionally)
Deformityofcecaloutline
Rightlowerquadrantsofttissuedensity
MagneticresonanceimagingMagneticresonanceimaging(MRI)canassistwiththeevaluationofacute
abdominalandpelvicpainduringpregnancy(image6)[45,46].Anormalappendixisvisualizedasatubular
structurelessthanorequalto6mmindiameterandfilledwithairand/ororalcontrastmaterial[47].Anenlarged
fluidfilledappendix(>7mmindiameter)isconsideredanabnormalfinding,whileanappendixwithadiameterof6
to7mmisconsideredaninconclusivefinding[47].(See"Approachtoabdominalpainandtheacuteabdomenin
pregnantandpostpartumwomen"and"Acuteappendicitisinpregnancy".)
DIFFERENTIALDIAGNOSISAvarietyofinflammatoryandinfectiousconditionsintherightlowerquadrant
canmimicthesignsandsymptomsofacuteappendicitis.(See"Differentialdiagnosisofabdominalpainin
adults".)
PerforatedappendixDuringthefirst24hoursaftertheonsetofabdominalpainandassociatedsymptoms,
approximately90percentofpatientsdevelopinflammationandperhapsnecrosisoftheappendix,butnot
4/27
18/11/2015
perforation.Oncesignificantinflammationandnecrosisoccur,theappendixisatriskforperforation,whichleads
tolocalizedabscessformationordiffuseperitonitis.Thetimecoursetoperforationisvariable.Onestudyshowed
that20percentofpatientsdevelopedperforationlessthan24hoursaftertheonsetofsymptoms[17].Sixtyfive
percentofpatientsinwhomtheappendixperforatedhadsymptomsforlongerthan48hours.
Aperforatedappendixmustbeconsideredinapatientwhosetemperatureexceeds103.0F(39.4C),theWBC
countisgreaterthan15,000cells/microL,andimagingstudiesrevealafluidcollectionintherightlowerquadrant.
(See'Pathogenesis'aboveand'Laboratoryfindings'aboveand"Acuteappendicitisinadults:Diagnostic
evaluation",sectionon'Imaging'and'Imagingstudies'above.)
CecaldiverticulitisCecaldiverticulitisusuallyoccursinyoungadultsandpresentswithsignsandsymptoms
thatcanbevirtuallyidenticaltothoseofacuteappendicitis.Rightsideddiverticulitisoccursinonly1.5percentof
patientsinWesterncountries,butismorecommoninAsianpopulations(accountingforasmanyas75percentof
casesofdiverticulitis).Patientswithrightsideddiverticulitistendtobeyoungerthanthosewithleftsideddisease
andoftenaremisdiagnosedwithacuteappendicitis.Computedtomographic(CT)scanningoftheabdomenwithIV
andoralcontrastisthediagnostictestofchoiceinpatientssuspectedofhavingacutediverticulitis.(See"Clinical
manifestationsanddiagnosisofacutediverticulitisinadults"and"Nonoperativemanagementofacute
uncomplicateddiverticulitis",sectionon'Rightsided(cecal)diverticulitis'.)
Meckel'sdiverticulitisMeckel'sdiverticulitispresentsinafashionsimilartoacuteappendicitis.AMeckel's
diverticulumisacongenitalremnantoftheomphalomesentericductandislocatedonthesmallintestinetwofeet
fromtheileocecalvalve[48,49].Meckel'sdiverticulitisshouldbeincludedinthedifferentialdiagnosis,asthesmall
bowelmaymigrateintotherightlowerquadrantandmimicthesymptomsofappendicitis.Ifaninflamedappendix
isnotfoundonabdominalexplorationforacuteappendicitis,thesurgeonshouldsearchforaninflamedMeckel's
diverticulum.(See"Meckelsdiverticulum",sectionon'Clinicalpresentations'.)
AcuteileitisAcuteileitis,duemostcommonlytoanacuteselflimitedbacterialinfection(Yersinia,
Campylobacter,Salmonella,andothers),shouldbeconsideredwhenacutediarrheaisaprominentsymptom.
Otherclinicalmanifestationsofacuteyersiniosisincludeabdominalpain,fever,nauseaand/orvomiting.
Yersiniosiscannotbereadilydistinguishedclinicallyfromothercausesofacutediarrheathatpresentwiththese
symptoms.However,localizationofabdominalpaintotherightlowerquadrantalongwithacutediarrheamaybea
diagnosticclueforyersiniosis.(See"ClinicalmanifestationsanddiagnosisofYersiniainfections",sectionon
'Acuteyersiniosis'.)
Acuteyersiniosispresentingwithrightlowerabdominalpain,fever,vomiting,leukocytosis,andunderstated
diarrheamaybeconfusedwithacuteappendicitis.Atsurgery,findingsincludevisibleinflammationaroundthe
appendixandterminalileumandinflammationofthemesentericlymphnodestheappendixitselfisgenerally
normal.Yersiniacanbeculturedfromtheappendixandinvolvedlymphnodes.(See"Clinicalmanifestationsand
diagnosisofYersiniainfections",sectionon'Pseudoappendicitis'.)
Crohn'sdiseaseCrohn'sdiseasecanpresentwithsymptomssimilartoappendicitis,particularlywhen
localizedtothedistalileum.Fatigue,prolongeddiarrheawithabdominalpain,weightloss,andfever,withor
withoutgrossbleeding,arethehallmarksofCrohn'sdisease.AnacuteexacerbationofCrohnsdiseasecanmimic
acuteappendicitisandmaybeindistinguishablebyclinicalevaluationandimaging.
Crohn'sdiseaseshouldbesuspectedinpatientswhohavepersistentpainaftersurgery,especiallyiftheappendix
ishistologicallynormal.(See"Clinicalmanifestations,diagnosisandprognosisofCrohndiseaseinadults".)
GynecologicandobstetricalconditionsThefollowinggynecologicdiseasesmaypresentwithsymptoms
and/orclinicalfindingsthatareincludedinthedifferentialofacuteappendicitis:
TuboovarianabscessAtuboovarianabscess(TOA)isaninflammatorymassinvolvingthefallopiantube,
ovary,and,occasionally,otheradjacentpelvicorgans(eg,bowel,bladder).Theseabscessesarefoundmost
commonlyinreproductiveagewomenandtypicallyresultfromuppergenitaltractinfection.Tuboovarianabscess
5/27
18/11/2015
isusuallyacomplicationofpelvicinflammatorydisease.Theclassicpresentationincludesacutelowerabdominal
pain,fever,chills,andvaginaldischarge.However,feverisnotpresentinallpatients,somepatientsreportonly
lowgradenocturnalfeversorchills,andnotallwomenpresentinanacutefashion.ClinicalhistoryandCT
imagingcanhelpdifferentiateTOAfromacuteappendicitis(picture1).(See"Epidemiology,clinicalmanifestations,
anddiagnosisoftuboovarianabscess",sectionon'Clinicalpresentation'.)
PelvicinflammatorydiseaseLowerabdominalpainisthecardinalpresentingsymptominwomenwith
pelvicinflammatorydisease(PID),althoughthecharacterofthepainmaybequitesubtle.Therecentonsetofpain
thatworsensduringcoitusorwithjarringmovementmaybetheonlypresentingsymptomofPIDtheonsetofpain
duringorshortlyaftermensesisparticularlysuggestive.Onphysicalexamination,onlyaboutonehalfofpatients
withPIDhavefever.Abdominalexaminationrevealsdiffusetendernessgreatestinthelowerquadrants,which
mayormaynotbesymmetrical.Reboundtendernessanddecreasedbowelsoundsarecommon.Onpelvic
examination,thefindingofapurulentendocervicaldischargeand/oracutecervicalmotionandadnexaltenderness
withbimanualexaminationisstronglysuggestiveofPID.ClinicalhistoryandCTimagingcanhelpdifferentiate
PIDfromacuteappendicitis(See"Pelvicinflammatorydisease:Clinicalmanifestationsanddiagnosis".)
RupturedovariancystRuptureofanovariancystisacommonoccurrenceinwomenofreproductiveage
andmaybeassociatedwiththesuddenonsetofunilaterallowerabdominalpain.Therightlowerquadrantismost
commonlyaffected,possiblybecausetherectosigmoidcolonprotectstheleftovaryfromtheeffectsofabdominal
trauma.Thepainoftenbeginsduringstrenuousphysicalactivity,suchasexerciseorsexualintercourse,andmay
beaccompaniedbylightvaginalbleedingduetoadropinsecretionofovarianhormonesandsubsequent
endometrialsloughing.Bloodfromtherupturesitemayseepintotheovary,whichcancausepainfromstretching
oftheovariancortex,oritmayflowintotheabdomen,whichhasanirritanteffectontheperitoneum.Serousor
mucinousfluidreleaseduponcystruptureisnotveryirritatingthepatientmayremainasymptomaticdespite
accumulationofalargevolumeofintraperitonealfluid.Ontheotherhand,spillageofsebaceousmaterialupon
ruptureofadermoidcystcausesamarkedgranulomatousreactionandchemicalperitonitis,whichisusuallyquite
painful.IntraabdominalhemorrhagemaybeassociatedwithCullen'ssign(ie,periumbilicalecchymoses).Clinical
historyandCTimagingcanhelpdifferentiatearupturedovariancystfromacuteappendicitis(image7andimage
8).(See"Evaluationandmanagementofrupturedovariancyst".)
MittelschmerzMittelschmerzreferstomidcyclepaininanovulatorywomancausedbynormalfollicular
enlargementjustpriortoovulationortonormalfollicularbleedingatovulation.Thepainistypicallymildand
unilateralitoccursmidwaybetweenmenstrualperiodsandlastsforafewhourstoacoupleofdays.Fluidor
bloodisreleasedfromtherupturedeggfollicleandcancauseirritationoftheliningoftheabdominalwall.(See
"Physiologyofthenormalmenstrualcycle".)
OvarianandfallopiantubetorsionOvariantorsionreferstothetwistingoftheovaryonitsligamentous
supports,oftenresultinginimpedanceofitsbloodsupply(picture2).Isolatedfallopiantubetorsionisuncommon
(picture3).Expedientdiagnosisisimportanttopreserveovarianfunctionandpreventadversesequelae.However,
thediagnosiscanbechallengingbecausethesymptomsarerelativelynonspecific.
Themostcommonsymptomofovariantorsionissuddenonsetlowerabdominalpain,oftenassociatedwith
wavesofnauseaandvomiting.Fever,althoughanuncommonfindinginovariantorsion,maybeamarkerof
necrosis,particularlyinthesettingofanincreasedwhitebloodcellcount.ClinicalhistoryandCTimagingcanhelp
differentiatethediagnosisfromacuteappendicitis(picture4).(See"Ovarianandfallopiantubetorsion".)
EndometriosisEndometriosisisdefinedasthepresenceofendometrialglandsandstromaatextrauterine
sites.Theseectopicendometrialimplantsareusuallylocatedinthepelvis,butcanoccurnearlyanywhereinthe
body(picture5).
Commonsymptomsofendometriosisincludepelvicpain(whichisusuallychronicandoftenmoresevereduring
mensesoratovulation),dysmenorrhea,deepdyspareunia,cyclicalbowelorbladdersymptoms,abnormal
menstrualbleeding,andinfertility.Thereareoftennoabnormalfindingsonphysicalexaminationwhenfindingsare
present,themostcommonistendernessuponpalpationoftheposteriorfornix.Ultrasoundismostlyusefulfor
6/27
18/11/2015
diagnosingovarianendometriomasitlacksadequateresolutionforvisualizingadhesionsandsuperficial
peritoneal/ovarianimplants,whicharemorecommonthanendometriomas.(See"Endometriosis:Pathogenesis,
clinicalfeatures,anddiagnosis".)
OvarianhyperstimulationsyndromeOvarianhyperstimulationsyndrome(OHSS)isaniatrogenic
complicationofovulationinductiontherapy,andmaybeaccompaniedbyormistakenforcystrupture.Clinical
findingsincludebloating,nausea,vomiting,diarrhea,lethargy,shortnessofbreath,andrapidweightgain.
Severeovarianhyperstimulationsyndromeischaracterizedbylargeovariancysts,ascites,and,insomepatients,
pleuraland/orpericardialeffusion,electrolyteimbalance(hyponatremia,hyperkalemia),hypovolemia,and
hypovolemicshock.Markedhemoconcentration,increasedbloodviscosity,andthromboembolicphenomena,
includingdisseminatedintravascularcoagulation,occurinthemostseverecases.(See"Pathogenesis,clinical
manifestations,anddiagnosisofovarianhyperstimulationsyndrome".)
EctopicpregnancyEctopicpregnancyhasclinicalsymptomsandsonographicfeaturessimilartothoseof
arupturedovariancyst.Inwomenwithacutepelvicpainorabnormalvaginalbleeding,apositivepregnancytest
stronglysuggeststhepresenceofanectopicpregnancyifanintrauterinepregnancycannotbevisualized
sonographically.Ifanintrauterinepregnancyisvisualized,thenpelvicpainandintraperitonealfluidcouldbedueto
arupturedovariancyst(eg,corpusluteumcyst,thecaluteincyst)orheterotopicpregnancy.(See"Ectopic
pregnancy:Clinicalmanifestationsanddiagnosis",sectionon'Heterotopicpregnancy'.)
AcuteendometritisAcuteendometritisoccursafteranobstetricaldeliveryor,rarely,afteraninvasive
uterineprocedure.Thediagnosisislargelybaseduponthepresenceoffever,gradualonsetofuterinetenderness,
fouluterinedischarge,andleukocytosisinanatrisksetting.(See"Postpartumendometritis"and"Endometritis
unrelatedtopregnancy".)
Urologicconditions
RenalcolicPainisthemostcommonsymptomandvariesfromamildandbarelynoticeableacheto
discomfortthatissointensethatitrequiresparenteralanalgesics.Thepaintypicallywaxesandwanesinseverity,
anddevelopsinwavesorparoxysmsthatarerelatedtomovementofthestoneintheureterandassociated
ureteralspasm.Paroxysmsofseverepainusuallylast20to60minutes.Painisthoughttooccurprimarilyfrom
urinaryobstructionwithdistentionoftherenalcapsule.(See"Diagnosisandacutemanagementofsuspected
nephrolithiasisinadults"and"Acutemanagementofnephrolithiasisinchildren".)
TesticulartorsionTesticulartorsionisaurologicemergencythatismorecommoninneonatesand
postpubertalboys,althoughitcanoccuratanyage.Testiculartorsionresultsfrominadequatefixationofthetestis
tothetunicavaginalis.Iffixationofthelowerpoleofthetestistothetunicavaginalisisinsufficientlybroadbased
orabsent,thetestismaytorse(twist)onthespermaticcord,potentiallyproducingischemiafromreducedarterial
inflowandvenousoutflowobstruction.(See"Causesofscrotalpaininchildrenandadolescents",sectionon
'Testiculartorsion'and"Evaluationoftheacutescrotuminadults",sectionon'Testiculartorsion'.)
EpididymitisEpididymitisoccursmorefrequentlyamonglateadolescents,butalsooccursinyoungerboys
whodenysexualactivityandisthemostcommoncauseofscrotalpaininadultsintheoutpatientsetting.Several
factorsmaypredisposepostpubertalboystodevelopsubacuteepididymitis,includingsexualactivity,heavy
physicalexertion,anddirecttrauma(eg,bicycleormotorcycleriding).Bacterialepididymitisinprepubertalboysis
associatedwithstructuralanomaliesoftheurinarytract.Inacuteinfectiousepididymitis,palpationreveals
indurationandswellingoftheinvolvedepididymiswithexquisitetenderness.Moreadvancedcasesoftenpresent
withtesticularswellingandpain(epididymoorchitis)withscrotalwallerythemaandareactivehydrocele.(See
"Causesofscrotalpaininchildrenandadolescents",sectionon'Epididymitis'and"Evaluationoftheacute
scrotuminadults",sectionon'Epididymitis'.)
TorsionoftheappendixtestisorappendixepididymisTheappendixtestisisasmallvestigialstructure
ontheanterosuperioraspectofthetestis(anembryologicremnantoftheMllerianductsystem).Theappendix
7/27
18/11/2015
epididymisisavestigialremnantoftheWolffianductthatislocatedattheheadoftheepididymis.The
pedunculatedshapeoftheseappendagespredisposesthemtotorsion,whichcanproducescrotalpainthatranges
frommildtosevere.Mostcasesoftorsionoftheappendixtestisoccurbetweentheagesof7and14years,and
rarelyoccurinadults.(See"Causesofscrotalpaininchildrenandadolescents",sectionon'Torsionofthe
appendixtestisorappendixepididymis'and"Evaluationoftheacutescrotuminadults",sectionon'Torsionofthe
appendixtestis'.)
TREATMENTThemanagementofacuteappendicitisinchildrenandadultsisdiscussedindetailseparately.
(See"Acuteappendicitisinchildren:Management"and"Managementofacuteappendicitisinadults".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Appendicitisinadults(TheBasics)").
SUMMARYANDRECOMMENDATIONSAppendicitisisoneofthemostcommoncausesoftheacute
abdomenandoneofthemostfrequentindicationsforanemergentabdominalsurgicalprocedureworldwide.
Thetipoftheappendixcanbefoundinaretrocecalorpelviclocation,aswellasmedial,lateral,anterior,or
posteriortothececum.Anatomicvariabilitycancomplicatethediagnosis,asclinicalpresentationwillreflect
theanatomicpositionoftheappendix.(See'Anatomy'above.)
Appendicealobstructionplaysaroleinthepathogenesisofappendicitis,butitisnotrequiredforthe
developmentofappendicitis.(See'Pathogenesis'above.)
Theclassicsymptomsofappendicitisincluderightlowerquadrantabdominalpain,anorexia,fever,nausea,
andvomiting.Theabdominalpainisinitiallyperiumbilicalinnaturewithsubsequentmigrationtotheright
lowerquadrantastheinflammationprogresses(see'Clinicalmanifestations'above).Patientswith
appendicitiscanalsopresentwithatypicalornonspecificsymptoms,suchasindigestion,flatulence,bowel
irregularity,andgeneralizedmalaiseandnotallpatientswillhavemigratoryabdominalpain.
Thedifferentialdiagnosisofrightlowerquadrantabdominalpainincludesinflammatorydiseaseprocesses
(eg,Crohnsdisease,rupturedcyst),infectiousdiseases(eg,acuteileitis,tuboovarianabscess),and
obstetricalconditions(eg,ectopicpregnancy).(See'Differentialdiagnosis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1. WilliamsGR.PresidentialAddress:ahistoryofappendicitis.Withanecdotesillustratingitsimportance.Ann
Surg1983197:495.
2. Fitz,RH.Perforatinginflammationofthevermiformappendixwithspecialreferencetoitsearlydiagnosis
andtreatment.AmJMedSci188692:321.
3. Jaffe,BM,Berger,DH.TheAppendix.In:SchwartzPrinciplesofSurgery,8thed,Schwartz,SI,Brunicardi,
CF(Ed),McGrawHillHealthPub.Division,NewYork2005.
8/27
18/11/2015
4. BuschardK,KjaeldgaardA.Investigationandanalysisoftheposition,fixation,lengthandembryologyofthe
vermiformappendix.ActaChirScand1973139:293.
5. Mulholland,MW,Lillemoe,KD,Doherty,GM,etal.Greenfield'sSurgery,4thed,LippincottWilliams&
Wilkins,Philadelphia,PA2005.
6. Kumar,V,Abbas,AK,Fausto,N.RobbinsandCotran:PathologicBasisofDisease,7thed,Saunders
Elsevier,Philadelphia,PA2007.
7. AddissDG,ShafferN,FowlerBS,TauxeRV.Theepidemiologyofappendicitisandappendectomyinthe
UnitedStates.AmJEpidemiol1990132:910.
8. BirnbaumBA,WilsonSR.Appendicitisatthemillennium.Radiology2000215:337.
9. BurkittDP.Theaetiologyofappendicitis.BrJSurg197158:695.
10. ButlerC.Surgicalpathologyofacuteappendicitis.HumPathol198112:870.
11. MirandaR,JohnstonAD,O'LearyJP.Incidentalappendectomy:frequencyofpathologicabnormalities.Am
Surg198046:355.
12. ArnbjrnssonE,BengmarkS.Obstructionoftheappendixlumeninrelationtopathogenesisofacute
appendicitis.ActaChirScand1983149:789.
13. NiteckiS,KarmeliR,SarrMG.Appendicealcalculiandfecalithsasindicationsforappendectomy.Surg
GynecolObstet1990171:185.
14. JonesBA,DemetriadesD,SegalI,BurkittDP.Theprevalenceofappendicealfecalithsinpatientswithand
withoutappendicitis.AcomparativestudyfromCanadaandSouthAfrica.AnnSurg1985202:80.
15. LauWY,TeohChanCH,FanST,etal.Thebacteriologyandsepticcomplicationofpatientswith
appendicitis.AnnSurg1984200:576.
16. BennionRS,BaronEJ,ThompsonJEJr,etal.Thebacteriologyofgangrenousandperforatedappendicitis
revisited.AnnSurg1990211:165.
17. TempleCL,HuchcroftSA,TempleWJ.Thenaturalhistoryofappendicitisinadults.Aprospectivestudy.
AnnSurg1995221:278.
18. LeeSL,WalshAJ,HoHS.Computedtomographyandultrasonographydonotimproveandmaydelaythe
diagnosisandtreatmentofacuteappendicitis.ArchSurg2001136:556.
19. RaoPM,RheaJT,NovellineRA,etal.HelicalCTtechniqueforthediagnosisofappendicitis:prospective
evaluationofafocusedappendixCTexamination.Radiology1997202:139.
20. ChungCH,NgCP,LaiKK.Delaysbypatients,emergencyphysicians,andsurgeonsinthemanagementof
acuteappendicitis:retrospectivestudy.HongKongMedJ20006:254.
21. GuidrySP,PooleGV.Theanatomyofappendicitis.AmSurg199460:68.
22. McBurney,C.Experiencewithearlyoperativeinterferenceincasesofdiseaseofthevermiformappendix.
NYMedJ188950:676.
23. GolledgeJ,TomsAP,FranklinIJ,etal.Assessmentofperitonisminappendicitis.AnnRCollSurgEngl
199678:11.
24. AnderssonRE,HuganderAP,GhaziSH,etal.Diagnosticvalueofdiseasehistory,clinicalpresentation,
andinflammatoryparametersofappendicitis.WorldJSurg199923:133.
25. LaneR,GrabhamJ.Ausefulsignforthediagnosisofperitonealirritationintherightiliacfossa.AnnRColl
SurgEngl199779:128.
26. Rovsing,NT.IndirektesHervorrufendestypischenSchmerzesanMcBurney'sPunkt.EinBeitragzur
diagnostikderAppendicitisundTyphlitis.ZentralblattfrChirurgie,Leipzig,190734:1257.
27. IzbickiJR,KnoefelWT,WilkerDK,etal.Accuratediagnosisofacuteappendicitis:aretrospectiveand
prospectiveanalysisof686patients.EurJSurg1992158:227.
28. AlshehriMY,IbrahimA,AbuaishaN,etal.Valueofreboundtendernessinacuteappendicitis.EastAfrMed
J199572:504.
29. JahnH,MathiesenFK,NeckelmannK,etal.Comparisonofclinicaljudgmentanddiagnostic
ultrasonographyinthediagnosisofacuteappendicitis:experiencewithascoreaideddiagnosis.EurJSurg
1997163:433.
30. BerryJJr,MaltRA.Appendicitisnearitscentenary.AnnSurg1984200:567.
9/27
18/11/2015
31. JohnH,NeffU,KelemenM.Appendicitisdiagnosistoday:clinicalandultrasonicdeductions.WorldJSurg
199317:243.
32. Silen,W.Cope'sEarlyDiagnosisoftheAcuteAbdomen,19thedition,OxfordUniversityPress1996.p.70.
33. ColemanC,ThompsonJEJr,BennionRS,SchmitPJ.Whitebloodcellcountisapoorpredictorofseverity
ofdiseaseinthediagnosisofappendicitis.AmSurg199864:983.
34. TehraniHY,PetrosJG,KumarRR,ChuQ.Markersofsevereappendicitis.AmSurg199965:453.
35. ThompsonMM,UnderwoodMJ,DookeranKA,etal.RoleofsequentialleucocytecountsandCreactive
proteinmeasurementsinacuteappendicitis.BrJSurg199279:822.
36. GrnroosJM,GrnroosP.LeucocytecountandCreactiveproteininthediagnosisofacuteappendicitis.Br
JSurg199986:501.
37. BrJSurg199986:501.
38. GurayaSY,AlTuwaijriTA,KhairyGA,MurshidKR.Validityofleukocytecounttopredicttheseverityof
acuteappendicitis.SaudiMedJ200526:1945.
39. SandM,BecharaFG,HollandLetzT,etal.Diagnosticvalueofhyperbilirubinemiaasapredictivefactorfor
appendicealperforationinacuteappendicitis.AmJSurg2009198:193.
40. RaoPM,RheaJT,NovellineRA.SensitivityandspecificityoftheindividualCTsignsofappendicitis:
experiencewith200helicalappendicealCTexaminations.JComputAssistTomogr199721:686.
41. WhitleyS,SookurP,McLeanA,PowerN.TheappendixonCT.ClinRadiol200964:190.
42. ChoiD,ParkH,LeeYR,etal.Themostusefulfindingsfordiagnosingacuteappendicitisoncontrast
enhancedhelicalCT.ActaRadiol200344:574.
43. KesslerN,CytevalC,GallixB,etal.Appendicitis:evaluationofsensitivity,specificity,andpredictive
valuesofUS,DopplerUS,andlaboratoryfindings.Radiology2004230:472.
44. JeffreyRBJr,LaingFC,TownsendRR.Acuteappendicitis:sonographiccriteriabasedon250cases.
Radiology1988167:327.
45. SpallutoLB,WoodfieldCA,DeBenedectisCM,LazarusE.MRimagingevaluationofabdominalpainduring
pregnancy:appendicitisandothernonobstetriccauses.Radiographics201232:317.
46. OtoA,ErnstRD,GhulmiyyahLM,etal.MRimaginginthetriageofpregnantpatientswithacuteabdominal
andpelvicpain.AbdomImaging200934:243.
47. PedrosaI,LevineD,EyvazzadehAD,etal.MRimagingevaluationofacuteappendicitisinpregnancy.
Radiology2006238:891.
48. LeeTH,KimJO,KimJJ,etal.AcaseofintussusceptedMeckel'sdiverticulum.WorldJGastroenterol
200915:5109.
49. BanliO,KarakoyunR,AltunH.IleoilealintussusceptionduetoinvertedMeckel'sdiverticulum.ActaChir
Belg2009109:516.
Topic1386Version23.0
http://www.uptodate.com/contents/acuteappendicitisinadultsclinicalmanifestationsanddifferentialdiagnosis?topicKey=SURG%2F1386&elapsedTimeM
10/27
18/11/2015
GRAPHICS
Variationsinthepositionoftheappendix
Graphic64911Version2.0
11/27
18/11/2015
Bloodsupplytothecolonandrectum
ThebloodsupplytothecolonoriginatesfromtheSMAandtheIMA.TheSMA
arisesapproximately1cmbelowtheceliacarteryandrunsinferiorlytowardthe
cecum,terminatingastheileocolicartery.TheSMAgivesrisetotheinferior
pancreaticoduodenalartery,severaljejunalandilealbranches,themiddlecolic
artery,andtherightcolicartery.Asageneralrule,themiddlecolicarteryarises
fromtheproximalSMAandsuppliestheproximaltomidtransversecolon.
However,itoccasionallyprovidesthepredominantbloodflowtothesplenic
flexure.Therightcolicarteryariseseitherfromacommontrunkwith,orjust
below,themiddlecolicartery,andsuppliesbloodtothemiddistalascending
colon.Theileocolicarterysuppliesthedistalileum,cecum,andproximal
ascendingcolon.
TheIMAarisesapproximately6to7cmbelowtheSMA.TheIMAgivesrisetothe
leftcolicarteryandsigmoidarteriescontinuingasthesuperiorrectal
(hemorrhoidal)artery.Itislargelyresponsibleforbloodsupplyfromthedistal
transversecolontotherectum.
SMA:superiormesentericarteryIMA:inferiormesentericartery.
12/27
18/11/2015
13/27
18/11/2015
CTscannormalappendix
CTscandepictsanormalappendix.Thefigureontheleftshowsanappendiceallumen
containingairandwallthicknessof3mm(yellowarrow).Thefigureontherightshowsthe
tipofthenormalappendix(greenarrow)thatmeasures6mmandnoassociatedinduration.
14/27
18/11/2015
CTscanacuteappendicitis
TheCTscanwasobtainedusingoralandintravenouscontrastfromapatientwhopresented
withrightlowerquadrantabdominalpain.Thesefiguresshowaninflammedappendixthat
measures21mmindiameterandcontainsanappendicolithandfluidthatislikelypurulent.
(A)Showsanappendicolithintheappendixusingawhitearrow.
(B)Showstheappendicolith,anoverlayoforangetoshowfluidinsidetheappendix,anda
yellowarrowindicatesfreefluid.
(C)Showstheenlargedappendixandfluidwithoutanoverlay.
(D)Showsacoloredoverlay:redcircledepictstheenhancingappendicealwallorange
depictstheintraappendicealfluidyellowdepictsthefreefluid.
15/27
18/11/2015
Normalappendixbyultrasoundimaging
Thegrayscaleultrasound(A,andmagnifiedinB)andDopplerimage(C)oftheappendixare
projectedinthetransverseplane.ImagesAandBshowanormalappendixmeasuringalmost
6mminmaximumtransversedimension(arrow).Theappendixwascompressibleandno
hyperemiawasdemonstrated(arrow)ontheDopplerimage(C).Thesefindingsareconsistent
withanormalappendixbyultrasound.
16/27
18/11/2015
Acuteappendicitisultrasound
Thepatientisa19yearoldfemalewhopresentedtotheemergencydepartmentwithright
lowerquadrantpain.Thegrayscaleultrasoundoftheappendixisprojectedinthe
longitudinal(A)andtransverseplanes(B).Anoncompressibleappendixmeasuresalmost20
mmindiameter,consistentwithadiagnosisofacuteappendicitis.Theechogenicmucosal
andsubmucosalportionsofthewallhavebecomediscontinuous(redarrows)suggesting
disruptionasaresultofsloughing.Luminalair(yellowarrows)resultsinposteriorshadowing.
17/27
18/11/2015
Appendicolithonabdominalfilms
Thisplainfilmoftheabdomenrevealsa1.2cmcalcificdensity,an
appendicolith.Thepatientpresentedwithrightlowerquadrantpainand
wasdiagnosedwithacuteappendicitis.
18/27
18/11/2015
Magneticresonanceimageofappendicitisin
pregnancy
T2weightedmagneticresonanceimageofawomanwithappendicitis
at9weeksofgestation.Theappendixwasfluidfilledandmeasured7
mm(arrow).Thegestationalsac(gs)isseenlowerinthepelvis.
CourtesyofDeborahLevine,MD.
19/27
18/11/2015
Tuboovarianabscess
Grossintraoperativephotographofalefttuboovarianabscessina
patientwithpelvicinflammatorydisease.
CourtesyofMitchelHoffman,MD.
20/27
18/11/2015
Rupturedovariancyst
Computedtomography.Arrowsindicatefreebloodwithinperitoneal
cavitysurroundingliverandspleen.
CourtesyofWilliamJMann,Jr,MD.
21/27
18/11/2015
Adnexalmass
Computedtomography.Arrowindicatespoorlydefinedadnexalmass,whichat
explorationwasrupturedcorpusluteumcystandclot.
CourtesyofWilliamJMann,Jr,MD.
22/27
18/11/2015
Ovarianandtubaltorsiondemonstratingmarked
vascularengorgementaswellasincreasedsize
anddistension
Anatomywasrestoredandbothstructuresweresalvageddespitenon
viableappearance.
Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6th
ed,EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,
Philadelphia2012.Copyright2012LippincottWilliams&Wilkins.
www.lww.com.
23/27
18/11/2015
Tubaltorsiondemonstratingseveredistensionofthe
distaltube
Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6thed,
EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,
www.lww.com.
24/27
18/11/2015
Enlargedleftovaryfoundtorseduponlaparotomy
demonstratingadark,duskyappearance
secondarytovenouslymphaticcongestioninthe
settingofcontinuedarterialperfusion
Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6th
ed,EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,
www.lww.com.
25/27
18/11/2015
Peritonealendometriosis
Theperitoneuminthiswomanwithendometriosisisstuddedwith
reddish,irregularlyshapedimplants.
Reprintedwithpermission.Copyright1990SyntexLaboratories,Inc.Allrights
reserved.
26/27
18/11/2015
Disclosures
Disclosures:RonaldFMartin,MDNothingtodisclose.MartinWeiser,MDNothingtodisclose.WenliangChen,MD,PhDNothingto
disclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
27/27

Corin 1

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Corin 1

Uploaded by

Copyright:

Available Formats

18/11/2015

You might also like