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Despite advances in diagnostic tests, appendicitis remains a clinical

diagnosis. Published guidelines note that the combination of clinical and

laboratory findings of characteristic abdominal pain, localized tenderness,
and laboratory evidence of inflammation will identify most patients with
suspected appendicitis. There is evidence that the order that the symptoms
present in is often diagnostic. Authors have suggested that pain usually
comes before nausea or fever and if the order is reversed then the
diagnosis is not appendicitis.
In addition, the appendix contains an abundance of lymph follicles in the
submucosa, numbering approximately 200. The highest number of lymph
follicles occurs in the 10- to 20-year-old age group, with a decline in number
after age 30; lymph follicles are typically absent after age 60.
The appendix arises from the cecum approximately 2.5 cm below the
ileocecal valve. It varies in length from complete agenesis to more than 30
cm, but it is usually 5 to 10 cm in length. The mean width is 0.5 to 1.0 cm.

Specifically, proximal obstruction (by any number of initiating factors) leads

to ongoing mucous secretion of the appendiceal mucosa distal to the
obstruction into a closed lumen with elevation of intraluminal pressure. Rapid
distention of the appendix ensues because of its small luminal capacity and
intraluminal pressures can reach 50 to 65 mm Hg. Distension of the appendix
stimulates visceral afferent pain fibers, producing a somewhat vague and
diffuse periumbilical pain. Distention of the appendix often causes reflex
nausea and/or vomiting with a progressive increase in the severity of the
visceral pain.

If unimpeded, luminal pressure rises to a level that induces venous infarction,

full-thickness necrosis, and perforation. The length of time required for the
disease to progress to gangrene and perforation is highly variable. One study
demonstrated a mean duration of abdominal pain of 46.2 hours in patients
with gangrene and 70.9 hours for perforation.
Fecal stasis and fecaliths are the most common cause of appendiceal
obstruction (in adult), followed by lymphoid hyperplasia (more in young),
vegetable matter and fruit seeds, inspissated barium from previous
radiographic studies, intestinal worms (especially ascarids), and tumors (such
as carcinoid). It is important to note that the offending agent causing
obstruction is only found in 50% of the cases. Accordingly, it is fair to state
that luminal obstruction appears to account for many cases of appendicitis,
but the cause for a substantial number of cases remains elusive.

Ultimately, the “gold standard” for a positive diagnosis is the histopathologic

confirmation of appendicitis, although standard criteria are lacking.

Laboratory values that have been associated with acute appendicitis include
leukocytosis, left shift, and elevated markers of inflammation such as C-
reactive protein (CRP) and erythrocyte sedimentation rate.

A meta-analysis revealed that the greatest discriminators and predictors of

acute appendicitis included a history of migration of pain, clinical findings of
peritoneal irritation, and laboratory values reflecting an inflammatory
response (i.e., CRP).
The long-term risk of small bowel obstruction is estimated at 1.3% at 30
years after appendectomy.

Reported as “stump appendicitis,” patients typically present with recurrent

symptoms of appendicitis approximately 9 years after their initial surgery.

Although incidental appendectomy is generally neither clinically nor

economically appropriate, there are some special patient groups in whom it
should be performed during laparotomy or laparoscopy for other indications.
These include children about to undergo chemotherapy, the disabled who
cannot describe symptoms or react normally to abdominal pain, patients
with Crohn’s disease in whom the cecum is free of macroscopic disease,
and individuals who are about to travel to remote places where there is
no access to medical or surgical care.

A patient with a score of 5 or 6 is typically observed, whereas a patient with a

score of 7 or greater should undergo operation.

A "left shift" is a phrase used to note that there are a high number of young,
immature white blood cells present. Most commonly, this means that there is
an infection or inflammation present and the bone marrow is producing more
WBCs and releasing them into the blood before they are fully mature. This is
a natural immune response to infection and inflammation.
It is believed that cytokines (including IL-1 and TNF) accelerate the release
of cells from the postmitotic reserve pool in the bone marrow, leading to an
increased number of immature cells.
It is usually noted on microscopic examination of a blood smear. This
systemic effect of inflammation is most often seen in the course of an
active infection and during other severe illnesses such as hypoxia and shock.

Neutrophil left shift and white blood cell (WBC) count are routine laboratory
tests used to assess neutrophil state, which depends on supply from the bone
marrow and consumption in the tissues. If WBC count is constant, the
presence of left shift indicates an increase of neutrophil consumption that is
equal to an increase of production. A decrease in WBC count indicates that
neutrophil consumption surpasses supply. During a bacterial infection, large
numbers of neutrophils are consumed. Thus, from onset of infection to
recovery, dynamic changes occur in WBC count and left shift data, reflecting
the mild to serious condition of the bacterial infection. Although various
stimuli in healthy and pathological conditions also cause left shift, a change
as sudden and significant is only seen in bacterial infection. Left shift does
not occur in the extremely early or late phases of infection; therefore,
assessing data from a single time point is unsuitable for diagnosing a
bacterial infection. We argue that time-series data of left shift and WBC
count reflect real-time neutrophil consumption during the course of a
bacterial infection, allowing more accurate evaluation of patient condition.
Copyright © 2016. Published by Elsevier B.V.

A larger left shift indicates a larger neutrophil consumption in the blood.
A larger left shift represents a more severe bacterial infection.
Left shift reflects the severity of a bacterial infection consuming neutrophils
High WBC count in the blood shows sufficient neutrophil supply to the infected site.
WBC (or neutrophil) count in the blood depends on neutrophil supply and consumption.
A recent meta-analysis identified four studies that presented data for
perforated appendicitis. Based on these studies, high values of laboratory
markers of inflammation such as a WBC and granulocyte count and the CRP
level were relatively strong predictors of perforated appendicitis, whereas
low values were relatively strong predictors of not having perforated

In addition, the “negative” appendectomy rate ranges from 10% to 20%,

and remains unchanged despite the widespread use of CT.

Spontaneous resolution of appendiceal inflammation does occur, although its

frequency is unknown. Presumably, increasing intraluminal pressure
dislodges the obstructing material back into the cecum, thereby relieving the
distention and inflammatory process.

Appendiceal cancer represents approximately 1% of colon malignancies.

Appendiceal cancer typically presents as unexpected finding on final
pathology after appendectomy for presumed acute appendicitis.
The Surgical Infection Society and Infectious Disease Society of America
guidelines recommend helical CT with IV contrast as the test of choice
when imaging is indicated in patients with suspected appendicitis.
Appendectomy for acute appendicitis is one of the most common surgical
procedures performed worldwide
Inclusion of a CT scan result in the Alvarado score has been shown to
increase the rate of appendectomy. When classified as having a low
likelihood of appendicitis (Alvarado score ≤ 4), patients who underwent a CT
scan had an appendectomy rate of 48%. In contrast, those with an Alvarado
score ≤ 4 who did not undergo a CT scan had an appendectomy rate of only
12% suggesting that some percentage of the population resolved

Appendiceal abscess is commonly associated with delayed presentation,

fever, leukocytosis, and a palpable mass in the right lower quadrant
Appendiceal abscess is commonly associated with delayed presentation,
fever, leukocytosis, and a palpable mass in the right lower quadrant. The
diagnosis is confirmed with CT or US. Management of these patients remains
controversial. The traditional nonsurgical approach consists of percutaneous
drainage and IV antibiotics, with or without interval appendectomy.
Immediate appendectomy is associated with greater incidence of ileus or
bowel obstruction, abdominal or pelvic abscess, and wound infection
compared to nonsurgical treatment.
The management of acute appendicitis complicated by an appendiceal
phlegmon typically involves 1 of 3 treatment strategies. The first, and most
commonly accepted, is initial treatment with broad spectrum antibiotics and
IV fluids until the acute inflammation subsides; appendectomy is then
performed on an interval basis. Another strategy involves appendectomy
upon initial presentation. Finally, following resolution of the acute
inflammation with broad-spectrum antibiotics, the patient is managed
expectantly without interval appendectomy.
The optimal management strategy of an appendiceal phlegmon or abscess
remains elusive as most recommendations are based on retrospective data,
but recent randomized trials in children indicate that early appendectomy
results in faster return to normal activity with favorable complication rates
when compared to interval appendectomy.
Stump Appendicitis: Incomplete appendectomy represents a failure of
removing the entire appendix on the initial procedure. Reported as “stump
appendicitis,” patients typically present with recurrent symptoms of
appendicitis approximately 9 years after their initial surgery. The key to
avoiding stump appendicitis is prevention. Use of the “appendiceal critical
view” (appendix placed at 10 o’clock, taenia coli at 3 o’clock, and terminal
ileum at 6 o’clock).