140 Appendicitis

rebound tenderness along with fever are

BASIC INFORMATION more indicative of appendicitis in children
than in adults.
DEFINITION • Abdominal pain: Initially the pain may be
Appendicitis is the acute inflammation of the epigastric or periumbilical in nearly 50% of
vermiform appendix. patients; it subsequently localizes to the right
lower quadrant within 12 to 18 hr. Pain can
be found in back or right flank if appendix is
ICD-10CM CODES
retrocecal or in other abdominal locations if
K35.2 Acute appendicitis with generalized
there is malrotation of the appendix.
peritonitis
• Pain with right thigh extension (psoas sign),
K35.3 Acute appendicitis with localized
low-grade fever: Temperature may be >38° C
peritonitis
if there is appendiceal perforation.
K35.80 Unspecified acute appendicitis
• Pain with internal rotation of the flexed right
K35.89 Other acute appendicitis
thigh (obturator sign) is present.
K36 Other appendicitis
• Right lower quadrant (RLQ) pain on palpation
K37 Unspecified appendicitis
of the left lower quadrant (LLQ) (Rovsing sign):
Physical examination may reveal right-sided
EPIDEMIOLOGY & tenderness in patients with pelvic appendix.
DEMOGRAPHICS
• Point of maximum tenderness is in the RLQ
• Appendicitis occurs in 10% of the population, (McBurney point).
most commonly between the ages of 10 and • Nausea, vomiting, tachycardia, cutaneous
30 yr. Median age is 22 yr. Lifetime risk is 7% hyperesthesias at the level of T12 can be
to 14%. present.
• Approximately 300,000 appendectomies are
performed in the U.S. each yr. ETIOLOGY
• It is the most common abdominal surgical Obstruction of the appendiceal lumen with
emergency. subsequent vascular congestion, inflammation,
• Incidence of appendicitis has declined over and edema; common causes of obstruction are:
the past 30 yr. • Fecaliths: 30% to 35% of cases (most com-
• Male/female ratio is 3:2 until mid-20s; it mon in adults)
equalizes after age 30 yr. • Foreign body: 4% (fruit seeds, pinworms,
tapeworms, roundworms, calculi)
PHYSICAL FINDINGS & CLINICAL • Inflammation: 50% to 60% of cases (submu-
PRESENTATION cosal lymphoid hyperplasia [most common
• 
In children with abdominal pain, fever is etiology in children, teens])
the single most useful sign associated with • Neoplasms: 1% (carcinoids, metastatic dis-
appendicitis. Vomiting, rectal tenderness, and ease, carcinoma)
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Intestinal: Regional cecal enteritis, incar-
cerated hernia, cecal diverticulitis, intesti-
nal obstruction, perforated ulcer, perforated
cecum, Meckel diverticulitis
• Reproductive: Ectopic pregnancy, ovarian
cyst, torsion of ovarian cyst, salpingitis, tubo-
ovarian abscess, mittelschmerz, endometrio-
sis, seminal vesiculitis
• Renal: Renal and ureteral calculi, neoplasms,
pyelonephritis
• Vascular: Leaking aortic aneurysm
• Psoas abscess
• Trauma
• Cholecystitis
• Mesenteric adenitis
• Table 1 summarizes the differential diagnosis
of appendicitis
WORKUP
Patients with RLQ pain, nausea, vomiting,
anorexia, and RLQ rebound tenderness should
undergo prompt clinical and laboratory evalua-
tion. Imaging studies are generally not necessary
in typical appendicitis and generally reserved for
patients with an equivocal likelihood of appen-
dicitis. They are useful when the diagnosis is
uncertain. Laparoscopy may be useful as both a
diagnostic and a therapeutic modality.
LABORATORY TESTS
• Complete blood count with differential reveals
leukocytosis with a left shift in 90% of patients
with appendicitis. Total white blood cell (WBC)
count is generally lower than 20,000/mm3.

TABLE 1  Differential Diagnosis of Appendicitis

Diagnosis
Bacterial or viral enteritis
Epiploic appendagitis
Mesenteric adenitis
Pyelonephritis
Renal colic
Acute pancreatitis
Crohn disease
Cholecystitis
Meckel diverticulitis
Cecal diverticulitis
Sigmoid diverticulitis
Small bowel obstruction
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Acute salpingitis or tubo-
ovarian abscess
Findings That Help Differentiate Entity from Appendicitis
Nausea, vomiting, and diarrhea are severe; pain usually develops after vomiting.
Focal abdominal pain and tenderness without migration or progression of the pain; patients have a paucity of other GI symptoms such as
anorexia or nausea. Laboratory findings are usually normal.
Duration of symptoms is longer; fever is uncommon; RLQ physical findings are less marked; WBC count is usually normal.
Pain is more likely to be felt in the right flank; high fever and rigors are common; marked pyuria or bacteriuria and urinary symptoms are
present; abdominal rigidity is less marked.
Pain radiates to the right groin; significant hematuria; character of the pain is clearly colicky.
Pain and vomiting are more severe; tenderness is less well localized; serum amylase and lipase levels are elevated.
History of recurrent similar attacks; diarrhea is more common; palpable mass is more common; extraintestinal manifestations may have
occurred or be present.
History of prior attacks is common; pain and tenderness are greater; radiation of pain is to the right shoulder; nausea is more marked; liver
biochemical tests are more likely to be abnormal.
Nearly impossible to distinguish preoperatively from appendicitis.
Difficult to distinguish preoperatively from appendicitis; symptoms are milder and of longer duration; CT is helpful; patients are usually older.
Usually occurs in older patients; changes in bowel habits are more common; radiation of the pain is to the suprapubic area, not RLQ; fever
and WBC count are higher.
History of abdominal surgery; pain is colicky; vomiting and distention are more marked; RLQ localization is uncommon.
History of menstrual irregularities; characteristic progression of symptoms is absent; syncope; positive pregnancy test.
Occurs in the middle of the menstrual cycle; pain is of sudden onset; nausea and vomiting are less common; WBC count is normal.
Vomiting is more marked and occurs at the same time as the pain; progression of symptoms is absent; abdominal or pelvic mass often is palpable.
Longer duration of symptoms; pain begins in the lower abdomen; often there is a history of STDs; vaginal discharge and marked cervical
tenderness often are present.

RLQ, Right lower quadrant; STD, sexually transmitted disease.

From Feldman M, et al.: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.

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Higher counts may be indicative of perforation.
Less than 4% have a normal WBC and differ-
ential. A WBC count <10,000/mm3 decreases
the likelihood of appendicitis. Low hemoglobin
and hematocrit levels in an older patient
should raise suspicion for GI tract carcinoma.
• Microscopic hematuria and pyuria may occur
in <20% of patients.
• HCG to rule out pregnancy in females of
reproductive age.
IMAGING STUDIES
• Multidetector computed tomography (Fig. 1)
is a useful test for routine evaluation of sus-
pected appendicitis in adults. CT of the abdo-
men/pelvis without contrast has a sensitivity
of >90% and an accuracy >94% for acute
appendicitis. A distended appendix, periap-
pendiceal inflammation, and a thickened
appendiceal wall are indicative of appendici-
tis. Table 2 describes CT findings of appendi-
citis. In children and young adults, exposure
to CT radiation is of particular concern. Trials
with low-dose CT (116 mGy cm) have shown
that low-dose CT is not inferior to standard-
dose CT (521 mGy cm) with respect to nega-
tive (unnecessary) appendectomy rates in
young adults with suspected appendicitis.
• Ultrasonography (Fig. 2) has a sensitivity of
75% to 90% for the diagnosis of acute appen-
dicitis, although it is highly operator dependent
and difficult in patients with large body habitus.
Ultrasound is useful, especially in pregnan-
cy and in younger women when diagnosis
is unclear. Normal ultrasonographic findings
should not deter surgery if the history and phys-
ical examination are indicative of appendicitis.
• MRI of the abdomen and pelvis can also be
used to accurately diagnose acute appendicitis
in pregnant patients (100% sensitivity, 93.6%
specificity) without exposure to ionizing radiation.
TREATMENT
NONPHARMACOLOGIC THERAPY
• Nothing by mouth
• Do not administer analgesics until the diag-
nosis is made
ACUTE GENERAL Rx
• Urgent appendectomy (laparoscopic or open),
correction of fluid and electrolyte imbalance
with vigorous IV hydration, and electrolyte
replacement
• IV antibiotic prophylaxis to cover gram-nega-
tive bacilli and anaerobes (ampicillin/sulbac-
tam 3 g IV q6h or piperacillin/tazobactam 4.5
g IV q8h in adults)
PEARLS &
CONSIDERATIONS
COMMENTS
• 
Perforation is common (20% in adult
patients). Indicators of perforation are pain
lasting >24 hr, leukocytosis >20,000/mm3,
temperature >102° F, palpable abdominal
mass, and peritoneal findings.
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Appendicitis 141
Appendicolith
Fat stranding Enlarged
appendix with
thickened,
A
Cecum enhancing wall
Normal
mesenteric
fat
and Disorders
Diseases
I
A B Normal subcutaneous fat
FIG. 1  Appendicitis, computed tomography (CT) with intravenous and oral contrast. This CT dem-
onstrates classic findings of appendicitis in an 18-year-old male with right lower quadrant pain, as seen with
CT with IV and oral contrast. Studies suggest that CT without contrast has similar sensitivity and specificity. An
enlarged appendix is seen near the cecum as a right lower quadrant tubular structure in short-axis cross section,
giving it a circular appearance. The surrounding fat shows stranding, a smoky appearance indicating inflam-
mation (compare with normal mesenteric and subcutaneous fat, which is nearly black). The appendiceal wall
shows enhancement, a brightening after administration of IV contrast. This slice also shows an appendicolith, an
occasional finding of appendicitis. It does not appear to be within the appendix in this slice, because the appen-
dix bends in and out of the plane of this slice. An appendicolith usually appears as a calcified (white) rounded
structure, visible without any contrast. A, Axial CT image. B, Close-up. (From Broder JS: Diagnostic imaging for
the emergency physician, Philadelphia, 2011, Saunders.)
TABLE 2  Computed Tomography Findings of Appendicitis: SCALPEL
Mnemonic
Term Description
Stranding Fat stranding suggests regional inflammation, possibly because of appendicitis.
Cecum The appendix originates from the cecum, which should be identified first to help localize the
appendix. The cecum may show wall thickening, suggesting appendicitis.
Air Air outside of the lumen of the appendix is pathologic and suggests perforation. Air within
the appendiceal wall is also abnormal.
Large The normal appendix is <6 mm; an enlarged appendix >6 mm suggests appendicitis. Wall
thickening >1 mm also suggests appendicitis.
Phlegmon Inflammatory changes surrounding the appendix suggest a perforated appendix. A heteroge-
neous collection called a phlegmon may be seen. If the appendix has ruptured, a perice-
cal phlegmon may be the only remaining evidence, because the appendix itself may not
be seen.
Enhancement The wall of an abnormal appendix enhances with IV contrast and appears brighter than the
normal bowel or the normal psoas muscle.
Lith An appendicolith is a calcified stone sometimes found in the lumen of an inflamed appendix.
From Broder JS: Diagnostic imaging for the emergency physician, Philadelphia, 2011, Saunders.
• In general, prognosis is excellent. Mortality least 24 hours followed by oral antibiotics
rate is <1% in young adults without compli- for 10 days revealed that 90% of children
cations; however, it exceeds 10% in elderly managed nonoperatively had no progres-
patients with ruptured appendix. sion within 30 days.1 Another trial among
• In approximately 20% of patients who under- patients with CT-proven, uncomplicated
go exploratory laparotomy because of sus- appendicitis revealed that antibiotic treat-
pected appendicitis, the appendix is normal. ment did not meet the prescribed criterion
• An increasing amount of evidence sup- for noninferiority compared with appendec-
ports the use of antibiotics instead of sur- tomy. Most patients randomized to antibiotic
gery for treating patients with uncompli- treatment for uncomplicated appendicitis did
cated appendicitis. A trial assessing the not require appendectomy during the 1-yr
feasibility of nonoperative management for
uncomplicated acute appendicitis in children 1 Minneci PC, et al.: Feasibility of a nonoperative man-
using either IV piperacillin-tazobactam or agement strategy for uncomplicated acute appendi-
ciprofloxacin metronidazole therapy for at citis in children, J Am Coll Surg 219:272-279, 2014.
142 Appendicitis

A B
FIG. 2  Appendicitis. A, Transabdominal ultrasound using a linear transducer demonstrates a thick, tubular, noncompressible structure. B, Same imaging method with
addition of color Doppler ultrasound shows increased vascularity within the luminal wall consistent with inflammation (arrow). (From Fielding JR, et al.: Gynecologic
imaging, Philadelphia, 2011, Saunders.)

follow-up period, and those who required RELATED CONTENT

appendectomy did not experience significant EVIDENCE Appendicitis (Patient Information)
complications.2 A 5-yr follow-up of antibiotic
therapy for uncomplicated acute appendi- Available at ExpertConsult.com AUTHOR: FRED F. FERRI, M.D.
citis in the APPAC randomized clinical trial
revealed that among patients who were SUGGESTED READINGS
initially treated with antibiotics for uncom- Available at ExpertConsult.com
plicated acute appendicitis, the likelihood of
late recurrence within 5 yr was 39.1%.4 It
remains to be determined whether the ben-
efits of potentially avoiding an operation with
antibiotics-first approach are outweighed by
the burden to the patient related to future
appendicitis episodes, more days of antibiotic
therapy, lingering symptoms, and uncertainty
that may affect quality of life.3

2 Salminen P, et al.: Antibiotic therapy vs appendecto-

my for treatment of uncomplicated acute appendicitis,
the APPAC Randomized trial, JAMA 313(23):2340-
2348, 2015.
3 Flum DR: Acute appendicitis—appendectomy or the

“antibiotics first” strategy, N Engl J Med 372:1937-

43, 2015.
4 Salminen P, et al.: Five-year follow-up of antibiotic

therapy for uncomplicated acute appendicitis in the

APPAC randomized clinical trial, JAMA 320(12):1259–
1265, 2018.

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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2019. Elsevier Inc. Todos los derechos reservados.
Appendicitis
EVIDENCE
Abstract[1]
Background:
Researchers have suggested that antibiotics could cure acute appendi-
citis. We assessed the efficacy of amoxicillin plus clavulanic acid by
comparison with emergency appendectomy for treatment of patients
with uncomplicated acute appendicitis.
Methods:
In this open-label, noninferiority, randomized trial, adult patients (aged
18–68 years) with uncomplicated acute appendicitis, as assessed by CT
scan, were enrolled at six university hospitals in France. A computer-
generated randomization sequence was used to allocate patients ran-
domly in a 1:1 ratio to receive amoxicillin plus clavulanic acid (3 g per
day) for 8–15 days or emergency appendectomy. The primary endpoint
was occurrence of postintervention peritonitis within 30 days of treat-
ment initiation. Noninferiority was shown if the upper limit of the two-
sided 95% CI for the difference in rates was lower than 10 percentage
points. Both intention-to-treat and per-protocol analyses were done. This
trial is registered with ClinicalTrials.gov, number NCT00135603.
Findings:
Of 243 patients randomized, 123 were allocated to the antibiotic group
and 120 to the appendectomy group. Four were excluded from analysis
because of early dropout before receiving the intervention, leaving 239
(antibiotic group, 120; appendectomy group, 119) patients for intention-
to-treat analysis. 30-day postintervention peritonitis was significantly
more frequent in the antibiotic group (8%, n=9) than in the appendec-
tomy group (2%, n=2; treatment difference 5·8; 95% CI 0·3-12·1). In the
appendectomy group, despite CT-scan assessment, 21 (18%) of 119
patients were unexpectedly identified at surgery to have complicated
appendicitis with peritonitis. In the antibiotic group, 14 (12% [7·1-18·6])
of 120 underwent an appendectomy during the first 30 days and 30
(29% [21.4–38.9]) of 102 underwent appendectomy between 1 month
and 1 year, 26 of whom had acute appendicitis (recurrence rate 26%;
18.0–34.7).
Interpretation:
Amoxicillin plus clavulanic acid was not noninferior to emergency ap-
pendectomy for treatment of acute appendicitis. Identification of predic-
tive markers on CT scans might enable improved targeting of antibiotic
treatment.
Abstract[2]
Background:
The skin is closed in open appendectomy traditionally with few inter-
rupted nonabsorbable sutures. The use of this old method is based on a
suggestion that this technique decreases wound infections. In pediatric
surgery, skin closure with running intradermal absorbable sutures has
been found to be as safe as nonabsorbable sutures, even in complicated
cases. Our purpose was to compare the safety of classic interrupted
nonabsorbable skin closure to continuous intradermal absorbable su-
tures in appendectomy wounds in adult patients.
Methods:
A total of 206 adult patients with clinically suspected appendicitis were
allocated to the study and prospectively randomized into two groups of
wound closure: the interrupted nonabsorbable (NA) suture and the intra-
dermal continuous absorbable (A) suture group. Primary wound healing
was controlled on the first postoperative day, at 1 week clinically, and
after 2 weeks by means of a telephone interview. Follow-up data were
obtained from 185 patients (90 in group NA and 95 in group A).
Results:
Continuous absorbable intradermal suturing was as safe as nonabsorb-
able sutures in regard to wound infections.
Conclusion:
Continuous, absorbable sutures can be used safely even in complicated
appendectomies without increasing the risk of wound infection. Consid-
ering the benefits of absorbable suturing, we recommend this method in
all open appendectomies.
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142.e1
Appendectomy for acute appendicitis results in a clean contaminated
or contaminated wound. Thus, many forms of wound closure have been
used to obviate the risk of postoperative wound infection. This prospec-
tive, randomized trial evaluated continuous absorbable suture closure vs
interrupted nonabsorbable suture as a technique of skin/wound closure.
Evaluation of wound complications was done at 1 week clinically (nurse,
resident, attending physician) and by telephone interview. It is presumed
that all wound infectious complications would present themselves by at
least 2 weeks, although some declare themselves after this period. No
significant differences in wound infections and other complications were
noted comparing the 2 groups. As the authors noted, the use of continu-
ous absorbable suture technique is easier on the patient. Given the re-
sults of this trial, continuous nonabsorbable suture technique should
become the gold standard after uncomplicated appendectomy.
JM Daly, MD
Abstract[3]
Objective:
The aim of the current study was to perform a multicentered prospective
double-blinded randomized controlled trial comparing laparoendoscopic
single-site access (LESS) versus conventional three-port laparoscopic
appendectomy (TPLA).
Background:
The clinical benefits and disadvantages of LESS appendectomy are un-
certain.
Methods:
Between October 2009 and March 2011, consecutive patients admitted
with clinical or radiologic evidence of appendicitis were randomly as-
signed to receive either LESS or TPLA. The main outcome measurement
was overall pain score. Secondary outcome measurements included
operative time, conversion rates, morbidity rates, activity pain scores,
activity scores, patient satisfaction, and cosmesis scores.
Results:
During the study period, 200 patients were recruited to the study. There
were no significant differences in the morbidity rates, operative time,
conversion rates, and postoperative recovery. There were also no differ-
ences in the overall pain score and pain score at rest. However, patients
in the LESS group experienced significantly more pain upon coughing or
standing and required more intravenous analgesics (P = 0.001, 0.038,
and 0.035, respectively). Wound cosmesis and satisfaction scores on the
contrary were better in the LESS group (P = 0.002 and P = 0.052). No
differences in the quality-of-life assessments were present at 2 weeks
after operation.
Conclusions:
LESS and conventional appendectomy resulted in similar perioperative
outcomes. However, LESS appendectomy resulted in worst pain scores
upon exertion and required a higher dosage of intravenous analgesics
when compared with TPLA. On the contrary, wound cosmesis and satis-
faction scores were better in the LESS group. Hence, adoption of the
technique for appendectomy will depend on patient preferences and the
presence of local expertise.
This group from Hong Kong presents a double-blinded, randomized,
controlled trial of laparoendoscopic single-site access (LESS) compared
with conventional 3-port appendectomy (TPLA). Adult patients (200) with
a diagnosis of appendicitis with 5 days or less of symptoms and without
a palpable right lower quadrant mass were randomized to 1 of either
procedure. Reasons for exclusion from the study included previous sur-
gery, peritonitis, extended symptoms, coagulopathy, previous pregnancy,
palpable mass, shock, myocardial infarction, or refusal to enter the
study. LESS was performed by making a 13-mm transumbilical incision
with insertion of a 10-mm and two 5-mm trocars through separate
fascial incisions. The TPLA approach included a 10-mm subumbilical
port and a 5-mm port in each of the right and left lower quadrants. The
mesoappendix was divided with ultrasonic dissection and the appendix
ligated with 2 Endoloop sutures. The fascial defects of the 10-mm ports
were closed along with the skin, and 3 wound dressings were left in
place simulating the wound coverage for the TPLA. This clever approach,
Appendicitis 142.e2

therefore, blinded the patient and the data collection staff to the surgical SUGGESTED READINGS
technique. Evaluation of the efficacy of either procedure revealed no Kim K, et al.: Low-dose abdominal CT for evaluating suspected appendicitis,
advantage to either approach with regard to morbidity, operative time N Engl J Med 366:1596–1605, 2012.
(63 vs 60 minutes), conversion rate (8 vs 3%), or hospital stay. Overall, Pickhardt P, et al.: Diagnostic performance of multidetector computed tomog-
LESS patients reported improved cosmesis with the single-site approach raphy for suspected acute appendicitis, Ann Intern Med 154:789–796, 2011.
and overall satisfaction with the operation. Although total pain scores Vons C, et al.: Amoxicillin plus clavulanic acid versus appendicectomy for treat-
were equal, patients undergoing LESS had more pain with standing and ment of acute uncomplicated appendicitis: an open-label, non-inferiority,
extended coughing, which correlated with higher pain medication usage. randomized controlled trial, Lancet 377:1573–1579, 2011.
This also correlated with less activity in the LESS group early in the
postoperative period. The authors surmise that the difference in pain
may be explained by the fact that the total fascial incision distance is the
same with each procedure, and that the pelvic peritoneum where the
5-mm TPLA trocars were introduced is less sensitive to pain triggers
than the peritoneum in the rest of the abdominal cavity. However, most
surgeons performing laparoscopic procedures recognize that patients
complain most commonly about the umbilical trocar site, and in the
LESS group all 3 ports were placed through the umbilicus. Whether
single-site appendectomy ultimately becomes the newest standard is
unknown. This well-executed study does demonstrate, though, that
single-site appendectomy can be safely performed with little additional
time over that of a traditional laparoscopic approach. Also, supply cost-
savings may be realized with the described procedures in this study. The
appendiceal stump can be safely controlled with an Endoloop rather than
an Endo GIA, and a single-port approach does not require special access
devices. The same trocars used for a laparoscopic appendectomy can be
used for a LESS procedure.
J Hine, MD

Evidence-Based References
1. Vons C, et al.: Amoxicillin plus clavulanic acid versus appendicectomy for
treatment of acute uncomplicated appendicitis: an open-label, non-inferiority,
randomised controlled trial, Lancet 377:1573–1579, 2011.
2. Kotaluoto S, et al.: Wound healing after open appendectomies in adult patients:
a prospective, randomised trial comparing two methods of wound closure,
World J Surg 36:2305–2310, 2012.
3. Teoh AYB, et al.: A double-blinded randomized controlled trial of laparoendo-
scopic single-site access versus conventional 3-port appendectomy, Ann Surg
256:909–914, 2012.

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