Acute appendicitis

Epidemiology

the most common acute abdominal emergency

remains the most common indication for emergency abdominal surgery

Clinical features
combination of the classic symptoms and
the typical progression of symptoms coupled with right lower
quadrant tenderness allows good diagnostic accuracy

In the classic presentation of acute appendicitis, patients first note vague, poorly localized epigastric or periumbilical discomfort,
which typically is not severe and often is attributed to “gastric upset.” Patients commonly report feeling that a bowel move ment
should make the pain better, a sensation known as the downward urge.
Diarrhea sometimes is seen early on with appendicitis, but this is not common. Within 4 to 12 hours of the onset of pain, most
patients note nausea, anorexia, vomiting, or some combination of these 3 symptoms.

The nausea usually is mild to moderate, and most patients have only a few episodes of emesis. If vomiting is the major symptom,
the diagnosis of appendicitis should be questioned. Likewise, emesis that occurs before the onset of pain should suggest other
diagnoses.

Many patients report mild fever or chills; high fevers or significant rigors are uncommon.

The patient’s abdominal pain typically increases in intensity, and a characteristic shift in pain to the right lower quadrant occurs
over 12 to 24 hours. The character of the pain becomes achy and more localized. Localization of the pain to the right lower
quadrant is a valuable finding when present and occurs in over 80% of patients with appendicitis. 2

On physical examination, most patients appear slightly ill.

Tachycardia is uncommon with simple appendicitis, but it may be seen with complicated appendicitis. Most patients with simple
appendicitis have a temperature below 100.5°F; temperature above 100.5°F is most often associated with perforated or
gangrenous appendicitis

Patients with appendicitis, like other patients with peritonitis, tend to lie still rather than move about. Right lower quadrant
tenderness and rigidity, both voluntary and involuntary, are common findings. Localized right lower quadrant tenderness is an
important finding when present, but its absence does not rule out appendicitis.

A variety of methods exist to elicit localized right lower quadrant peritonitis, including the cough sign (the presence of point
tenderness with a cough), percussion tenderness, and formal elicitation of rebound tenderness. Although all of these techniques
are reasonably sensitive, 1 small study showed rebound tenderness to be the most accurate predictor of the localized peritonitis
associated with appendicitis.3

appendicitis include the psoas sign, the obturator sign, Rovsing’s sign, and rectal tenderness.

The psoas sign is sought by having a supine patient actively flex the right hip against resistance, or by the examiner flexing and
extending the patient’s right hip with the patient in the left lateral decubitus position. Pain with either of these maneuvers is
thought to result from irritation of the underlying psoas muscle by an inflamed retroperitoneal appendix.

The obturator sign is elicited by internally and externally rotating the flexed right hip. Pain is thought to arise when the inflamed
pelvic appendix irritates the adjacent obturator internus muscle.

Rovsing’s sign is the finding of right lower quadrant pain during palpation of the left side of the abdomen or when left-sided
rebound tenderness is elicited.
Rectal tenderness may be elicited when the examining finger reaches the wall of rectum adjacent to the inflamed appendix. All of
these findings are valuable when present, but their absence does not exclude appendicitis. 2
Appendicitis can be easy to diagnose when the presentation is typical, but a typical presentation is encountered in only 50% to
60% of cases. An atypical presentation of appendicitis occurs for a variety of reasons. The classic migration of periumbilical pain
to the right lower quadrant is thought to occur when the parietal peritoneum in the right lower quadrant becomes irritated by the
inflamed appendix. In cases of retrocecal or pelvic appendicitis, this site might not become irritated. Atypical presentations of
appendicitis are particularly common in patients who are at the extremes of age, pregnant, or immunosuppressed, including those
with AIDS and a low CD4 cell count.

The diagnosis of appendicitis in older adult patients also may be a challenge. In older adults, the classic pattern of pain migration,
right lower quadrant tenderness, fever, and leukocytosis are observed in only 15% to 30% of cases.
. For all of these reasons, the complication and perforation rates can be as high as 63% in patients older than 50 years of age.37