See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/341879619

Acute Appendicitis in Adults: Current Concept of Diagnosis and Management

Article · June 2020

CITATION READS
1 1,872

1 author:

Febyan Febyan
Orthopaedic & Traumatology - Sanglah General Hospital, Faculty of Medicine, Udayana University
40 PUBLICATIONS   9 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Semitendinosus and Gracilis Autograft for Neglected Patellar Tendon Rupture View project

All content following this page was uploaded by Febyan Febyan on 17 July 2020.

The user has requested enhancement of the downloaded file.

 Asian Journal of Research and Reports in Gastroenterology

3(1): 1-7, 2020; Article no.AJRRGA.56863

Acute Appendicitis in Adults: Current Concept of

Diagnosis and Management
Febyan1*
1
Department of Medicine, Bhayangkara Hospital, Denpasar, Bali, Indonesia.

Author’s contribution

The sole author designed, analysed, interpreted and prepared the manuscript.

Article Information

Editor(s):
(1) Dr. Sarah Ralte, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, India.
(2) Dr. John K. Triantafillidis, IASO General Hospital, Greece.
Reviewers:
(1) Kofina Konstantinia, Democritus University of Alexandroupolis, Greece.
(2) Apollon Zygomalas, University of Patras, Greece.
(3) Leonard Derkyi-Kwarteng, University of Cape Coast, Ghana.
Complete Peer review History: http://www.sdiarticle4.com/review-history/56863

Received 23 March 2020

Mini-review Article Accepted 29 May 2020
Published 03 June 2020

ABSTRACT

Appendicitis is a special type of inflammation form in the vermiform appendix lumen. It is part of
most life-threatening cases. The obstruction and accumulation of bacterial in the lumen may be
induced in the pathogenesis of appendicitis. This condition will develop worse if the patient nor
getting treatment properly, as a physician we have to know about clinical manifestations, physical
examination findings, laboratory tests and management. When antibiotic treatment is not changing
the symptoms during the initial admission, surgery treatment might be considered to be performed.
In recurrent disease, either a second course of antibiotics or appendectomy can be applied. The
aim of this review, to explain the current concept of appendicitis on diagnosis approach and
management.

Keywords: Appendicitis; adults; diagnosis; management.

1. INTRODUCTION emergency department [1]. Clinicians from a

wide world of medical specialities including
Acute appendicitis (AA) is a special type of internal medicine and surgeons, often facing the
inflammation and commonly found in the patient with AA in daily practice. It is relatively
_____________________________________________________________________________________________________

*Corresponding author: Email: febyanmd@gmail.com;


easy, when typical symptoms may occur.
Unfortunately, young ages and elderly aged are
often shown atypical symptoms, that may be
delayed of diagnosis and treatment will be not
properly [1]. The incidence of AA average about
90 to 100 patients per 100 000 per year in
developed countries. The highest incidence
occurs in the second or third decade of life.
Previously study reported there was the highest
risk of AA in the amount of 16% in South Korea,
9.0% in the USA, and 1.8% in Africa [2]. The
lifetime risk of AA is highest in males than
females population, however, the risk of
undergoing appendectomy is much lower for
males than for females (12 vs 23%) and it occurs
most often between the ages of 10 and 30 years
old, with a male: female ratio of 1.4:1 [3]. This
review aims to provide an update about the
existing in concept, and management of acute
appendicitis.
2. DEFINITION
Appendicitis is a part of the inflammation
condition inside the vermiform appendix [3]. It
located 1.7 – 2.5 cm below the terminal ileum.
The low part of appendix consists of three
taeniae coli of the caecum, which fuses to form
the outer longitudinal muscle of the appendix.
The movement of majority appendix position
such as 74% are retrocecal, 21% pelvic, 2%
paracecal, 1.5% subcecal, 1% pre-ileal and 0.5%
post ileal [2,4]. Patients may also have their
appendix behind the ascending colon and liver,
this position might occur atypical symptoms.
Appendicitis will be complicated if not treating
properly. That is why clinicians have to know well
about the diagnosis and management of acute
appendicitis [4].
3. PATHOLOGY OF ACUTE
APPENDICITIS
Appendicitis occurs when present of obstruction
in the lumen with the accumulation of bacterial
normal intestine [5]. The obstruction may be
induced by many mechanisms and it will be
retention of mucus. When bacterial infection
supervenes, the intraluminal pressure increases,
it leading to obstruction of lymphatic flow and
blood circulation that will be appendiceal oedema
condition. This process leading to acute
appendicitis when present of distension in the
appendix and vascular congestion. Appendiceal
oedema and vascular congestion might be
progress to be of multiple abscesses in the wall
lumen and purulent. This condition is called as
phlegmonous appendicitis. Dysfunction of the
2
Febyan; AJRRGA, 3(1): 1-7, 2020; Article no.AJRRGA.56863
appendiceal artery and veins leads thrombosis
and infarctinthe junction between the meso-
appendix and appendix, where the blood supply
is inadequate. As a result, the appendix becomes
congested dark red with black necrotic tissues,
this condition as designated as gangrenous
appendicitis [6]. If perforation present, appendicitis
becomes complicated by peritonitis. Usually,
peritonitis is localized, being confined to the
ileocecal region. In young children, however, the
omentum is not fully developed, so the clinical
course is often complicated by diffuse peritonitis
[6].
4. DIAGNOSIS OF ACUTE APPENDICITIS
4.1 Clinical Manifestations
Diagnosing acute appendicitis accurately by
symptoms can reduce morbidity and mortality
from perforation and further complications. The
clinical manifestation of AA such as abdominal
pain, fever, anorexia, vomiting, and mostly, the
pain may occur in the upper abdomen at first, but
it migrates to the right lower quadrant [7].
4.2 Finding on Physical Examination
Physical exam findings are often subtle,
especially in early appendicitis. As inflammation
progresses, signs of peritoneal inflammation
develop. Signs include Right lower quadrant
guarding and rebound tenderness over Mc
Burney's point. In 1894, McBurney described a
new technique for the management of acute
appendicitis, this method is still used when an
open approach is required [8,9]. Rovsing’s sign
(right lower quadrant pain elicited by palpation of
the left lower quadrant), Dunphy;s sign
(increased abdominal pain with coughing). Other
associated signs such as psoas sign (pain on
external rotation or passive extension of the hip
suggesting retrocecal appendicitis) or obturator
sign (pain on internal rotation of the right hip
suggesting pelvic appendicitis) are rare. The time
course of symptoms is variable but typically
progresses from early appendicitis at 12 to 24
hours to perforation at greater than 48 hours.
75% of patients present within 24 hours of the
onset of symptoms. The risk of rupture is variable
but is about 2% at 36 hours and increases about
5% every 12 hours after that [10].
4.3 Laboratory Tests
The laboratory tests for acute appendicitis such
as white blood cell count (WBC) and C-Reactive
protein (CRP) are of diagnostic value. But WBC
 Febyan; AJRRGA, 3(1): 1-7, 2020;; Article no.AJRRGA.56863
no.

usually exceeds 10,000/mm [3]. In severe cases 4.4 Imaging Diagnosis

associated with diffuse peritonitis, however, the
WBC may be decreased rather than increased,
so, care must be taken. Although the CRP
rises in appendicitis, the increase is not
necessarily associated with the severity of
inflammation [11].
The use of the Alvarado scoring system, which
includes clinical examination findings and
laboratory values, helps rule out appendicitis
(Table 1). Score range from 1 to 10, with higher
scores indicating a greater risk of appendicitis.
When the score is less than 4, appendicitis is
uncommon and imaging and other interventions
can be avoided. When imaging is used, high- high
quality ultrasonography (USG) should be
considered the first approach, but only in practice
practic
settings where is accuracy is sufficiently high. If
high-quality
quality USG is not available or fails to
visualize the appendix, Abdominal Computed
Tomography (CT) with lower-dose dose radiation
protocols is often used [12].
4.4.1 Abdominal Ultrasonography (USG)
The ultrasound in the diagnosis of AA was the
first invented by Puylaert in 1986, one hundred
years after the publication of the first paper on
acute appendicitis by Fitz [13,14].
A normal appendix is not visualized by USG,
When the presence of inflammation condition
and dilated, it can be visualized. The features of
appendicitis include hypertrophy of the
appendiceal wall, disturbance of the normal
layered structure, destruction of the wall, and
purulent fluid or fecaliths within the appendiceal
lumen. Appendicitis can be divided into three
types depending on USG findings. The
classification depended on the features of the
high echo bands representing the submucosal
layer, as well ass the presence or absence of a
visualized
lized appendix and the length of the shorter
diameter of the appendix (Table 2 and Fig
Fig. 1).

Table 1. Alvarado score [12]

*
Component Possible points
Symptoms
Migration of pain to the right lower quadrant 1
Anorexia 1
Nausea or vomiting 1
Signs
Tenderness in the right lower quadrant 2
Rebound pain 1
Elevated temperature 1
Laboratory findings
Leukocytosis 2
**
Left shift 1
Total score 10
* Points are described to each symptom, sign, and laboratory finding; patients with a score of less 4 are unlikely
to have appendicitis.
**A left shift is an increase in levels of immature neutrophil forms circ
circulating
ulating in the peripheral blood

Fig. 1. Ultrasonographic of appendicitis. (a) Catarrhal appendicitis, (b) Phlegmonous

appendicitis, (c) Gangrenous appendicitis [15]

3

Table 2. Identification of acute appendicitis based on ultrasonographic findings [15]
Type Pathological diagnosis The layer structure of
the appendiceal wall
Type I Catarrhal Clear
Type II Phlegmonous Indistinct
Type III Gangrenous Disrupted
A retrospective cohort study by Hanafi et al.
reported that accuracy such as sensitivity and
specificity was 96% and 100%. With the positive
predictive value was 100%, and the negative
predictive value was 82.35%, they conclusion
diagnosis accuracy was 100% for under 15 age,
and 94.6% for the above 15 years age in
appendicitis case [16]. As described above, USG
is an indispensable modality because it can be
used to both diagnose appendicitis assess its
severity.
4.4.2 Abdominal Computed Tomography (CT)
Many studies are focusing on the examination
technique of CT and optimal reconstruction
parameters for the diagnosis of AA. In
adolescent and adult patients, CT has become
the most widely accepted imaging strategy. In
the USA, it is used in 86% of patients, with a
sensitivity of 92.3% [17]. In one study of a
randomized controlled trial comparing low dose
versus standard dose of CT in 891 patients, the
normal appendectomy rate was 3.5% for low
dose CT versus 3.1% for standard-dose CT [18].
For older patients at increased risk of
malignancy, preoperative CT recommended
identifying malignancy masquerading as (or
causing) appendicitis. Selective CT based on
clinical risk score is likely to target its use and
justify radiation exposure [19]. According to the
American College of Radiology and American
College of Surgeon, the recommendation that CT
examination is not indicated for evaluation of
suspected appendicitis in children until after USG
be done [20].
5. DIFFERENT DIAGNOSIS
In general, when the diagnosis of AA is not clear,
the physician has to take into consideration other
diagnostic possibilities and the best form to do it
is to assess the patient according to the
anatomical location of the pain or tenderness. In
this case, the abdomen is divided into four
quadrants. If the pain or tenderness is localized
in the right upper quadrant, the most probable
causes such as hepatitis, cholangitis,
4
Febyan; AJRRGA, 3(1): 1-7, 2020; Article no.AJRRGA.56863
Submucosal layer
No hypertrophy
Hypertrophied
Indistinct and partly lost
pancreatitis, cholecystitis, peptic ulcer, retrocecal
appendicitis, intestinal obstruction. If the pain is
localized in the left upper quadrant, we must
consider such as splenic rupture, gastritis, peptic
ulcer, diverticulitis, pneumonia, pericarditis. If the
pain is localized in the right lower quadrant, the
most probable causes are appendicitis, stump
appendicitis, intestinal obstruction, hernia,
ectopic pregnancy (for female patients),
pyelonephritis, nephrolithiasis. If the pain is
localized in the left lower quadrant, the most
probable causes are colon diverticulitis,
appendicitis, salpingitis, ureteral calculus [21].
6. MANAGEMENT OF ACUTE
APPENDICITIS
Another study with meta-analysis of 9
randomized controlled trials found that the use of
opioid groups did not significantly increase the
risk of delayed or unnecessary surgery in 862
adults and children with acute appendicitis [22].
Nonsteroidal anti-inflammatory drugs and
acetaminophen should also be considered for
pain management in patients with suspected
acute appendicitis, especially in those with
contraindications to opioids. The previous study
found that there was no difference between 107
patients with acute appendicitis to narcotics plus
acetaminophen vs. placebo, and no change the
Alvarado score also [23].
6.1 Non Surgical Management
Several European trials have demonstrated in
the last 20 tears that in adults, conservative
management of AA is feasible. Treating
appendicitis with antibiotics alone is not a new
concept. Since the inauguration of antibiotics
therapy, it is feasible in trials as early as in the
1950s, or simply just out of need, e.g. in a
maritime or military setting [24]. Gee D et al.
stated that there were 252 passengers with
suspected AA on ships in the sea who did not
have the option of immediate surgery and thus
were treated with antibiotics, which was
successful in 84% of the patients. Also, in some
forms of complicated appendicitis, antibiotics
therapy are well established as initial treatment,

often in combination with drainage of large
abscesses if needed [25]. Most treatment
protocols include an initial course of intravenous
antibiotics for 1-3 days, followed by oral
antibiotics for 7 days. Usually, either a
combination of a cephalosporin and tinidazole or
broad-spectrum penicillin combined with beta-
lactam inhibitor is being administered. In one
trial, ertapenem has been used, leading to
deserved criticism for inadequately using reserve
antibiotics [26].
Salminen et al. found, there were no
intraabdominal abscesses or another major
complications associated with delayed
appendectomy in their patients randomized to
antibiotic treatment [26]. Timing of antibiotics
therapy is important since beginning treatment as
early as possible has shown to increase success
rates significantly [27]. If antibiotic treatment is
not successful during the initial admission,
rescue appendectomy must be performed. In
recurrent disease, either a second course of
antibiotics or appendectomy can be applied.
Under both conditions, complications and risks of
appendectomy are not elevated [26].
6.2 Surgical Managements
Sohn M et al. stated that there were four different
techniques available for appendicitis surgeries,
such as open appendectomy (OA),
(conventional) laparoscopic appendectomy,
single port laparoscopic appendectomy (LA) and
NOTES-appendectomy with its different
variations [28]. In another 5-year non-
randomized study from Yau et al. consisted 1133
patients of which 244 had complicated
appendicitis (among them, 175 underwent LA
and 69 OA), LA patients had a shorter operative
time (55 min vs 70 min), reduced length of stay
(5 d vs 6 d) and a lower incidence of SSI (0.6%
vs 10%) [29]. In the case of complicated
appendicitis (gangrenous or perforated), the
laparoscopic approach also reduced
postoperative pain [30]. For the patient, the
advantages of LA are reported to include faster
recovery of muscle tone, low risk of
postoperative adhesions, earlier return to normal
daily activities, minimal scarring. On the other
hand, conventional OA seldom causes, scarring,
can be ventral hernia, surgical site infection. In
other words, the LA and OA procedures may
only be different in patient's degree of difficulty. A
study of the systematic review found that wound
infection was less likely with LA compared OA
(OD =0.43; 95% CI 1.19 to 2.93) [31].
5
Febyan; AJRRGA, 3(1): 1-7, 2020; Article no.AJRRGA.56863
7. COMPLICATIONS
The most concerning complication of AA
perforation, it may lead to abscesses, peritonitis,
bowel obstruction, fertility issues, and sepsis. It
will happen among adults range from 17% to
32%, even with the increased use of imaging,
and may lead to an increased length of hospital
stay, extended antibiotic administration, and
more severe postoperative complications. The
risk factors that related to the patient for
perforation event depends on older age, three or
more comorbid conditions, and male sex. Time
from symptom onset to diagnosis and surgery is
directly associated with perforation risk [32,33].
Free perforation into the peritoneal cavity can
lead to purulent or feculent peritonitis. A
contained perforation can lead to appendix
abscess phlegmon (inflammatory mass) [31].
8. CONCLUSION
The diagnosis and management of acute
appendicitis in adults have been described with a
focus on some current concept. For clinical
manifestations with physical examinations and
diagnosis finding on ultrasonography and CT are
important to decide for management of antibiotic
only or operative. For the management of acute
appendicitis is still appendectomy as definitive
therapy.
CONSENT
It is not applicable.
ETHICAL APPROVAL
It is not applicable.
COMPETING INTERESTS
Author has declared that no competing interests
exist.
REFERENCES
1. Stewart B, Khanduri P, McCord C, Ohene-
Yeboah M, Uranues S, Vega Rivera F, et
al. Global disease burden of conditions
requiring emergency surgery. Br J Surg.
2014;101:e9-22.
2. Lee JH, Park YS, Choi JS. The
epidemiology of appendicitis and
appendectomy in South Korea: National
registry data. J Epidemiol. 2010;20:97-105.

3. Di Saverio S, Birindelli A, Kelly MD,
Catena F, Weber DG, Sartelli M, et al.
WSES Jerusalem guidelines for diagnosis
and treatment of acute appendicitis. World
Journal of Emergency Surgery. 2016;
11(34):1-25.
4. Lewis SR, Mahony PJ, Simpson J.
Appendicitis. Br Med J. 2011;343:d5976.
5. El-Daou S, Adaimi F, Fakih A, El-Assaad
R, Maasarani D, Kanj M, et al. A
clinicopathological review of 655
appendices removed for acute appendicitis
in a tertiary care medical center in
Lebanon: A retrospective study. J Gastro &
Digestive Sytems. 2019;3(2):1-4.
6. Chandrasekaran TV, Johnson N. Acute
appendicitis. Surgery. 2014;32(8):413-17.
7. Chandrashekar S, Lokesh MG, Avinash
SR. Prevalence of perforated appendicitis
and its determinants in pediatric
appendicitis patients admitted in tertiary
care centre, South India: A cross sectional
study. Int Surg J. 2018;5(12):3926-29.
8. McBurney C.IV. The incision made in the
abdominal wall in cases of appendicitis,
with a description of a new method of
operating. Ann Surg.1894;20:38-43.
9. Semm K. Endoscopic appendectomy.
Endoscopy. 1983;15:59-64.
10. Smith MP, Katz DS, Lalani T, Carucci LR,
Cash BD, Kim DH, et al. Right lower
quadrant pain-suspected appendicitis.
Ultrasound Q. 2015;31(2):85-91.
11. Ebell MH, Athens, Georgia. Diagnosis of
appendicitis: Part II. Laboratory and
imaging tests. Am Fam Physician. 2008;
77(8):1153-55.
12. Jones RP, Jeffrey RB, Shah BR, Desser
TS, Rosenberg J, Olcott EW. The Alvarado
score as a method for reducing the
number of CT studies when appendiceal
ultrasound fails to visualize the appendix in
adults. AJR Am J Roentgenol. 2015;204:
519-26.
13. Seal A. Appendicitis: A historical review.
Can J Surg. 1981;24(4):427-33.
14. Puylaert JB. Acute appendicitis: US
evaluation using graded compression.
Radiology. 1986;158(2):355-60.
15. Yamashita Y, Nishino Y, Hirakawa K.
Radiographic diagnosis of acute
appendicitis, a disease commonly treated
by emergency surgery. Establishment of
the diagnosis depending on characteristic
findings. Shokaki Geka (Intestinal Surgey).
2000;23:1903-10.
6
Febyan; AJRRGA, 3(1): 1-7, 2020; Article no.AJRRGA.56863
16. Hanafi MG, Shiri A. Diagnostic accuracy of
acute appendicitis by ultrasound in
Hospital Emergency. IJP. 2018;7(1):8787-
93.
17. Cushieri J, Florence M, Flum DR,
Jurkovich GJ, Lin P, Steele SR, et al.
Negative appendectomy and imaging
accuracy in the Washington Stase Surgical
Care and outcomes assessment program.
Ann Surg. 2008;248:557-63.
18. Kim K, Kim YH, Kim SY, Kim S, Lee YJ,
Kim KP, et al. Low dose abdominal CT for
evaluating suspected appendicitis. N Engl
J Med. 2012;366:1596-605.
19. Terasawa T, Blackmore CC, Bent S,
Kholwes RJ. Systematic review: Computed
tomography and ultrasonography to detect
acute appendicitis in adults and
adolescents. Ann Intern Med. 2004;141:
537-46
20. Snyder MJ, Guthrie M, Cagle S. Acute
appendicitis: Efficient diagnosis and
management. AFP. 2018;98(1):25-33.
21. Hardy A, Butler B, Crandall M. The
evaluation of the acute abdomen. In:
Moore LJ et al. editors. Common problems
in acute care surgery. New York; Springer
Science+Business Media; 2013.
22. Ranji SR, Goldman LE, Simel DL,
Shojania KG. Do opioid affect the clinical
evaluation of patients with acute
abdominal pain? JAMA.
2006;296(14):1764-74.
23. Mousavi SM, Paydar S, Tahmasebi S,
Ghahramani L. The effects of intravenous
acetaminophen on pain and clinical
findings of patients with acute appendicitis:
A randomized clinical trial. Bull Emerg
Trauma. 2014;2(1):22-6.
24. Wojciechowicz KH, Hoffkamp HJ, van
Hulst RA. Conservative treatment of acute
appendicitis: An overview. Int Marit Health.
2010;62:265-72.
25. Gee D, Babineau TJ. Theoptimal
management of adult patients presenting
with appendiceal abscess: Conservative vs
immediate operative management. Curr
Surg. 2004;61:524-28.
26. Salminen P, Paajanen H, Rautio T,
Nordstrom P, Aarnio M, Rantanen T, et al.
Antibiotic therapy vs appendectomy for
treatment of uncomplicated acute
appendicitis: The APPAC randomized
clinical trial. JAMA. 2015;313:2340-48.
27. Coccolini F, Fugazzola P, Sartelli M,
Enrico C, Maria GS, Gioacchino L, et al.
 Febyan; AJRRGA, 3(1): 1-7, 2020; Article no.AJRRGA.56863

Conservative treatment of acute 30. Gard CP, Vaidya BB, Chengalath MM.
appendicitis. Acta Biomed. 2018;89(9): Efficacy of laparoscopic in complicated
119-34. appendicitis. Int J Surg. 2009;7:250-52.
28. Sohn M, Agha A, Bremer S, Lehmann KS, 31. D’souza N, Nugent K. Appendicitis. AFP.
Bormann M, Horchrein H. Surgical 2016;93(2):142-43.
management of acute appendicitis in 32. Mandeville K, Monuteaux M, Pottker T,
adults: A review of current techniques. Bulloch B. Effect of timing to diagnosis and
International Journal of Surgery. 2017;48: appendectomy in pediatric appendicitis.
232-39. Pediatr Emerg Care. 2015;31(11):753-
29. Yau KK, Siu WT, Tang CN, Yang 58.
GP, Li MK. Laparoscopic versus 33. Ohene-Yeboah M, Abantanga FA.
open appendectomy for complicated Incidence of acute appendicitis in Kumasi,
appendicitis. J Am Coll Surg. 2007;205:60- Ghana. West afr J Med. 2009;28:122-
5. 25.

© 2020 Febyan; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

Peer-review history:
The peer review history for this paper can be accessed here:
http://www.sdiarticle4.com/review-history/56863

View publication stats