CHAPTER 93 

Acute Appendicitis
Jeannette M. Wolfe and Philip L. Henneman

PERSPECTIVE
PRINCIPLES OF DISEASE:
Epidemiology PATHOPHYSIOLOGY
Appendicitis is a common condition requiring emergency The appendix is a hollow, muscular, closed-ended tube arising
surgery. About 7% of people will develop appendicitis sometime from the posterior medial surface of the cecum, about 3 cm below
during their lifetime. Most cases occur in adolescents and young the ileocecal valve. Its average length is approximately 10 cm, and
adults, with the incidence in men being slightly higher than in its normal capacity is 0.1 to 0.3 mL. The role of the appendix
women.1,2 in human physiology is unclear, but some recent studies on bio-
Although the diagnosis is clinically clear in classic presentations, films suggest that the appendix may act as a repository for com-
it still remains elusive in atypical presentations; after missed myo- mensal bacteria that inoculate the large bowel and protect it from
cardial infarction and fractures, missed appendicitis represents the pathogens.7 Innervation of the appendix is derived from sympa-
largest number of malpractice claims for practicing emergency thetic and vagus nerves from the superior mesenteric plexus.
physicians.3 Afferent fibers that conduct visceral pain from the appendix
accompany the sympathetic nerves and enter the spinal cord at
Historical Perspective the level of the 10th thoracic segment. This causes referred pain
to the umbilical area.
The earliest evidence of appendicitis is suggested by the presence The majority of patients develop appendicitis because of an
of right lower quadrant adhesions in an Egyptian mummy from acute obstruction of the appendiceal lumen. This is often from an
the Byzantine era. In 1492, Leonardo da Vinci drew pictures of the appendicolith, but obstruction can also be caused by a calculi, a
colon and the appendix and called the structure an “orecchio,” tumor, a parasite, or enlarged lymph nodes. Of historical note, one
which literally means ear. Claudius Amyand removed the first of the more common causes of acute appendicitis from foreign
appendix incidentally in 1735 during the repair of a scrotal hernia objects in the early 19th century was ingested lead shells buried in
in an 11-year-old boy. The appendix had perforated, and a cutane- quail meat.8 A recent case study describes lumen obstruction from
ous fecal-draining fistula had developed.4 The half-hour operation a swallowed tongue stud.9
was done without anesthesia, and the boy fully recovered. In the After acute obstruction, intraluminal pressures rise and mucosal
early 1800s during the Lewis and Clark expedition, the only trip secretions are unable to drain. The resulting distention stimulates
mortality was Charles Floyd, who was rumored to have died from visceral afferent pathways and is perceived as a dull, poorly
a ruptured appendix.5 localized pain. Abdominal cramping may occur as a result of
In 1880 in Europe, Lawson Tait performed the first successful hyperperistalsis. Next, ulceration and ischemia develop as the
planned appendectomy by removing a gangrenous appendix intraluminal pressure exceeds the venous pressure, and bacteria
from a 17-year-old woman. Six years later Reginald Fitz, a pathol- and polymorphonuclear cells begin to invade the appendiceal
ogist, coined the term “appendicitis” when he read his classic wall. The appendix may appear grossly normal at this time with
paper at the first meeting of the Association of American Physi- evidence of pathology apparent only on microscopic examination.
cians. Fitz correctly described many of the pathophysiologic With time, the appendix becomes swollen and begins to irritate
changes associated with appendicitis and advocated early surgery. surrounding structures, including the peritoneal wall. The pain
Three years later, Charles McBurney described a point “deter- then becomes more localized to the right lower quadrant. If swell-
mined by the pressure of one finger” between “one and a half ing does not abate, hypoxia leads to necrosis and perforation
and two inches from the anterior spinous process” which, through the appendiceal serosal layer. This can lead to abscess
when palpated, was associated with the greatest discomfort in formation or diffuse peritonitis. The time required for the appen-
patients with acute appendicitis (McBurney’s point). The general dix to perforate is highly variable and controversial; some
acceptance that appendicitis is a surgical disease did not occur experts believe that unless a virulent organism or genetic predis-
until several decades later. Early surgical intervention became position exists, many cases will spontaneously resolve. In most
popular in the early 1900s around the time that King Edward cases, perforation occurs within 24 to 36 hours. Elders may be
VII perforated his appendix and was operated on days before more prone to earlier perforation owing to anatomic changes
his coronation.6 in the appendix associated with aging, such as a narrowed

1225
1226   PART III  ◆  Medicine and Surgery / Section Five • Gastrointestinal System
appendiceal lumen, thinner mucosal lining, decreased lymphoid Although any of the aforementioned signs may be present in
tissue, and atherosclerosis.10 patients with acute appendicitis, a review of 10 studies that evalu-
No direct cause of obstruction is noted in approximately one ated 13 signs and symptoms of adult appendicitis identified
third of cases; it is surmised that in these cases inflammation is certain findings that have a high positive likelihood ratio of iden-
caused by viral, bacterial, or parasitic infection with subsequent tifying patients with appendicitis. These were migration of pain
mucosal ulceration or lymphoid hyperplasia.2 from the periumbilical area to the right lower quadrant, right
lower quadrant tenderness, and abdominal wall rigidity.2 Con-
versely, the presence of pain for more than 48 hours, a history of
CLINICAL FEATURES previous episodes of similar pain, the lack of migration and right
History lower quadrant pain, and the lack of worsening pain with move-
ment or cough make appendicitis less likely.2,13 A similar review of
Appendicitis is classically described as starting with the vague children with appendicitis concluded that fever and rebound ten-
onset of dull periumbilical pain and continuing with the develop- derness are the most common findings.14
ment of anorexia, nausea, and vomiting. The pain then migrates Vital signs are often normal, particularly early in the course. A
to the right lower quadrant, and a low-grade fever may develop. low-grade fever is present in 15% of all patients with appendicitis,
In most instances the patient has not previously experienced and in 40% of patients if perforation has occurred.15
similar pain.2 Unfortunately, the presentation may be highly vari-
able. If the appendix is retrocecal or retroiliac, the pain may be
blunted by the presence of overlying bowel. If the appendix
is elongated, the pain may be referred to the flank, pelvis, or Special Considerations
right upper quadrant. Other, less typical symptoms seen with Children
appendicitis are increased urinary frequency and the desire to
defecate.2 Young children with acute appendicitis usually are diagnosed after
perforation has occurred. This may be because many common
Physical Examination childhood illnesses are associated with nausea, anorexia, and vom-
iting, and young children may have difficulty communicating their
The most common finding on physical examination is localized discomfort.16 Anatomically, children have a thinner appendiceal
abdominal tenderness, usually in the right lower quadrant. Ten- wall and a less developed omentum, which may predispose them
derness is often noted over McBurney’s point, an area approxi- to perforation and diffuse peritonitis.
mately 2 cm from the anterior superior iliac spine on an imaginary
line drawn from that anatomic landmark to the umbilicus. Women
However, because only 35% of patients have the base of their
appendix within 5 cm of this point, the pain of appendicitis can The diagnosis of acute appendicitis in women of childbearing age
be localized in other areas of the abdomen.11 is especially challenging. Before the advent of imaging, as many as
Other physical examination findings include guarding and 45% of women with symptoms suggestive of appendicitis had a
rigidity. Guarding is usually voluntary, and the patient can often normal appendix at surgery, and as many as one third of women
be persuaded to relax. Rigidity is involuntary and implies more with true appendicitis were initially misdiagnosed. Gynecologic
significant underlying pathology.2 Both of these findings reflect disease can easily masquerade as appendicitis owing to the prox-
the tensing of the abdominal wall musculature to protect the imity of the right ovary, the fallopian tube, and the uterus to the
underlying bowel. appendix.17,18 Findings that may be more suggestive of abdominal
Rovsing sign is present when palpation of the left lower quadrant pain of gynecologic origin are included in Table 93-1. Of note,
causes pain referred to the right lower quadrant. Psoas sign, indica- although cervical motion tenderness is more common in patients
tive of a retrocecal appendix, is the increase in pain when the psoas with pelvic inflammatory disease, up to a quarter of women with
muscle is stretched by extending the right leg at the hip while the appendicitis may also exhibit it.19 Because obtaining an accurate
patient lies on the left side. Obturator sign, indicative of a pelvic diagnosis of appendicitis is especially challenging in women, ancil-
appendix, is the elicitation of pain in a supine patient as the right lary imaging should strongly be considered.
hip is flexed and externally rotated.
Rebound tenderness, indicative of peritoneal inflammation, is Pregnant Women
a late finding in patients with appendicitis and usually occurs only
after the appendix is significantly inflamed or ruptured. Rebound Pregnant women have an overall risk of developing appendicitis
tenderness can be elicited by gradually pressing over the area of similar to the general population.20 Of the three trimesters, appen-
tenderness for 5 to 10 seconds and then quickly withdrawing the dicitis appears to occur slightly more often in the second trimester
hand to just above the skin level. A positive response occurs when
the patient reports increased pain as the hand is removed. Patients
with rebound tenderness are very uncomfortable with this maneu-
ver, and it should not be repeated unnecessarily.11 Evidence of
peritoneal irritation can also be elicited by abdominal wall percus-
sion or by having the patient cough, resulting in pain referred to Table 93-1 Abdominal Pain in Women
the right lower quadrant. More suggestive of Migration of pain and tenderness localized
Isolated rectal tenderness may rarely be the only site of local- appendicitis to the right lower quadrant, anorexia, normal
ized pain in patients with a low-lying or retrocecal appendix. In or minimally abnormal pelvic examination
general, however, rectal tenderness has a very limited diagnostic findings (i.e., isolated right adnexal
tenderness)
value, especially if concurrent right lower quadrant pain and
tenderness are present.12,13 Although a single rectal examination More suggestive of pelvic Several days of symptoms, history of pelvic
may provide other important information, such as the discovery inflammatory disease inflammatory disease, hunger, diffuse lower
abdominal pain, bilateral adnexal tenderness,
of a rectal mass or occult blood, multiple examinations are cervical motion tenderness, vaginal discharge
not justified.
 Chapter 93 / Acute Appendicitis   1227
for unknown reasons. The diagnosis of appendicitis during preg-
nancy can be difficult, as early symptoms of appendicitis such as DIAGNOSTIC STRATEGIES
nausea and vomiting occur frequently in a normal pregnancy.
Laboratory values are even less helpful, as leukocytosis is common Laboratory Testing
during pregnancy. The accuracy of the physical examination may Leucocyte Count and C-Reactive Protein
also be compromised, as enlargement of the uterus may alter the
location of the appendix to the right flank or right upper quad- Approximately 80 to 90% of patients with acute appendicitis have
rant. However, one study of pregnant patients with appendicitis a white blood cell (WBC) count above 10,000/mm3. Unfortu-
found that most women still had presenting symptoms of right nately, the WBC count is nonspecific and often elevated with other
lower quadrant pain and tenderness, even when it occurred late causes of abdominal pain.
in pregnancy.21 C-reactive protein (CRP) is an acute-phase reactant synthesized
Although maternal death from appendicitis is extremely rare, by hepatocytes in response to an acute injury or inflammation. It
fetal abortion occurs in about 5 to 15% of simple appendicitis has a slower rate of rise than the WBC count and a shorter half-
cases and up to 37% of complicated cases.22 Because the morbidity life. A meta-analysis suggests that the overall sensitivity of CRP is
is high, extra caution should be taken with pregnant women with approximately 62% and specificity 66%, thereby limiting its use-
abdominal pain. fulness as a stand-alone diagnostic tool in patients with appendi-
citis.30 Several studies, however, have examined the diagnostic
Elder Patients utility of combining the CRP and WBC count. Although most
patients with complicated (perforated) appendicitis will have
Elders are three times more likely to have a perforated appendix elevations of either or both laboratory values, most authorities
at surgery compared with the general population. There appear to have concentrated on the negative predictive value of a normal
be multiple causes for this, including anatomic age-related changes WBC count and CRP in ruling out appendicitis. Two meta-
of the appendix, delay in seeking medical care, atypical presenta- analyses assessing use of the combined values in adults found that
tions, and minimally elevated laboratory values.9 patients with a WBC count below 10,000/mm3 and a CRP below
6 to 12 mg/L were unlikely to have appendicitis (negative likeli-
Complications hood ratio of 0.09), whereas those with a WBC count above
10,000/mm3 and a CRP above 8 mg/L were likely to have appen-
The complication rate after the removal of a normal appendix or dicitis (positive likelihood ratio of 23.32).31,32 Unfortunately, this
an acutely inflamed appendix is roughly 3% and increases approx- test combination appears less helpful in pediatric patients, with
imately three to four times if perforation occurs.14 The most one study showing that 7% of patients with acute uncomplicated
common complication is infection. Localized wound infection appendicitis have a normal WBC count and CRP.32
occurs in about 2 to 7%, and deep intra-abdominal abscess occurs In infection, CRP doubles every 8 hours and peaks at 36 to 50
in 0.8 to 2%, with the higher percentages representing cases in hours; there is therefore growing interest in tracking a repeat CRP
which perforation has occurred.23 in patients with examination findings equivocal for appendicitis.
Other complications include a prolonged ileus, small bowel A recent pediatric study showed that children with appendicitis
obstruction, pneumonia, and urinary retention and infection. In had a 6-hour CRP increase of at least 4.8 mg/L.33
young women, perforation may cause obstruction of the fallopian
tubes, leading to infertility, though recent studies suggest this is Urinalysis
not as prevalent as once believed.24,25 Pregnant patients with
appendicitis have an increased risk of premature labor (15-45%) A urinalysis is helpful in differentiating urinary tract disease from
and fetal death. acute appendicitis. Mild sterile pyuria may be seen if the inflamed
The mortality of uncomplicated appendicitis in otherwise appendix lies in proximity to the ureter. Significant pyuria (>20
healthy individuals is less than 0.1% but increases to about 3 to WBCs per high-power field [hpf]) or hematuria (>30 red blood
4% with perforation in patients with comorbidities or advanced cells [RBCs]/hpf) is highly suggestive of urinary tract pathology.
age. Although reported perforation rates vary significantly from
study to study, the overall average is 20 to 30%. This increases Pregnancy Test
greatly at the extremes of age. Elders have perforation rates as high
as 60%, and children younger than 3 years can have perforation A urine pregnancy test should be performed for all women of
rates as high as 80 to 90%.9,15 childbearing age with abdominal pain, as a positive test result
The identification of factors that may increase a patient’s risk expands the differential diagnosis.
for perforation is evolving. The traditional belief has been that
the natural course of appendicitis is inflammation that, if surgery Diagnostic Scores
is delayed, ultimately progresses to necrosis and perforation.
Many experts now feel that in most patients the natural course Several scoring systems have been developed that assign numerical
of appendicitis is spontaneous resolution without perforation.26 values to different aspects of the history, physical examination, and
This view is supported by general autopsy reports from the pre- laboratory test results in patients with right lower quadrant pain
surgical era, in which up to one third of corpses had evidence in an attempt to assist risk stratification in clinical decision-
of periappendiceal scarring, and by studies that report successful making. The modified Alvarado score uses a 9-point scoring
resolution of early appendicitis with nonoperative management.27 system as follows: migratory right lower quadrant pain, 1 point;
It is hypothesized that a subset of the population is genetically anorexia, 1 point; nausea or vomiting, 1 point; temperature above
predisposed to perforation owing to an early aggressive and 37.5° C, 1 point; right lower quadrant tenderness, 2 points;
exaggerated inflammatory response.28 The evidence for this is rebound tenderness, 1 point; and leukocytosis, 2 points. A score
the relatively consistent population perforation rate even with below 4 is considered low risk, 4 to 6 represents moderate risk,
the advent of increased imaging and earlier diagnoses. Most cases and more than 6 represents high risk. Unfortunately, these scoring
of perforation occur before medical evaluation, and hospital systems have yielded inconsistent results when used by themselves
delays in operative management rarely appear to increase perfo- to determine the need for operative intervention and were particu-
ration rates.29 larly inaccurate when applied to female patients and patients at
1228   PART III  ◆  Medicine and Surgery / Section Five • Gastrointestinal System
the extremes of age.2,34 Recent renewed interest in these scales has tomography (CT) scan if the patient’s symptoms have not
occurred, however, to determine if they can be used to stratify a improved.
patient’s need for advanced imaging. Whereas a low modified
Alvarado score (<4) does not reliably exclude acute appendicitis, Computed Tomography
high scores (>6) may identify patients who would benefit from
surgical consultation without imaging studies.35,36 Abdominal pelvic CT scanning has been prospectively studied and
shown to improve the clinical accuracy of the diagnosis of appen-
dicitis.45,46 CT findings suggestive of appendicitis include an
Imaging Studies enlarged appendix (diameter greater than 6 mm), pericecal
Plain Radiographs inflammation, the presence of an appendicolith (Fig. 93-1), or a
periappendiceal phlegmon or abscess (Fig. 93-2). The sensitivity
Plain radiographs are not useful in diagnosing appendicitis owing
to very low sensitivity and specificity. They are not recommended
in the evaluation of appendicitis unless there is a significant
concern for bowel obstruction, free air, or pneumonia.37
Periappendiceal
fat streaking
Barium Enemas
Barium enemas have a sensitivity of about 80 to 90% for detection
of appendicitis, and the diagnosis is essentially ruled out if the
entire appendix is filled with contrast.35 Unfortunately, a normal
appendiceal lumen is often not visualized with this technique.
Barium enemas are most helpful when other colon pathology is
high in the differential diagnosis.

Nuclear Medicine Scans Appendiceal

wall thickening
The use of nuclear imaging with tagged WBCs has been
well studied as a diagnostic tool for acute appendicitis.36,38 The
reported sensitivities of nuclear scans depend on the tag used and
range from 88 to 98%. The overall usefulness of these scans
is limited owing to poor specificity; any process causing inflam-
matory changes in the lower abdomen can lead to a false-
positive scan.

Ultrasonography
Graded compression ultrasound (US) has been prospectively Figure 93-1.  Oral contrast computed tomography scan showing
evidence of acute appendicitis with periappendiceal fat streaking.
shown to improve the clinical accuracy of the diagnosis of acute (Courtesy Jefferson Radiology.)
appendicitis.39 The reported sensitivity and specificity of US for
acute appendicitis in most studies are 75 to 90% and 85 to 95%,
respectively.40 There have been some recent advances in US tech-
niques. One group reports an astonishing 98% visualization rate
(compared with the often cited 2-45%) with the addition of
simple repositioning maneuvers.41 Similarly, small studies using
contrast-enhanced Doppler or harmonic waves (which allow for
better resolution) show promise of higher sensitivities with lower
radiation exposure.42-44 Fat stranding
US is considered positive for appendicitis if the appendix is
noncompressible and has a diameter of more than 6 to 7 mm. US
is inexpensive, requires no exposure to radiation or dye, adds no
extra time for contrast filling, and has had long-standing success
in diagnosis of pelvic pathology in women. It also allows the
ultrasonographer to correlate the patient’s pain with the direct
visualization of underlying abdominal contents. The major disad-
vantage of US is that the visualization of the appendix (normal or
abnormal) is operator dependent, and can be especially difficult
if the patient is obese, has strictures from previous surgeries, or
has a retrocecal appendix. A diagnostic US also becomes more Discrete abscess
difficult after the appendix has perforated, and patients with sig- from perforated
nificant right lower quadrant pain may not tolerate the graded appendix
compression.
A positive US study for appendicitis has a positive predictive
value of about 90%. A negative study, however, is not helpful
unless the appendix is clearly visualized or alternative pathology Figure 93-2.  Oral contrast computed tomography scan showing
is identified. For this reason, it is appropriate to follow a negative discrete abscess from appendiceal perforation, with periappendiceal fat
US study with either in-hospital observation or a computed streaking. (Courtesy Jefferson Radiology.)
 Chapter 93 / Acute Appendicitis   1229
(87-100%) and specificity (89-98%) of CT scan varies by study alternative pathology. In one study, patients received oral contrast,
and technique and by how authors categorize inconclusive scans followed by a focused 15-cm right lower quadrant scan, followed
in their statistical analyses. There are several different protocols by a scan of the entire abdomen with intravenous contrast. CT
used in scanning patients with right lower quadrant pain, includ- sensitivities increased from 83 to 93% with the addition of the
ing any one or a combination of oral contrast, rectal contrast, intravenous contrast scan.57
intravenous contrast, no contrast, low-dose radiation, and a 15-cm Several studies have given convincing arguments in favor of the
focused scan. use of an intravenous-contrasted scan without enteric contrast.
CT scanning has some advantages over US in the diagnostic Kharbanda looked at historical data comparing a protocol that
evaluation of appendicitis. The appendix can usually be visualized, included both rectal and IV contrast with a new IV contrast only
the technique is standardized, and alternative pathology often is protocol and found similar sensitivities (92 and 93%, respec-
identified. An added benefit is that the CT signs are relatively tively).58 Likewise, Kaiser reported sensitivities of 97% with intra-
straightforward in most patients with appendicitis. This is an venous contrast alone in children for appendicitis.59 The downside
important consideration because the initial interpretation of the of intravenous contrast is the potential for adverse reactions, such
CT scan usually dictates patient disposition, and in academic as anaphylactoid reactions, skin extravasation, and renal injury,
teaching centers the scans may be interpreted by junior radiology and its slightly increased cost.
residents after hours.47 Recently there has been increased interest in the use of CT scans
The biggest disadvantages of CT scanning are the radiation that bypass the need for both enteric and intravenous contrast.
exposure and the expense. The amount of radiation exposure on The argument is that CT technology is advancing with multidetec-
a routine full abdominal and pelvic CT study can vary dramati- tor helical scanners and that an enlarged inflamed appendix with
cally depending on scanning parameters but is usually cited as surrounding periappendiceal fat streaking should be visualized on
being around 10 millisieverts (mSv), which is the same radiation most noncontrast scans. These scans avoid the potential complica-
dose as 500 chest radiographs. This amount is theoretically carci- tions of enteric and intravenous contrast and decrease emergency
nogenic, and it has been proposed, based on World War II atomic department (ED) length of stay. A meta-analysis of seven studies
bomb data, that the radiation from a single abdominal CT scan showed an overall sensitivity and specificity of 93% and 96%,
could cause a fatal cancer in 1 of every 2000 adults or 500 children respectively, for the diagnosis of appendicitis with noncontrast
scanned.48 One study estimates that of the 70 million patients who scans.60 However, the study that contributed the most data to the
underwent CT scanning in 2007, over 27,000 patients (14,000 analysis had a large number of patients with equivocal scans
from abdominal pelvic CT) will ultimately develop a radiation- and a 23% rescan rate.61 It is not clear that such a high rescan
induced cancer.49 rate is justifiable in lieu of the additional radiation exposure.
There are techniques that can be used to decrease radiation At this time, the sensitivities for these noncontrast scans appear
exposure in the evaluation of appendicitis. A limited focused scan to be institution-specific. Several studies have found that noncon-
through the right lower quadrant will decrease exposure but must trast scans have sensitivities for appendicitis that range from 60
be weighed against the possibility of missing an unusually placed to 83%.62-65
appendix or alternative pathology. There have also been a few The results of all these studies raise more questions than provide
recent studies examining the use of low-dose CT scans in the definitive answers regarding the ideal CT protocol to detect appen-
diagnosis of appendicitis.50,51 Seo studied the utility of a noncon- dicitis. However, three salient points seem to consistently emerge.
trast low-dose scan that uses a new software technology called First, young or slender patients are less likely to have significant
sliding slab ray-sum to rule out appendicitis. The researchers esti- intra-abdominal fat, and the use of additional contrast (intrave-
mated that a low-dose scan (approximately 4 mSv) would have a nous or enteric) may help delineate their anatomy. Second, intra-
sensitivity of 95% for appendicitis and have a less than 10% venous contrast may be useful in identifying other causes of pain,
required rescan rate.52 A small study in 2009 obtained similar which may be especially helpful in older patients with broader
results.53 Further research is needed to clarify several questions, differential diagnoses. Third, the use of intravenous or oral con-
such as the accuracy of the identification of a noninflamed appen- trast may be less important in establishing the diagnosis than the
dix, the ability to distinguish between simple and complicated interpreting radiologist’s preference, experience, and access to
appendicitis, the sensitivity of diagnosing alternative pathology, clinical information. Hof showed that the difference in the inter-
and optimal scanning parameters. reader sensitivities of a noncontrast scan for appendicitis depends
Currently the most commonly used protocol to scan patients on the experience level of the radiologist, with sensitivities ranging
with right lower quadrant pain is with oral and intravenous con- from 81 to 95%.66 Kaiser compared real-time CT interpretations
trast. Enteric contrast (either oral or rectal) is advocated by many with blinded retrospective interpretations and found the latter to
radiologists because they feel it helps better delineate right lower be associated with decreased sensitivities for appendicitis (90% vs.
quadrant anatomy by cecal contrast opacification. Oral contrast 97%).67 Keyzer found that perfect agreement regarding what was
abdominal pelvic CT generally requires a 60- to 90-minute delay consistently identified as the appendix occurred only 71% of the
after contrast administration for distal small bowel opacification time on noncontrast and intravenous scans interpreted by three
(though even then contrast may not be visualized in the cecum different readers, and that scan reproducibility appeared to be
20-30% of the time) and may be poorly tolerated in patients with more related to the presence of intra-abdominal fat and the skills
nausea or an ileus. One study addressed poor oral transit time by of the individual radiologist than to the use of intravenous
adding polyethylene glycol to the oral contrast, which allowed contrast.68
good cecal opacification in 1 hour.49 Finally, CT is not 100% accurate. Overall, approximately 5 to
Rectal contrast appears to be very sensitive for detecting acute 10% of CT scans are considered inconclusive for appendicitis, and
appendicitis, with rates as high as 98%.54 It confers a number of this number varies significantly among hospitals. Care should be
theoretic advantages over oral contrast: It may be better tolerated taken not to label all inconclusive CT scans as “negative,” because
in nauseated patients; there is no delay in scanning because of up to 30% of these patients ultimately have histologic confirma-
contrast transit time; and there is more consistent cecal opacifica- tion of appendicitis.62 The appendix is not visualized in 10 to
tion.55,56 These benefits must be weighed against patient and tech- 15% of inconclusive examinations. When this happens in patients
nician preference, as many find these scans invasive and messy. with adequate cecal fat, secondary findings of appendicitis such
Intravenous contrast is used at many institutions, as it will as free fluid or fat stranding may suggest the diagnosis. Levine
enhance an inflamed appendiceal wall and may aid in delineating retrospectively reviewed 24 patients with histologically proven
1230   PART III  ◆  Medicine and Surgery / Section Five • Gastrointestinal System
appendicitis who had “missed” CT scans and found 96% had a
paucity of fat and 50% had a lack of cecal contrast opacification.63 Table 93-2 Differential Diagnosis for Appendicitis
When the appendix is not seen in an otherwise normal CT scan
ALL PATIENTS WOMEN CHILDREN
in a patient with adequate abdominal fat, the risk of acute appen-
dicitis appears to be extremely low, with one study showing it to Nonspecific abdominal Ovarian cyst Henoch-Schönlein
be less than 2%.64,65 pain Ovarian torsion purpura
These studies underscore the importance of sharing accurate Gastroenteritis Pelvic inflammatory Testicular torsion
Ascending diverticulitis disease Epiploic appendagitis
clinical information with radiologists and considering their Gallbladder disease Ectopic pregnancy Mesenteric adenitis or
experience and comfort level when institutional scanning proto- Inflammatory bowel ileocolitis
cols are being developed. Because accuracy rates vary among radi- disease Meckel’s diverticulum
ologists, institutions should consider periodic review of their own Renal colic
experiences. The Washington state surgical study, the SCOAP Col-
laborative, showed that CT accuracy rates and negative appendec-
tomy rates vary significantly across hospitals and recommended MANAGEMENT
that local data be used in quality improvement and education
interventions.69 In recent years there has been renewed debate as to whether acute
In general, even patients with a true “negative” scan should be appendicitis is truly a surgical emergency. The traditional view
explicitly told to be reevaluated if their symptoms progress or do that untreated early appendicitis inevitably progresses to a necrotic
not resolve in the following 24 to 36 hours. This is particularly and perforated appendix has been questioned. As stated previ-
true in patients evaluated within the first few hours of symptoms, ously, some experts believe that patients with complicated appen-
as early appendicitis may be missed on CT scan.70 dicitis have either a genetic predisposition to an exaggerated
inflammatory response or possible infection with a more virulent
Magnetic Resonance Imaging pathologic organism, leading to early aggressive disease.28 In
general, this group of patients arrive for medical care with already-
Magnetic resonance imaging (MRI) is an emerging tool used in advanced disease. Along this reasoning, the remaining subset of
the evaluation of suspected appendicitis, with reported sensitivi- patients usually have acute uncomplicated appendicitis and often
ties similar to those of CT. Access to MRI is currently limited in will get better with medical management, including antibiotics
most EDs, and its use is often confined to pregnant patients with and intravenous fluid alone. A meta-analysis of three studies that
an indeterminate US as an alternative to CT.70-74 As MRI becomes looked at nonoperative versus operative management of acute
more available and concerns about nephrotoxicity from intrave- appendicitis showed that although the majority of patients recover
nous contrast and cancer-related deaths from ionizing radiation without surgery, 42% require surgery, either during their initial
continue, MRI is likely to become increasingly popular and may hospitalization or during readmission.78 Currently, a nonsurgical
eventually replace CT scanning in the evaluation of select patients approach is probably best reserved only for patients who are poor
with possible appendicitis.75 operative candidates.
A strategy to manage patients with possible appendicitis is
Laparoscopy depicted in Figure 93-3. Patients should be kept on nothing-by-
mouth (NPO) status and undergo a complete physical examina-
Laparoscopy can be performed for diagnosis or definitive treat- tion, including a pelvic examination, with consideration of a rectal
ment. Historically, its greatest advantage was in the differentiation examination if there is concern for an atypically placed appendix
of appendicitis from gynecologic disease in young female patients. or strong alternative diagnosis. Dehydrated patients should receive
Enteric contrast CT scan can now usually visualize the appendix, intravenous crystalloid fluids, and parenteral antiemetics should
and the use of diagnostic laparoscopy with its anesthetic risks has be given to patients who are nauseated or vomiting. All patients
therefore decreased significantly. should be offered pain medicine. Multiple studies show that giving
opiate pain medicine to adults or children with signs of appendi-
In-Hospital Observation citis does not mask important physical findings or impair surgical
decision-making.79,80 A recently published meta-analysis examin-
Despite the increased tendency to pursue diagnostic imaging in ing the relationship of opiate administration and changing
patients with right lower quadrant abdominal pain, studies suggest abdominal findings concluded that, although the existing litera-
that most cases of appendicitis can be accurately diagnosed by ture was not definitive, changes in physical signs appear to be
performing serial physical examinations.76,77 A review of studies minor and do not alter patient management.81 The practice of
that have used active inpatient observation in patients with an withholding analgesia from patients with abdominal pain pending
equivocal diagnosis of appendicitis found a negative appendec- surgical consultation is not supported by the medical literature. In
tomy rate of roughly 6% without an increase in perforation rates.59 rare instances in which local surgical preference or institutional
Alternatives to inpatient observation that are used but have not policy requires this approach, delays in obtaining consultations
been well studied include use of an ED observation unit and dis- should be minimized.
charge with short-term follow-up for reevaluation. A urine dipstick or urinalysis is suggested for all patients, along
with a WBC count and, in women of childbearing age, a preg-
nancy test.
DIFFERENTIAL DIAGNOSIS Controversy exists regarding when and how to best use advanced
imaging techniques. Some authors have shown that CT scanning
An elongated appendix can irritate almost any abdominal significantly decreases the rate of negative laparotomies, even in
structure, so the differential diagnosis of appendicitis includes patients for whom the clinical suspicion of appendicitis is high.82-84
essentially any pathology that can cause abdominal pain. The Others feel that diagnostic imaging is overused and has not
more common diseases that can mimic appendicitis are listed improved patient care.85,86 Considering both these views, diagnos-
in Table 93-2. Of note, the diagnosis of gastroenteritis should tic imaging appears to be most helpful in a select group of patients,
be made with caution and only in patients with vomiting and with the initial history, physical examination, and laboratory tests
diarrhea. used to stratify patients by risk.
 Chapter 93 / Acute Appendicitis   1231

Physical examination including pelvic in women Historically, it has been very difficult to accurately diagnose
NPO, IV fluids, analgesia, urine dip, hCG,1 and CBC women with appendicitis, and negative laparotomy rates of 40
to 45% were common. Fortunately, imaging can dramatically
decrease these rates and should be strongly considered. US is the
Low Medium High
risk risk risk3 reasonable initial test if there is increased suspicion for gyneco-
logic pathology, if the patient is slender, or if the institution has
excellent experience in diagnosing appendicitis with US. Having
Consider surgical Surgical patients drink oral contrast while waiting for their US examina-
Treat alternative
diagnosis, consult2 consult4 tion allows them to be fully prepared for CT if the US is
discharge with nondiagnostic.
precautions1 US is also the first-line test to exclude other obstetric diagnoses
in pregnant patients. If the US is equivocal, MRI should be con-
Ultrasound: CT scan6: sidered if it is readily available. Although CT is less preferable, its
Children Overweight patients use may still be justified after appropriate surgical and gynecologic
Pregnant women5 Older patients consultation to avoid the risks of potentially unnecessary anesthe-
Abnormal pelvic exam Patients with significant sia and surgery.
Slender patients comorbidities Children with a suspicious presentation for appendicitis but
who lack classic findings and have no clear alternative diagnosis
may also be considered “equivocal.” US is usually considered the
Normal appendix seen: Positive: IV initial imaging study in children because it does not expose
Reevaluate and consider IV antibiotics antibiotics
them to radiation. This should be a significant consideration, as
alternative diagnosis and OR and OR
children are particularly vulnerable to the risks of radiation
owing to their increased cell division and their longer life
Nondiagnostic: Negative or nondiagnostic expectancy.52,55
Reexamine and consider Reevaluate — if significant Researchers at Packard Children’s Hospital at Stanford pub-
observation or CT scan tenderness, consider lished their experience using a graded approach of US with
observation; if improving, selected follow-up CT for children with equivocal workups for
consider discharge with appendicitis.87 They found that the US findings were definitively
precautions
positive or negative in about 30% of patients. In patients with
an equivocal US who went on to undergo CT, about 20% had
1. Improving or unchanged repeat exam along with vital signs should be documented appendicitis. It is interesting to note that only 52% of children
prior to discharge. Patients should be given precautions and reevaluated in
12-24 hours if there are symptoms or patients are not improving or reevaluated with equivocal US findings went on to undergo CT. This was a
immediately if patients’ conditions worsen. retrospective study with limited follow-up, but the authors did
2. Timing and type of surgical consultation will be dependent on local preferences;
many institutions prefer formal imaging on moderate-risk patients prior to consultation. not detect large missed appendicitis rates. Although they did not
3. Men and children with classic presentations of appendicitis are considered high- quantify the specific reasons that led to patient discharge without
risk patients.
4. Surgical consult is appropriate prior to imaging in high-risk patients as imaging may CT, their study opens the door for further research in this area.
not be indicated. Improving physical examination findings after an equivocal US
5. If ultrasound is nondiagnostic in a pregnant patient, obstetric and surgical consult
should be obtained and MRI considered. is reassuring, but this may be a circumstance in which repeating
6. See section on CT scans to decide which type of scan to use. the CRP determination may be useful.35 If the US is nondiag-
nostic and the child’s clinical status has not improved, conserva-
Figure 93-3.  Suggested emergency department management of tive management with a follow-up CT scan or admission for
patients with possible appendicitis. CBC, complete blood count; CT, observation is encouraged.54
computed tomography; HCG, human chorionic gonadotropin; IV,
intravenous; MRI, magnetic resonance imaging; NPO, nil per os
Men with an equivocal presentation for appendicitis should be
(“nothing per mouth”); OR, operating room. considered candidates for US (if they are slender) or CT.

High-Risk Patients
Low-Risk Patients
Men and children with classic presentations of appendicitis are at
Patients may be considered low risk if they have minimal physical high risk for appendicitis and receive little benefit from further
findings and a strong alternative diagnosis or if they have had imaging. Men with classic signs of appendicitis have the disease
previous multiple episodes of similar pain. Excessive imaging in more than 90% of the time.89,90 A review of CT imaging for appen-
patients who are at low risk for appendicitis will result in increased dicitis at one institution showed that imaging dramatically
false-positive studies, as these patients have a low prevalence of decreased the number of negative appendectomies in women
disease. In these patients, the best course of action is education (from 43 to 7%) but had no significant effect in men.91 Another
concerning worsening signs of appendicitis and arrangement of study showed that 65% of men were able to go to the operating
close follow-up. They should be instructed to be reevaluated room without a scan, with only a 4% negative appendectomy
immediately if their symptoms acutely worsen, or in 12 to 24 rate.92 Surgical consultation before imaging is therefore encour-
hours if their condition has not improved. aged in these high-risk groups.
Emergency physicians should advocate institutional polices that
Equivocal-Risk Patients prevent unnecessary radiation in these high-risk groups. The
exception may be clinically toxic high-risk patients for whom there
“Equivocal” patients include most women (especially those of is a concern for perforation of the appendix. Patients with walled-
childbearing age), and men and children with atypical signs of off abscesses may be initially managed nonoperatively, and there-
appendicitis. Patients with equivocal signs of appendicitis should fore a CT scan may direct their clinical course.
be considered for diagnostic testing or active observation. Surgical Once the decision to operate has been made, prophylactic
input by phone or formal consultation may be appropriate before antibiotics should be given to cover gram-negative and anaerobic
imaging, depending on local surgical preference. organisms, as this has been proven to decrease both superficial
1232   PART III  ◆  Medicine and Surgery / Section Five • Gastrointestinal System
and deep postoperative wound infections. Intravenous second- Discharged patients should be encouraged to start on a liquid diet
generation cephalosporins, such as cefotetan or cefoxitin, provide and advance to solids when their symptoms improve. Patients
good coverage. If there is a high suspicion of perforation, the with abdominal pain of unclear cause who require significant
traditional treatment has been broad-spectrum triple antibiotics. doses of opiates to control their pain should be considered for
However, new studies suggest that monotherapy with a second- admission.102
generation cephalosporin or meropenem or piperacillin and tazo- If follow-up cannot be arranged, if there are concerns regarding
bactam is effective with easier administration. Alternatively a patient or family reliability, or if a significant language or trans-
once-a-day combination of ceftriaxone and metronidazole is also portation barrier exists, admission for continued observation
sufficient.93,94 should be considered.
The timing of surgical intervention has recently been chal-
lenged, with several studies suggesting that complication rates are
not adversely affected if surgery is delayed until daylight hours.95,96
If this practice is to be considered, it needs to be balanced against KEY CONCEPTS
the condition of the individual patient, the potential for disrupt-
ing the morning operating room schedule, and increase in the ■ Classic appendicitis is a clinical diagnosis.
overall length of hospital stay. ■ Patients with a low risk of appendicitis may be sent home
The appendix can be surgically removed either through the with close follow-up and education about progressive
traditional open technique or through laparoscopy. A Cochrane symptoms.
review of 45 randomized studies favors laparoscopic removal.97 ■ Patients with equivocal findings of appendicitis should
The authors conclude that laparoscopic appendix removal results undergo advanced diagnostic imaging or in-hospital serial
examinations.
in less frequent wound infections, less postoperative pain on day ■ Men and children with classic signs and symptoms of
1, shorter lengths of hospital stay, shorter time to return to normal appendicitis should undergo prompt surgical evaluation, as
activity, and decreased overall costs. Laparoscopy may be most imaging may be unnecessary.
helpful in female patients, as it allows inspection for pelvic pathol- ■ Ultrasound is an appropriate initial test in children, pregnant
ogy that may masquerade as acute appendicitis. patients, women suspected to have pelvic pathology, and
Some institutions have developed extensive operative and post- slender adults.
operative guidelines for the care of appendicitis patients.98,99 Use ■ Helical CT with enteric contrast is considered the initial test in
of these guidelines has decreased postoperative complications and all males with equivocal signs of appendicitis and in obese
costs and appears to be most helpful in the subgroup of patients females in whom gynecologic disease is not suspected.
■ Pain medicine should be offered to all patients with
with perforation.
suspected appendicitis.
For patients with evidence of perforation and abscess forma- ■ Antibiotics should be given preoperatively.
tion, many surgeons prefer to nonoperatively drain the abscess
and treat the patient with intravenous antibiotics initially, fol-
lowed by appendectomy 6 weeks later.100 Recently, it was even
suggested that the appendix may not have to be removed after The references for this chapter can be found online by
successful abscess resolution.101 accessing the accompanying Expert Consult website.

DISPOSITION
If the suspicion for appendicitis is low, the patient may be sent
home after appropriate counseling and arrangement of follow-up.
 Chapter 93 / Acute Appendicitis   1232.e1

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