FIRSTCONSULT

Acuteappendicitis
Revised:September12,2012
CopyrightElsevierBV.Allrightsreserved.

Keypoints
Acuteappendicitisiscausedbyluminalobstruction,resultinginmucosalischemiawithprogressiontofull
thicknessnecrosis.Obstructionmaybeduetoafecalith,lymphoidhyperplasia,tumor,oraforeignbody
Patientswithtypicalsignsandsymptomsofacuteappendicitisshouldbereferredtoasurgeonpromptly
Diagnosisofacuteappendicitisisrelativelystraightforwardinyoungmalepatients.However,infemalepatients
andinpatientsattheextremesofage,diagnosticdifficultymayariseduetoanexpandeddifferentialdiagnosis,
delayedpresentationtothehospital,anddifficultyinobtainingareliablehistoryandphysicalexamination
Computedtomography(CT)scanisgenerallythemostreliableimagingmodalityinpatientswithacute
appendicitisandmayalsoidentifyappendicealphlegmonandappendicealabscess,conditionswhichmaybe
effectivelymanagedwithmodalitiesotherthansurgery.However,CTscanscausesignificantinhospitaldelayin
treatmentofacuteappendicitisandshouldbedoneonlywhenthediagnosisisuncertain
Appendectomyforacuteappendicitisisthemostcommonlyperformedemergencysurgicalprocedureinthe
world
Treatmentconsistsofeitherlaparoscopicoropenappendectomy.Perioperativeadministrationofantibiotics
reducestheincidenceofpostoperativesurgicalsiteinfectionsandintraabdominalabscesses

Background
Description
Acuteappendicitisresultsfromappendicealdilationsecondarytoobstruction
Theclassicpresentationofacuteappendicitisiscrampingandintermittentdiffusecentral,periumbilical,or
epigastricabdominalpainusuallylastingseveralhours,withbriefcessation,followedbymigrationofpaintoa
constant,localizedareaintherightlowerquadrantattheMcBurneypointonethirdofthewayuptheoblique
linethatjoinstherightanteriorsuperioriliacspinetotheumbilicus.However,theabsenceofoneorall
featuresorprogressiondoesnotruleoutthediagnosis
Painmaybeatypicalinpatientswithretrocecalappendixandmaybeshiftedupintotherightupperquadrant
inpregnantwomen
Delayintreatment,mostfrequentlyrelatedtodelayedpresentationtothehospital,mayresultinperforation,
peritonitis,andgreatlyincreasedmorbidityandmortality

Epidemiology
Incidence
Approximately250,000appendectomiesaredoneannuallyintheU.S.

Approximately7%ofthepopulation(8.6%ofmalesand6.7%offemales)willhaveacuteappendicitisatsome
pointintheirlifetime
Patientsaged10to20yearshavethehighestincidenceofappendicitis(158per100,000persons)
Therateofcomplicatedappendicitis,includingfreeperforationwithperitonitisorappendicealabscess,isalso
agedependent,withthehighestrateamongpatientsaged0to5yearsandthoseaged60yearsandolder.The
overallincidenceofperforatedappendicitisacrossallagegroupsisapproximately20%
Demographics
Age:
Mostcommonlyseenfromthefirstthroughseconddecadeoflife
Therateofperforatedappendicitisishighestinpatientsoverage65(approximately50%)
Gender:
Slightlymorecommoninmaleswithamaletofemaleratioof1.2to1.4:1
Race:
Hispanicpersonshavethehighestrateofappendicitisrelatedhospitalization(118per100,000persons)
followedbywhitepersons(95per100,000persons)andblackpersons(60per100,000persons)
Genetics:
Recentstudieshavenotedanassociationbetweenpreviousappendectomyandinflammatoryboweldisease.
EarlyappendectomyhasbeenassociatedwithdelayedonsetofbothulcerativecolitisandCrohndisease
Geography:
Thereissomeevidenceofgeographicclusteringofcasesofacuteappendicitis.Theincidenceishighestinthe
developedworld
Socioeconomicstatus:
Thereisanincreasedriskofmorbidityandmortalityinunderinsuredpopulations,especiallyinchildren.This
mayberelatedtolaterpresentationformedicalcare
Disparitiesalsoexistwithrespecttoraceandincomelevelforthemanagementofadultswithappendicitis

Causesandriskfactors
Commoncauses:
Luminalobstructionisthemostcommonlyrecognizedinitiatingeventinpatientswithacuteappendicitis.The
mostfrequentcauseofluminalobstructionisafecalith.However,themajorityofpatientswithacute
appendicitisdonotshowevidenceoffecalith,suggestingthatobstructionisonlyoneofthepossibleetiologies
ofacuteappendicitis
Inchildren,lymphoidhyperplasiaisthoughttobethemostcommoncauseofluminalobstruction
Luminalobstructionresultsinincreasedintraappendicealpressureduetocontinuedmucosalsecretion.This
ultimatelyleadstovenousoutflowobstruction,causingvenouscongestionmultiplicationofresidentbacterial

floraand,finally,arterialcompromise,leadingtoischemia
Ischemialeadstoperforationwithsubsequentdevelopmentofgeneralizedperitonitis,phlegmon,orabscess
Somecasesofacuteappendicitisalsoappeartoresolvespontaneously
Rarecauses:
Tumor
Inspissatedbariumfromimagingstudies
Foreignbodies,suchasseedsandparasites
Seriouscauses:
Allpatientswithacutenonperforatedappendicitisarebesttreatedwithappendectomy
Somepatientswithacuteappendicitisresultingfromluminalobstructionbytumor(mucinouscystadenomaor
mucinouscystadenocarcinoma,adenocarcinoma,carcinoidtumor)mayrequireadditionalresectionofthe
bowel

Screening
Notapplicable.

Primaryprevention
Appendicitisisnotpreventableinthegeneralpopulation.

Diagnosis
Summaryapproach
Theextentofthediagnosticworkupshouldbebasedontheclinicalhistoryandphysicalexaminationfindings
Laboratorytests,suchasacompletebloodcount(CBC),maybehelpfulinthediagnosisofacuteappendicitis,
butnosingletestisdefinitive
Urinalysisshouldbeobtainedtoexcludeurinarytractinfection
Womenofchildbearingagemusthaveapregnancytest
Additionalbloodtestsbeforetransfertosurgicalcarearenotnormallyrequired
AbdominalCTscanhasanaccuracyofmorethan90%foracuteappendicitisandistheconfirmatorytestof
choiceinequivocalsituations
WhenabdominalCTscanshowsaninflammatoryappendicealmass(phlegmon)oranintraabdominal
abscess,treatmentmayinitiallybenonsurgical

Clinicalpresentation
Symptoms
Theclassicsequenceforprogressionofsymptomsisanorexia,followedbyabdominalpain,andthennausea
andvomitinghowever,atypicalpresentationiscommoninelderlyandimmunocompromisedpatientsaswell

asinchildren
Anorexiaiscommoninadultsandisaconsistentfeatureinchildren
Abdominalpain,classicallybeginningintheperiumbilicalorepigastricareaandreferredfromtheappendix
whenlocalizedinflammationoftheperitoneumdevelops.Painsubsequentlylocalizestotherightlower
quadrantwithin12hours.Thefinallocationofthepainisdeterminedbytheanatomiclocationofthe
appendix.Forexample,patientswitharetrocecalappendixmayhavebackorflankpain
Overtime,patientsmayreportworseningpainwithcoughorslightmovements,suchasthoseproducedby
bumpswhiletravelinginacar
Nauseaandvomitingfollowtheonsetoftheabdominalpain.Nauseaandvomitingprecedingabdominalpain
suggestanalternatediagnosis,suchasgastroenteritis
Patientsmayreportfeelingfeverish
Occasionally,diarrheaorconstipation
Dysuriaandtenesmusmayaccompanyabdominalpelvicappendicitis
Otherhistoricalinformation
Typicallythehistoryofappendicitisisshortlessthan48hoursinpatientswithacuteappendicitis.Inpatients
experiencingpainforlongerthan36hours,thelikelihoodofperforationisincreased
Althoughrare,chronicappendicitiswithpersistentabdominalpainhasbeendescribedandmaybeconsidered
ifothercausesofrightlowerquadrantpainhavebeenexcluded
Painisinitiallygeneralizedandthenlocalizestotherightlowerquadrant
Colickypainmaybeanearlyfeatureofappendicitis.Painusuallyprogressesandbecomescontinuous
Thetimeofsincelastfoodorliquidisimportanttodocumentbeforeadministeringanesthesiaandmaybe
usefulindetermininghowlongthepatienthasbeenanorexic
Askthepatientaboutnonspecificsymptomssuchasnauseaandvomiting,diarrhea,dysuriaandhematuria,
andbloodinthestool
Priorremovaloftheappendixprecludesappendicitisexceptintherarecaseofstumpappendicitis.The
appendixissometimesremovedduringhysterectomyandotherabdominalsurgeries
Infemalepatients:
Alwaysconsiderectopicpregnancyinfemalepatientsofchildbearingage.Establishwhetherthepatientis
sexuallyactiveandwhatkindofcontraceptionorprotectionsheuses.Askaboutlastmenstrualperiod.Ask
whethershecouldbepregnant
Askthepatientaboutanypelvicinfectionsshehashadinthepast
Askaboutanyvaginaldischarge
Inolderpatientsorpatientsinwhomcecalcancerissuspected:
Askabouthistoryofcolonoscopy.Cecalcarcinomaisunlikelyinpatientswithnormalrecentcomplete
colonoscopyfindings

Signs
Signsassociatedwithacuteappendicitisaredependentonthestageofdiseaseandtheanatomiclocationofthe
appendix
Rightlowerquadrantabdominaltendernessisthemostconsistentsign.Tendernessoncoughingorrebound
tendernessimpliesthepresenceoflocalizedperitonealinflammation
Temperatureelevationofmorethan1.8F(1C)isuncommon
Tachycardiamayormaynotbepresent
Psoassign(painwithrighthipextensionsuggestiveofretrocecalappendix),obturatorsign(painwithinternal
rotationofflexedrighthipsuggestiveofpelvicappendix),orRovsingsign(rightlowerquadrantpainon
palpationoftheleftlowerquadrant)maybepresent
CutaneoushyperesthesiabetweenT10andT12ontherightmaybepresent
Patientmaydemonstratebothvoluntaryandinvoluntaryguarding
Patientoftenliesstill,intherightlateraldecubitusposition,withslightflexionofthehip
OtherscoringsystemsthathavebeenpublishedincludetheLintulascore,theFenyLindbergscore,andthe
inflammatoryappendicitisresponsescore
Alvaradoscore:
TheAlvaradoscore,inwhichtypicalsymptoms,signs,andlaboratoryfindingsareassignedavalueof1or2,
hasbeenstudiedasacriteriatooltoestimatethelikelihoodofacuteappendicitis.Inonesmallseries,the
sensitivityofAlvaradoscores3orlowerfornothavingappendicitiswas96.2%andthespecificitywas67%.
PatientswithAlvaradoscores7orhigherhadanincidenceofacuteappendicitisof77.7%andaspecificityof
100%.ThesensitivityandspecificityofCTscansinpatientswithequivocalAlvaradoscores(46)ishigh,at
90.4%and95%,respectively
Symptoms:
Migrationofpain=1
Anorexia=1
Nauseaand/orvomiting=1
Signs:
Rightlowerquadranttenderness=2
Reboundpain=1
Elevatedtemperature=1
Laboratoryfindings:
Leukocytosis=2
Leftshiftinleukocytecount=1
Otherphysicalexaminationfactors
Temperatureandpulseratemaybeelevatedinpatientswithappendicitis.Checkbloodpressureaswell

Considerperforationifthepatientappearstoxicordehydrated
Performanabdominalexamination
Auscultatetheabdomenforbowelsounds,whichmaybeabsentinpatientswithperforation
Observefortendernessoncoughing,reboundtenderness,andguarding(bothvoluntaryandinvoluntary),
whicharesignsofperitonealirritation
Checkforpsoassign(painonextensionoftherighthip),obturatorsign(painonflexionandinternalrotationof
righthip),andRovsingsign(rightlowerquadrantpainonpalpationoftheleftlowerquadrant)
Tendernessontherightsideduringarectalexaminationmaybepresentinpatientswithappendicitis
Performabimanualpelvicexaminationinwomentocheckforadnexalmassesandcervicalmotiontenderness

Diagnostictesting
Serumpregnancytest(179269):Alwaysconsiderectopicpregnancyinwomenofchildbearingage
CBCwithdifferential(56244):Leukocytosiswithneutrophiliaispresentin90%ofpatientswithappendicitisbut

maybeminimal.Perforationislikelyifasignificantelevationispresent
Urinalysis(179276):Hematuriaandpyuriaoccurinlessthan20%ofpatientswithappendicitis,andtheir

presencemaysuggestanalternatediagnosis
AbdominalCTscan(570330)hasanaccuracyinexcessof90%andistheconfirmatorytestofchoiceinequivocal

situations.Ifnonsurgicaltreatmentoflocalizedperforatedappendicitisisbeingconsidered,CTscanmay
identifythepresenceofaphlegmonorabscess.Intravenousandoralcontrastareusuallyusedrectalcontrast
isusedinsomeinstitutions.UseofCTscanforallpatientswithrightlowerquadrantpainmayreducethe
overalluseofhospitalresources
Gradedcompressionultrasound(56268)isusefulinwomenofchildbearingagetoassessforgynecologicpathology.

Inthinpatientsandchildrenwithclinicalsuspicionofacuteappendicitis,ultrasoundshowingadilated,
noncompressibleappendixconfirmsthediagnosisofappendicitis.Accuracyishighlyoperatordependent
Magneticresonanceimaging(MRI)(1413378)isanalternateimagingmodalitythatcanbeconsideredinpatientsin

whomacuteappendicitisissuspecteditisusedprimarilyinpregnantpatientswhenultrasoundisnot
diagnostic

Serumpregnancytest

Description
Venousbloodsample
Normalresult
Negative
Comments
Shouldbeobtainedurgentlyinallfemalepatientsofchildbearingage
Serumpregnancytestsmeasureserumhumanchorionicgonadotropinlevels,whichareelevatedinthe
settingofpregnancy(includingectopicpregnancy),abortion,andgestationaltrophoblasticdisease

Apositiveresultinapatientwithabdominalpainshouldraisethepossibilityofectopicpregnancy,which
requiresemergencymanagement
Intheabsenceofectopicpregnancy,apositiveresultdictatestheneedforotherspecialmeasuresin
managingthepatientsoasnottoendangerthefetus.ThisincludesconsiderationofultrasoundorMRIfor
diagnosis

Completebloodcountwithdifferential

Description
Venousbloodsample
Normalranges
Leukocytecount:4,500to11,000/L
Differentialcount:
Neutrophilssegmented:1,800to7,800/L
Neutrophilsbands:0to700/L
Lymphocytes:1,000to4,800/L
Monocytes:0to800/L
Eosinophils:0to450/L
Basophils:0to200/L
Erythrocytecount:3.9to5.5106/L
Hemoglobin:14.0to17.5g/dL
Hematocrit:41%to50%
Plateletcount:150to350103/L
Comments
Significantlyelevatedleukocytecountmayindicateperforation
Nonspecificresultscanindicatethepresenceofinfectionbutnotthesource
Leukocytecountmaybenormalearlyinthediseasecourse

Urinalysis

Description
Cleancatchurinespecimen
Normalresult
Noerythrocytes,significantpyuria,orbacteriuria
Comments
Amilddegreeofpyuriaintheabsenceoferythrocytesmaybeseeninpatientswithappendicitis

Anysignificantdegreeofhematuria,pyuria,orbacteriuriashouldraisethesuspicionofaurinaryproblem
asthesourceofthepatient'ssymptoms
Presenceofaurinarytractinfectiondoesnotruleoutacuteappendicitis

Abdominalcomputedtomographyscan

Description
Threedimensionalimagingofbodyorgansandstructures
Generallydonewithintravenousandoralcontrastrectalcontrastisusedinsomeinstitutions
Normalresult
Contrastand/orairfilled,nondilatedappendixwithnosurroundinginflammation
Comments
Ofgreatestvalueinpatientswithatypicalhistoryorphysicalexaminationfindings
Sensitivityof92%to97%andspecificityof93%to96%forthediagnosisofacuteappendicitis
Providesexcellentvisualizationofintraabdominalprocesses
Allowsforassessmentofperforation,includingphlegmonandabscessformation
Arrowheadsign,focalthickeningofthececumaroundtherootoftheappendix,ispresentin30%ofpatients
withacuteappendicitisandhas100%specificityforthediagnosis
Usuallynotnecessaryinpatientsforwhomthereisahighindexofsuspicionforappendicitismaydelay
treatmentbecauseofthetimerequiredtoadministercontrast,performthestudy,andinterprettheresults
Relativelycontraindicatedinpregnantpatients
Intakeoforalcontrastmayincreasetheriskofaspirationwithanesthesia

Evidence
Asystematicreviewof28randomized,controlledtrials(RCTs)including9,330patientsfoundCTcutthe
negativeappendectomyratebyhalf(16.7%to8.7%)comparedtoclinicalexaminationaloneindiagnosis
ofacuteappendicitis.TherewasalsoasignificantlylowernegativeappendectomyrateduringtheCTera
comparedwiththepreCTera(10.0%vs21.5%,P<.001).Timetosurgerywasevaluatedin10ofthe28
studies,5ofwhichdemonstratedasignificantincreaseinthetimetosurgerywiththeuseofCT.
AppendicealperforationrateswereunchangedbytheuseofCT(23.4%intheCTgroupvs16.7%inthe
clinicalevaluationgroup,P=.15).Similarly,theperforationrateduringtheCTerawasnotsignificantly
differentthanthatduringthepreCTera(20.0%vs19.6%,P=.74).Theauthorsconcludedthatroutine
CTinallpatientspresentingwithsuspectedappendicitiscouldreducetherateofunnecessarysurgery
withoutincreasingmorbidity.[1]Levelofevidence:1
Asystematicreviewof7RCTsinvolving1,060patientsinwhomacuteappendicitiswassuspected
showedthatthesensitivityandspecificityofnoncontrastCTscanwere92.7%and96.1%,respectively,for
thediagnosis.[2]Levelofevidence:1
Asystematicreviewandmetaanalysisof6RCTScomparedthediagnosticperformanceofCTscan
versusgradedcompressionultrasoundin671patientsinwhomacuteappendicitiswassuspected

clinicallyandfoundthatCTscanperformedbetterthanultrasoundinconfirmingthediagnosisof
appendicitis.Thelikelihoodratiowas9.29forCTscanand4.50forultrasound,resultinginposttest
probabilitiesforpositivetestresultsof90%and82%,respectively.[3]Levelofevidence:1

References

Gradedcompressionultrasound

Description
Imagingperformedbyapplyingcontinuouspressurewithatransducerintherightlowerquadrantduring
transabdominalultrasound
Normalresult
Nondilatedappendixwithnosurroundinginflammation
Comments
AnalternativetoCTscaninpregnantpatientsorotherswitharelativecontraindicationtoionizingradiation
Sensitivityof83%to88%andspecificityof78%to84%forthediagnosisofappendicitis
Doesnotrequirecontrast
Especiallyusefulintheworkupofgynecologicandobstetriccausesofpaininwomenofchildbearingage

Evidence
Asystematicreviewandmetaanalysisof6RCTScomparedthediagnosticperformanceofCTscan
versusgradedcompressionultrasoundin671patientsinwhomacuteappendicitiswassuspected
clinicallyandfoundthatCTscanperformedbetterthanultrasoundinconfirmingthediagnosisof
appendicitis.Thelikelihoodratiowas9.29forCTscanand4.50forultrasound,resultinginposttest
probabilitiesforpositivetestresultsof90%and82%,respectively.[3]Levelofevidence:1

References

Magneticresonanceimaging

Description
MRIispromisingforthediagnosisofacuteappendicitisinpregnantpatientsandchildreninwhom
radiationshouldbeavoided
T2weightedimageswithandwithoutfatsuppression,noncontrastT1weightedandpostcontrastT1
weightedsequencesareobtained
Gadoliniumisnotusedforpregnantpatients
Normalresult
Contrastand/orairfilled,nondilatedappendixwithnosurroundinginflammation
Comments
ThefindingsofappendicitisarebestseenonT2weightedimages
Moreusefulthanultrasoundinobesepatients,pregnantwomen,andpatientswithretrocecalappendix

Limitedevaluationoftheentirelengthoftheappendixandpresenceofappendicolith

Evidence
AsystematicreviewandmetaanalysisofeightRCTsincluding363patientsfoundthatMRIhada
sensitivityof97%andspecificityof95%,withalikelihoodratiopositive(LR+)of16.3andanLRof0.09
forthediagnosisofacuteappendicitis.Mostpatientsincludedinthestudywerepregnantfemales.[4]
Levelofevidence:1

References
Differentialdiagnosis
Thedifferentialdiagnosisvariesdependingonthepatient'sgenderandage
Otherlesscommondifferentialdiagnosesthatshouldbeconsideredincludeappendicitisepiploica,omental
torsion,appendicealneoplasm,lowerlobepneumonia,andforeignbodyperforationofbowel

Mesentericlymphadenitis
Inflammationoflymphnodesatthebase/rootofmesenteryandappendix
Mostoftenconfusedwithacuteappendicitisinchildren
Usuallyfollowsaviralupperrespiratoryinfection
MaybeduetoinfectionwithYersinia,Shigella,Mycobacteriumtuberculosis,Actinomycosis,Salmonella
,orCampylobacter
Reboundtendernessandrigidityareusuallyabsent
Morecommoninchildren
Usuallyselflimited

Pelvicinflammatorydisease
Pelvicinflammatorydiseaseisaspectrumofinflammatorydisordersofthefemaleuppergenitaltract

Infectionisusuallybilateral
Patientsoftenwaitdaysorweeksbeforeseekingmedicalcare
Theremaybeahistoryofpreviouspelvicinfectionsorsexuallytransmitteddiseases
Abdominalpainislesslocalizedtotherightlowerquadrant
Cervicalmotiontenderness,vaginaldischarge,andbilateraltendernessofadnexaeareobservedonpelvic
examination
Purulentvaginaldischargemayrevealintracellulardiplococci
Transvaginalultrasoundmayaidindiagnosis

RupturedGraafianfollicleorcorpusluteumcyst
RupturedGraafianfollicleusuallyoccursmidmenses(mittelschmerz)
Rupturedcorpusluteumcystusuallyoccursattheonsetofmenses

Feverandleukocytosisareusuallyabsent
Painandtendernessareusuallydiffuse

Acutegastroenteritis
Acutegastroenteritismaybecausedbyviruses,bacteria,parasites,ortoxins
Nauseaandvomitingusuallyprecedesabdominalpain
Profusediarrhea
Painandtendernessaregenerallypoorlylocalized
Noperitonealsigns
Leukocytosisandfeverarelesscommon

Torsionofovariancyst
Classicallyoccursunilaterallyinapathologicallyenlargedovary
Therightsideisaffectedslightlymorethantheleftside
Clinicalhistoryandphysicalexaminationfindingsmaybeindistinguishablefromthoseofacuteappendicitis
Nauseaandvomitingoccurmorecommonly
Theremaybeahistoryofpreviousepisodesduetospontaneouslyresolvingtorsion
Massmaybepalpableonphysicalexamination
CTscanmayaidindiagnosis
Treatmentincludeslaparoscopywithdetorsionoftheovaryandpossibleoophoropexy
Salpingooophorectomymaybeindicatedifthereisseverevascularcompromiseortissuenecrosis

Ectopicpregnancy
Ectopicpregnancyoccurswhenafertilizedovumimplantsintissueotherthantheliningoftheuterus

Ninetysevenpercentofectopicpregnanciesarelocatedinthefallopiantube
Ruptureofarighttubalorovarianpregnancymaymimicappendicitis
Positivepregnancytestresultinthesettingofapelvicmass
Severeabdominalpain,maybecolickyinitially
Tendernessandfullnessinfornices
Transvaginalultrasoundorculdocentesismayconfirmthediagnosis

Crohnterminalileitis
Crohndiseaseischaracterizedbyinflammationofthegastrointestinaltract

Anyportionfromthemouthtotheanusmaybeinvolvedtheterminalileumismostcommonlyaffected

Fever,rightlowerquadrantpain,andleukocytosismaybepresent
Historyofdiarrheawithbloodandmucusandweightloss
CTscanmayshowthickeningoftheterminalileumand/orcecum
Diagnosismaybeestablishedatthetimeofsurgeryforacuteappendicitis
IfthepatientistakentotheoperatingroomforsuspectedacuteappendicitisandCrohnterminalileitisis
noted,anappendectomycanbedoneifthebaseoftheappendixisnotinvolvedintheinflammatoryprocess

Acutecholecystitis
Cholecystitisisacuteorchronicinflammationofthegallbladderresultingfromcysticductobstruction,often

secondarytogallstones
Commonlycausesepigastricorrightupperquadrantpain,frequentlywithrightscapularradiation
Symptomsmaybepostprandialandareclassicallydescribedafterafattymeal
Thereisoftenahistoryofpreviousepisodesofsimilarpain
Patientstendtomovearoundinanefforttofindapositionofcomfortasopposedtopatientswith
appendicitisandperitonealsigns,whotendtolieverystill
Murphysign(pauseininspirationwithpalpationoftherightupperquadrant)maybepresent
Feverislesscommon

Diverticulardisease
Diverticulaaresaclikeoutpouchingsofmucosaandsubmucosathroughthemuscularlayerofthecolon,
mostcommonlythesigmoidcolon.Whenadiverticulumperforates,theremaybelocalizedpericolonic
infectionandinflammation,whichisreferredtoasdiverticulardisease
Generallyseeninolderpatients,whomayhavehadpreviousepisodes
Painisgenerallylocatedintheleftlowerquadrantbutmayoccurontherightifthesigmoidcolonis
redundantoriftherearediverticulaintherightcolon
CTscanmayaidindiagnosis

Psoasabscess
Arisesfromdiseaseofthelumbarorlowervertebrae,withthepusdescendinginthesheathofthepsoas
muscle
MayresultfromhematogenousspreadorlocalinvolvementasaresultofCrohndisease,perforated
appendicitis,ordiverticulardisease
Theremaybeahistoryofinflammatoryboweldisease
Abdominalpainwithfever
Painonflexionofthehip
CTscanmayhelptodistinguishpsoasabscessfromotherdisorders

Cecaltumorwithlocalizedperforation
Generallyoccursinelderlypatients
Askabouthistoryofcolonicscreening(colonoscopy,bariumenema)
Constitutionalsymptoms,suchasweightloss,anemia,andfatigue,maybepresent
Rectalexaminationmayrevealhemepositivestools
Massorfullnessmaybeobservedonphysicalexamination
CTscanmayaidindiagnosis

Meckeldiverticulitis
Meckeldiverticulumisanilealdiverticulum,usuallylocatedwithin2feetoftheileocecalvalve,resulting
fromfailureoftheomphalomesentericducttobecompletelyobliteratedbytheeighthweekofgestation
Clinicalpictureisoftenindistinguishablefromthatofacuteappendicitis
Mostcommonlyoccursinchildren
Centralorlowerabdominalpain
MaybeidentifiedonCTscan
SurgeryisindicatedforsymptomaticMeckeldiverticulum,bleeding,orsuspicionoftumor
ResectionofincidentallynotednormalMeckeldiverticulumiscontroversial

Smallbowelobstruction
Obstructionofthesmallbowelbyadhesivebandstumors,malrotationoftheintestineandcongenitalbands

or,rarely,aheavyparasiticloadcanproducenonspecificsymptoms
Persistentvomiting,usuallybilestained
Increasingabdominaldistension
Diffusecentralabdominalpain,oftennotobviouslycolicky
Pallorandtachycardiamayaccompanyepisodesofpain
Maybesubacuteandrecurrentifduetoadhesions
Dilatedloopsofsmallbowelandairfluidlevelsareseenonabdominalradiograph

Perforatedduodenalulcer
Duodenalulcerscanfreelyperforateintotheperitonealcavity

Mostcommoninelderlypatients
Prominentmidbackpainsuggestspenetrationmorediffuseabdominalpainandreboundtendernesswith
perforationanddevelopmentofperitonitis
Vomitingsoonaftermealssuggestsoutletobstruction

Hematemesisandmelenaaresometimesassociatedwithduodenalulcers

Intussusception
Intussusceptionistheinvaginationofaportionofintestineintoamoredistalsegment,leadingtoedema

venousengorgementand,ultimately,ischemiaofthesegmentofaffectedbowel.
Usuallyseeninchildren,inwhomthececumintussusceptsintotheileum(ileocolicintussusception)
Adultintussusceptionsarelesscommonandusuallyhaveadistinctpathologicleadpoint,whichis
malignantinuptoonehalfofcases
Patientspresentwithintermittentabdominalpainandsignsandsymptomsofbowelobstruction
CTscanistheinvestigationofchoice,wherea'targetsign'maybeseen
Inchildren,treatmentisusuallynonsurgicalwithradiologicreduction
Inadults,treatmentissurgicalresectionoftheinvolvedsegmentandtheleadpoint

Urinarytractinfection
Urinarytractinfectionsoccurwhenbacteriainvadetheurinarytractcomplicatedcasesusuallyinvolvethe

lowertract
Dysuria
Increasedurinaryfrequencyandurgency
Urgeincontinence
Suprapubic,abdominal,orflankpain
Grossormicroscopichematuria
Fever

Pyelonephritis

Pyelonephritisisanacuteinfectionoftherenalpelvisorparenchyma.Canbeacomplicationofuncomplicated
lowerurinarytractinfection
Features
Flankpainandcostovertebralangletendernesswithpercussionareprominentdistinguishingfeatures
Dysuriaandurinaryfrequencyarecommon
Feverwithrigors
Urinalysisresultsmaybepositiveforleukocytes,nitrite,protein,andblood
Urineculturewillaidinconfirmingthediagnosisandnarrowingantibiotictreatment

Renalcalculi
Calculipresentintheureter
Suddenonsetofseverecolickyrightorleftflankpain
Frankormicroscopichematuria
NoncontrastabdominalCTscanfindingsmayconfirmthediagnosis

Testiculartorsion
Torsionofthetestisonthespermaticcord,leadingtointerruptionofbloodflowwithischemiaandinfarction

Usuallyoccursinneonatesoradolescentmales
Suddenonsetofabdominalorscrotalpainwithsubsequentscrotalswelling
Swollen,asymmetricscrotumwithatender,highridingtesticle
Dopplerultrasoundshowsdecreasedintratesticularbloodflowrelativetothecontralateraltestis
Immediatesurgicalexplorationfordetorsion,orchiopexy,andpossibleorchiectomyincasesofnecrotic
testicle

Epididymitis
Epididymitisischaracterizedbyscrotalpainandswellingoftheepididymis

Mostcommoninsexuallyactivemenbutcanoccuratanyage
Inprepubertalboys,themostcommoninfectiveorganismsarecoliformbacteria
Insexuallyactiveyoungmen,themostcommoninfectiveorganismsareNeisseriagonorrhoeaeand
Chlamydiatrachomatis
Inmenoverage35,themostcommoninfectiveorganismsareGramnegativebacteria
Tender,erythematousscrotum
Dysuriaand/orurethraldischarge
Fevermaybepresent
Mayprogresstoinvolvetestis(epididymoorchitis)
Outpatientmedicalmanagementisappropriateformostpatientswithepididymitis

Acutepancreatitis
Pancreatitisisfrequentlyassociatedwithexcessivealcoholconsumptionorgallstones.Lesscommoncauses

includemedications,hypertriglyceridemia,andhypercalcemia
Epigastrictendernessandguarding
Nauseaandvomiting
Hypoactivebowelsounds
Tachycardia
Elevatedamylaseandlipaselevels
TypicalfindingsonabdominalCTscanincludevaryingdegreesofpancreaticinflammation
Managementisbasedonseverityandetiology

Acutemesentericischemia

Acutemesentericischemiaistheocclusionofamajormesentericarteryorveinbyathrombusorembolus,

whichcanleadtointestinaldeath(infarction).Somecasesalsoresultfromnonocclusivemesenteric
ischemia
Mostcommoninelderlypatients
Severeabdominalpainthatisoutofproportiontothephysicalexaminationfindings
Nausea,vomiting,bloodydiarrhea
Rapidlyprogressingabdominaldistension
Ileus
Peritonitisandshockwithbowelwallnecrosisandperforationmayresultwithoutemergencytreatment
Highincidenceofconcomitantcardiovasculardisease(eg,congestiveheartfailure,cardiacarrhythmias,
recentpasthistoryofmyocardialinfarction,atheroscleroticdisease,previoushistoryofdeepvenousthrombosis,
digoxinadministration)

Incarceratedinguinalhernia
Anincarceratedinguinalherniaisaherniathatcannotbereduced
Surgicalemergencyiftherearesignsofcompromisedbloodsupplysuggestiveofstrangulation
Mayleadtobowelobstruction,andthereisariskofbowelischemiaandandfullthicknessnecrosis
Requiresurgentsurgery
Morecommoninmalepatientsandprematureinfants
Abdominalpainanddistressusuallyprecededbythedevelopmentofaninguinallump
Strangulationproducesapainful,tenderinguinalorscrotalswellingthatcannotbereducedandmaybe
accompaniedbyoverlyingskinchanges
Strangulationrequiresemergencytherapy

Consultation
Patientswithperitonitisorsignsoflocalizedperitonealirritationrequireimmediatereferral,regardlessofthe
underlyingdiagnosis.

Treatment
Summaryapproach
Antibioticsshouldbeinitiatedassoonacuteappendicitisissuspectedordiagnosed
Preoperativeempiriccoverageappropriateforgeneralabdominalsurgeryinpatientwithoutperforationshould
bestarted.Antibioticsneednotbecontinuedafteruncomplicatedappendectomy
Inpatientswithaperforatedappendix,postoperativecoverageisgenerallycontinueduntilthepatient's
conditionstabilizes,usuallyaboutaweek.Adjustmentsinempiriccoveragemaybenecessaryoncecultures
andsensitivitiesbecomeavailable
CommonorganismsassociatedwithappendicitisareBfragilis,Escherichiacoli,Pseudomonasaeruginosa,

Klebsiellaspecies,Streptococcusspecies,Enterococcusspecies,andClostridiumspecies
Singleagentsrecommendedforuseinpediatricpatientsincludecarbapenems(1413510),ticarcillinclavulanicacid,
andpiperacillintazobactam
Combinationtherapiesrecommendedforuseinpediatricpatientsincludeceftriaxone,cefotaxime,cefepime,or
ceftazidime,eachincombinationwithmetronidazoleorgentamicinortobramycin,eachincombinationwith

metronidazole(withorwithoutampicillin)orclindamycin(withorwithoutampicillin)
Singleagentsrecommendedforuseinadultswithoutperforationincludecarbapenems,moxifloxacin,tigecycline
,andticarcillinclavulanicacid
Combinationtherapiesincludecefazolin,cefuroxime,ceftriaxone,cefotaxime,ciprofloxacin,orlevofloxacin,each
incombinationwithmetronidazole
Singleagentsrecommendedforuseinpatientswithperforation,elderlypatients,orimmunocompromised
patientsincludecarbapenemsandpiperacillintazobactam
Combinationtherapiesincludecefepime,ceftazidime,ciprofloxacin,orlevofloxacin,eachincombinationwith
metronidazole
Appendectomy(56341)isthedefinitivetreatment

Medications

Carbapenems

Indication
Suspectedacuteappendicitisanditscomplications
Doseinformation
Imipenemcilastatin:

Pediatric,3monthsandolder:60to100mg/kg/dintravenouslyorintramuscularlyindivideddosesevery6
hourstoamaximumof4g/d
Adult:0.5to1gintravenouslyevery6to12hourstoamaximumof4g/d
Meropenem:

Pediatric,3monthsandolder:60to120mg/kg/dintravenouslyindivideddosesevery8hours
Adult:0.5to2gintravenouslyevery8to12hourstoamaximumof6g/d
Doripenem:

Adult:500mgintravenouslyevery8hours
Majorcontraindications
Carbapenemhypersensitivity
Amidelocalanesthetichypersensitivity(imipenemcilastatin)
AVblock(imipenemcilastatin)

Shock(imipenemcilastatin)

Penicillins

Indication
Suspectedacuteappendicitisanditscomplications
Doseinformation
Ampicillin:

Adult:150to200mg/kg/dintravenouslyorintramuscularlyindivideddosesevery3to4hourstoa
maximumof14g/d
Pediatric:150to200mg/kg/dintravenouslyorintramuscularlyindivideddosesevery3to4hours
Piperacillintazobactam:

Adult:3.375gintravenouslyevery6hoursor4.5gevery8hours
Pediatric(children,9monthsandolder):100mg/kgintravenouslyevery8hours
Pediatric(infants,2to9months):80mg/kgintravenouslyevery8hours
Dosesrefertopiperacillincomponent
Ticarcillinclavulanicacid:

Adult:3.1gintravenouslyevery6to8hours
Pediatric:200to300mg/kg/dintravenouslyindivideddosesevery4to6hours
Dosereferstoticarcillincomponent
Majorcontraindications
Penicillinhypersensitivity
Antimicrobialresistance(ampicillin)

Cephalosporins

Indication
Acuteappendicitisanditscomplications
Doseinformation
Cefazolin:

Adult:0.5to1.5gintravenouslyorintramuscularlyevery6to8hours
Cefuroxime:

Adult:1.5to3gintravenouslyorintramuscularlyevery8hours
Ceftriaxone:

Adult:1to2gintravenouslyevery12to24hours
Pediatric:50to75mg/kg/dintravenouslyindivideddosesevery12to24hours
Cefotaxime:

Adult:
Uncomplicatedinfections:1gintravenouslyorintramuscularlyevery12hours
Moderatetosevereinfections:1to2gintravenouslyorintramuscularlyevery8hours
Severeinfections:2gintravenouslyevery6to8hours
Lifethreateninginfections:2gintravenouslyevery4hours
Maximumdosageis12g/d
Pediatric(olderthan1monthandweighinglessthan50kg):50to180mg/kg/dintravenouslyor
intramuscularlyindivideddosesevery4to6hours
Ceftazidime:

Adult:Intravenous:1to2gintravenouslyevery8to12hours
Pediatric(olderthan1month):75to150mg/kg/dintravenouslyindivideddosesevery8hourstoa
maximumof6g/d
Cefepime:

Adult:0.5to2gintravenouslyevery8to12hours
Pediatric:100to150mg/kg/dintravenouslyindivideddosesevery8to12hourstoamaximumof6g/d
Majorcontraindications
Cephalosporinhypersensitivity
Jaundice(ceftriaxone)
Cornhypersensitivity(cefotaxime)

Evidence
InanRCTof269patientsaged15to70yearswithnonperforatedappendicitisundergoingopen
appendectomy,theratesofpostoperativeinfectiouscomplicationswerecomparedbetweenthegroups
receivingsingledosepreoperativetothreedoseandfivedayregimenofcefuroximeandmetronidazole.
Therateofpostoperativeinfectiouscomplicationwasnotsignificantlydifferentamongthegroups.
Complicationsrelatedtoantibiotictreatmentweresignificantlymorecommonforthe5daygroup
comparedwithsingledosegroup.[5]Levelofevidence:2

References

Metronidazole

Indication
Metronidazoleisindicatedforacuteappendicitisanditscomplications

Doseinformation
Pediatric:30mg/kg/dintravenouslyindivideddosesevery6hourstoamaximumof4g/d
Adult:500mgintravenouslyevery6to8hourstoamaximumof4g/d
Comments
Highactivityagainstanaerobicbacteriaandprotozoa

Evidence
InanRCTof269patientsaged15to70yearswithnonperforatedappendicitisundergoingopen
appendectomy,theratesofpostoperativeinfectiouscomplicationswerecomparedbetweenthegroups
receivingsingledosepreoperativetothreedoseandfivedayregimenofcefuroximeandmetronidazole.
Therateofpostoperativeinfectiouscomplicationwasnotsignificantlydifferentamongthegroups.
Complicationsrelatedtoantibiotictreatmentweresignificantlymorecommonforthe5daygroup
comparedwithsingledosegroup.[5]Levelofevidence:2

References

Clindamycin

Indication
Clindamycinisindicatedforacuteappendicitisanditscomplications

Doseinformation
Adult:1.2to1.8g/dintravenouslyorintramuscularlyindivideddosesevery6to12hourstoamaximumof
4.8g/d
Pediatric(1monthandolder):20to40mg/kg/dintravenouslyindivideddosesevery6to8hours
Majorcontraindications
Clindamycinhypersensitivity
Lincomycinhypersensitivity
Pseudomembranouscolitis
Ulcerativecolitis
Comments
MostactiveagainstGrampositivecocciandmanyanaerobes,includingBacteroidesfragilis

Aminoglycosides

Indication
Acuteappendicitisanditscomplications
Doseinformation
Gentamicin:

Adult:3to6mg/kg/dintravenouslyindivideddosesevery8hours

Pediatric:
Infantstoage5years:2.5mg/kgintravenouslyorintramuscularlyevery8hours
Childrenandadolescents:2to2.5mg/kgintravenouslyorintramuscularlyevery8hours
Tobramycin:

Adult:3to6mg/kg/dintravenouslyindivideddosesevery8hours
Pediatric:
Infantstoage5years:2.5mg/kgintravenouslyorintramuscularlyevery8hours
Childrenolderthan5yearsandadolescents:2to2.5mg/kgintravenouslyorintramuscularlyevery8
hours
Majorcontraindications
Aminoglycosidehypersensitivity
Comments
HighlyeffectiveagainstGramnegativeentericbacteria,particularlyinbacteremiaorsepsisinseverelyill
patientsitissometimesaddedtootheragentstobroadenthespectrumofcoverageandprovidesynergistic
activity

Quinolones

Indication
Acuteappendicitisanditscomplications
Doseinformation
Ciprofloxacin:

200to400mgintravenouslyevery12hours
Levofloxacin:

250to500mgintravenouslyevery24hours
Moxifloxacin:

400mgintravenouslyorbymouthdaily
Majorcontraindications
Quinolonehypersensitivity

Tigecycline

Indication
Tigecyclineisindicatedforacuteappendicitisanditscomplications

Doseinformation
100mginitiallyintravenously,followedby50mgevery12hours

Comments
Providesbroadspectrumcoveragesuitableforpolymicrobialinfectionssuchasintraabdominalinfection

Nondrugtreatments

Appendectomy

Description
Surgicalremovaloftheappendixdonelaparoscopicallyorthroughanincisionintherightlowerquadrant
Alowermidlineincisionisusedifthediagnosisisindoubttoallowmoreextensiveexaminationofthe
peritonealcavity
Appendixisremovedfromthebaseofthececum,andthestumpisclosedwithsuturesorstaples
Indication
Acuteappendicitis
Mucocele
Complications
Woundinfection
Bowelobstruction
Fecalfistula
Prolongedileus
Incisionalhernia
Comments
Overallmortalityrateinpatientswithperforatedappendicitisisapproximately1%andincreasesto
approximately5%withelderlypatients
Whendonepromptly,preventstheprogressionofacuteappendicitistoperforatedappendicitisandallof
thecomplicationsassociatedwithit
Laparotomyorlaparoscopyfacilitatespotentialidentificationandtreatmentofanalternatediagnosisifthe
appendixisnotedtobenormal
Routineperitonealcultureisnotuseful
Inpatientswithperforatedappendicitis,continuationofinpatientantibiotictherapyuntilresolutionof
leukocytosisandfever
Considerationofnonsurgicaltreatmentofintraabdominalabscesswithpercutaneousdrainagefollowedby
intervalappendectomyinpatientswithcomplicationsofperforation

Evidence
Asystematicreviewandmetaanalysisof4RCTsinclusiveof741patientsnotedasignificantlyhigher
efficacyofappendectomyintreatmentofacuteappendicitisversusconservativemanagementwith

antibiotics.Complicationrateswerehigherforpatientswhounderwentsurgery.Nodifferenceswere
foundinthenumbersofperforatedappendicesinpatientstreatedwithantibioticscomparedtothose
undergoingappendectomy.Theauthorsconcludedthatalthoughanonsurgicalapproachinappendicitis
canreducethetreatmentcomplicationrate,theloweroverallefficacyaffordedbyantibiotictreatment
precludesitsrecommendationtopatientsasanalternativetosurgery.[6]Levelofevidence:1
Asystematicreviewof67RCTsinclusiveofover6,000patientscomparedopenappendectomyversus
laparoscopicappendectomyinchildrenandadults.Thestudyfoundwoundinfectionswerehalfaslikely
withthelaparoscopicapproach,buttheincidenceofintraabdominalabscesseswasincreasedcompared
toopenappendectomy.Thedurationofsurgerywas10minuteslongerpainonpostoperativeday1was
reducedhospitalstaysignificantlyshortenedandreturntonormalactivity,work,andsportoccurred
earlierafterlaparoscopicappendectomy.Resultsinchildrenweresimilartothoseinadults.Theauthors
concludedthatlaparoscopicappendectomyisareasonablealternativetoopenappendectomy[7]Levelof
evidence:1
Asystematicreviewandmetaanalysisof44RCTsinclusiveof5,292patientscomparedopen
appendectomyversuslaparoscopicappendectomyandfoundlongeroperatingroomtime,earlierhospital
discharge,fasterreturntonormalactivity,andearlierresumptionofdietafterlaparoscopic
appendectomy.Woundinfectionafterlaparoscopicappendectomywasreducedbutintraabdominal
abscess,intraoperativebleeding,andurinarytractinfectionoccurredslightlymorefrequently.The
authorsconcludedthatlaparoscopicappendectomyprovidesareasonablealternativetoopen
appendectomy.[8]Levelofevidence:1
Asystematicreviewof45studiesincluding9,576patientsevaluatedtheeffectofperioperativeantibiotics
onpostoperativecomplicationsinpatientswithsimpleandcomplicatedappendicitisandfoundthat,
overall,antibioticprophylaxisissuperiortoplaceboinreducingtheratesofwoundinfectionandintra
abdominalabscess.[9]Levelofevidence:1
InanRCTof269patientsaged15to70yearswithnonperforatedappendicitisundergoingopen
appendectomy,therateofpostoperativeinfectiouscomplicationswascomparedbetweenthegroups
receivingsingledosepreoperativeto3doseand5dayregimenofcefuroximeandmetronidazole.The
rateofpostoperativeinfectivecomplicationwasnotsignificantlydifferentamongthegroups.
Complicationsrelatedtoantibiotictreatmentweresignificantlymorecommonforthe5daygroup
comparedwithsingledosegroup.[5]Levelofevidence:2
AnRCTevaluatedtheefficacyofpostoperativeoralantibioticsafterinpatientintravenousantibioticsin
acuteappendicitis.Afterappendectomyandwhenintravenousantibioticswerereadytobediscontinued,
patientswererandomizedtoreceivea7dayoutpatientcourseofeitherplaceboororalantibiotics.
Patientsweremonitoredforinfectiouscomplicationsforaminimumof3months,andtherewasno
statisticaldifferencebetweenthetwogroups.Theauthorsconcludedthataddingacourseofoutpatient
oralantibioticsaftercompletingacourseofintravenousantibioticsdoesnotdecreasepostoperative
infectiouscomplicationsinpostappendectomypatients.[10]Levelofevidence:2

References
Specialcircumstances
Comorbidities
Pediatricpatients:
Diagnosisofacuteappendicitismaybechallengingduetothedifficultyinobtaininganaccuratehistoryor
physicalexamination

Anorexiaisusuallyaconsistentfeature
Patientsaged0to4yearshavethelowestincidenceofacuteappendicitis,butthemajoritypresentwith
perforation
Ultrasoundispreferredastheinitialimagingmodality.Childrenhavelessperiappendicealfat,andCTmay
belessreliable.Inaddition,theradiationexposuremayhavepotentiallylongtermadverseeffects
Inadolescentfemaleswithrightlowerquadrantpain,ovarianpathologyincludingtorsionmustbe
considered
Treatmentofchoiceinnonperforatedacuteappendicitisisappendectomy
Pregnantpatients:
Acuteappendicitisisthemostcommonsurgicalemergencyinpregnantwomen.Incidenceiscomparableto
thatofagematchednonpregnantwomen,withequaldistributioninalltrimesters
Anatomicvariabilityinthelocationoftheappendixalongwithlaxityoftheabdominalwallandother
symptomsthatmaybepresentduringanormalpregnancy,suchasnauseaandvomiting,makediagnosing
acuteappendicitisdifficult.Thusacuteappendicitisshouldbeconsideredinanypregnantpatientwithnew
onsetabdominalpain
Themostconsistentsignencounteredinacuteappendicitisduringpregnancyisrightsidedabdominalpain.
Seventyfourpercentofpatientsreportpainlocatedintherightlowerquadrantwithnodifferenceseenin
earlycomparedtolatepregnancy
Ultrasoundisusuallythefirststudyobtained.Ifthediagnosisisuncertain,useofMRIispreferredoverCT
scan
Inpatientsundergoingappendectomyduringpregnancy,theoverallincidenceoffetallossis4%,andthe
riskofprematurelaboris7%.Theseincidencesareconsiderablyhigherinpatientswithperforated
appendicitis,inwhomthereisapproximatelya20%riskoffetalloss
Laparoscopicappendectomycanbesafelyperformedinalltrimestersofpregnancy,butthefrequencyof
technicalcomplicationsmaybehigherthanwiththeopenapproach
PatientswithHIV/AIDS:
Thereisahigherincidenceofbothacuteappendicitisandperforatedappendicitisinthispopulation.The
increasedriskofperforationmayberelatedtodelayedpresentationtothehospital
PresentationofacuteappendicitisissimilartothatinpatientswithoutHIV/AIDShowever,absolute
leukocytosismaynotbepresent
RightlowerquadrantpaininthesettingofHIV/AIDShasanexpandeddifferentialdiagnosis,including
opportunisticinfections(eg,cytomegalovirus),tumors(eg,KaposisarcomaandnonHodgkin
lymphoma),andneutropenicenterocolitis
CTscanmayaidindiagnosiswhendiagnosisisuncertainbasedonhistoryandexamination.Patientswitha
historysuggestiveofcolitismayneedtoundergocolonoscopy
Acuteappendicitisinthispatientpopulationshouldbetreatedwithurgentappendectomy.Theroleof
laparoscopicappendectomyisnotwellestablished

Thereisa25%incidenceofAIDSrelatedconditionsseenintheoperativespecimen,includingKaposi
sarcoma,lymphoma,andCMVinfection
Morbidityratesafterappendectomyaresimilartothegeneralpopulation,butpatientstendtohavean
increasedlengthofhospitalstay

Consultation
Referthepatienttoasurgeonassoonastypicalsymptomsandsignsofappendicitisareconfirmedorifanyother
acuteabdominalconditionsrequiringsurgeryaresuspected.

Followup
Factorsaffectingprognosis:
Withpromptsurgicaltreatment,prognosisisexcellent
Rateofcomplicatedappendicitisishighestamongpatientsaged0to5yearsandthoseaged60yearsandolder
Delayedpresentationtothehospitalandinhospitaldelayarethemostimportantfactorsassociatedwith
complicatedappendicitis
Chronicobstructivepulmonarydisease,renalinsufficiency,diabetesmellitus,obesity,andcurrentsmokingare
predictorsofadverseoutcomesafterappendectomy
Laparoscopicappendectomyhasbettershorttermoutcomescomparedtoopenappendectomywithregardto
postoperativewoundinfection,pain,hospitallengthofstay,andreturntowork.Therateofintraabdominal
abscessesmay,however,beincreased
Recurrence:
Rarely,inflammationofanoverlylongappendicealstumpcanresultinrecurrentappendicitis
Clinicalcomplications:
Untreatedappendicealperforationmayresultinsepticshockanddeath
Othercomplicationsofperforationincludeadhesionformationwithconsequentriskofreducedfertilityinwomen
Complicationsarerareifappendectomyisdonebeforeperforationbutmayincludewoundabscessformation
withsubsequentfascialdehiscenceandhernia,intraabdominalabscess,andfecalfistula
Appendectomyisthemostcommonprecedingsurgicalprocedureinpatientspresentingwithbowelobstruction

Patienteducation
Onlineinformationforpatients
TheNemoursFoundation:Surgeriesandprocedures:appendectomy
(http://kidshealth.org/parent/system/surgery/appendectomy.html)

MayoFoundationforEducationandResearch:Appendicitis
(http://www.mayoclinic.com/health/appendicitis/DS00274/DSECTION=treatmentsanddrugs)

JohnsHopkinsMedicine:Appendectomy
(http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/appendectomy_92,P07686/)

Children'sHospitalofPhiladelphia:Appendicitis/appendectomy(http://www.chop.edu/service/surgerygeneralthoracic
andfetal/conditionswetreat/pediatricsurgeryappendicitisappendectomy.html)

Resources
Summaryofevidence
Evidence
UseofpreoperativeabdominalCTisassociatedwithlowernegativeappendectomyrates.
Asystematicreviewof28randomized,controlledtrials(RCTs)including9,330patientsfoundCTcutthe
negativeappendectomyratebyhalf(16.7%to8.7%)comparedtoclinicalexaminationaloneindiagnosisof
acuteappendicitis.TherewasalsoasignificantlylowernegativeappendectomyrateduringtheCTera
comparedwiththepreCTera(10.0%vs21.5%,P<.001).Timetosurgerywasevaluatedin10ofthe28
studies,5ofwhichdemonstratedasignificantincreaseinthetimetosurgerywiththeuseofCT.
AppendicealperforationrateswereunchangedbytheuseofCT(23.4%intheCTgroupvs16.7%inthe
clinicalevaluationgroup,P=.15).Similarly,theperforationrateduringtheCTerawasnotsignificantly
differentthanthatduringthepreCTera(20.0%vs19.6%,P=.74).TheauthorsconcludedthatroutineCT
inallpatientspresentingwithsuspectedappendicitiscouldreducetherateofunnecessarysurgerywithout
increasingmorbidity.[1]Levelofevidence:1
Asystematicreviewof7RCTsinvolving1,060patientsinwhomacuteappendicitiswassuspectedshowed
thatthesensitivityandspecificityofnoncontrastCTscanwere92.7%and96.1%,respectively,forthe
diagnosis.[2]Levelofevidence:1
Asystematicreviewandmetaanalysisof6RCTScomparedthediagnosticperformanceofCTscanversus
gradedcompressionultrasoundin671patientsinwhomacuteappendicitiswassuspectedclinicallyand
foundthatCTscanperformedbetterthanultrasoundinconfirmingthediagnosisofappendicitis.The
likelihoodratiowas9.29forCTscanand4.50forultrasound,resultinginposttestprobabilitiesforpositive
testresultsof90%and82%,respectively.[3]Levelofevidence:1
AsystematicreviewandmetaanalysisofeightRCTsincluding363patientsfoundthatMRIhada
sensitivityof97%andspecificityof95%,withalikelihoodratiopositive(LR+)of16.3andanLRof0.09
forthediagnosisofacuteappendicitis.Mostpatientsincludedinthestudywerepregnantfemales.[4]Level
ofevidence:1
Appendectomyisthetreatmentofchoiceforpatientswithappendicitis.
Asystematicreviewandmetaanalysisof4RCTsinclusiveof741patientsnotedasignificantlyhigher
efficacyofappendectomyintreatmentofacuteappendicitisversusconservativemanagementwith
antibiotics.Complicationrateswerehigherforpatientswhounderwentsurgery.Nodifferenceswerefound
inthenumbersofperforatedappendicesinpatientstreatedwithantibioticscomparedtothoseundergoing
appendectomy.Theauthorsconcludedthatalthoughanonsurgicalapproachinappendicitiscanreducethe
treatmentcomplicationrate,theloweroverallefficacyaffordedbyantibiotictreatmentprecludesits
recommendationtopatientsasanalternativetosurgery.[6]Levelofevidence:1
Laparoscopicsurgeryisanalternativetoopenappendectomyinthetreatmentofacuteappendicitis.
Asystematicreviewof67RCTsinclusiveofover6,000patientscomparedopenappendectomyversus
laparoscopicappendectomyinchildrenandadults.Thestudyfoundwoundinfectionswerehalfaslikely
withthelaparoscopicapproach,buttheincidenceofintraabdominalabscesseswasincreasedcomparedto
openappendectomy.Thedurationofsurgerywas10minuteslongerpainonpostoperativeday1was

reducedhospitalstaysignificantlyshortenedandreturntonormalactivity,work,andsportoccurred
earlierafterlaparoscopicappendectomy.Resultsinchildrenweresimilartothoseinadults.Theauthors
concludedthatlaparoscopicappendectomyisareasonablealternativetoopenappendectomy[7]Levelof
evidence:1
Asystematicreviewandmetaanalysisof44RCTsinclusiveof5,292patientscomparedopenappendectomy
versuslaparoscopicappendectomyandfoundlongeroperatingroomtime,earlierhospitaldischarge,faster
returntonormalactivity,andearlierresumptionofdietafterlaparoscopicappendectomy.Woundinfection
afterlaparoscopicappendectomywasreducedbutintraabdominalabscess,intraoperativebleeding,and
urinarytractinfectionoccurredslightlymorefrequently.Theauthorsconcludedthatlaparoscopic
appendectomyprovidesareasonablealternativetoopenappendectomy.[8]Levelofevidence:1
Perioperativeantibioticadministrationreducestheincidenceofpostoperativecomplicationsinpatients
undergoingsurgeryforappendicitis.
Asystematicreviewof45studiesincluding9,576patientsevaluatedtheeffectofperioperativeantibioticson
postoperativecomplicationsinpatientswithsimpleandcomplicatedappendicitisandfoundthat,overall,
antibioticprophylaxisissuperiortoplaceboinreducingtheratesofwoundinfectionandintraabdominal
abscess.[9]Levelofevidence:1
Extendedprophylacticantibiotictherapyafterappendectomyfornonperforatedappendicitisdoesnotdecrease
woundinfectionandintraabdominalabscessrate.
InanRCTof269patientsaged15to70yearswithnonperforatedappendicitisundergoingopen
appendectomy,therateofpostoperativeinfectiouscomplicationswascomparedbetweenthegroups
receivingsingledosepreoperativeto3doseand5dayregimenofcefuroximeandmetronidazole.Therate
ofpostoperativeinfectivecomplicationwasnotsignificantlydifferentamongthegroups.Complications
relatedtoantibiotictreatmentweresignificantlymorecommonforthe5daygroupcomparedwithsingle
dosegroup.[5]Levelofevidence:2
AnRCTevaluatedtheefficacyofpostoperativeoralantibioticsafterinpatientintravenousantibioticsin
acuteappendicitis.Afterappendectomyandwhenintravenousantibioticswerereadytobediscontinued,
patientswererandomizedtoreceivea7dayoutpatientcourseofeitherplaceboororalantibiotics.Patients
weremonitoredforinfectiouscomplicationsforaminimumof3months,andtherewasnostatistical
differencebetweenthetwogroups.Theauthorsconcludedthataddingacourseofoutpatientoralantibiotics
aftercompletingacourseofintravenousantibioticsdoesnotdecreasepostoperativeinfectious
complicationsinpostappendectomypatients.[10]Levelofevidence:2

References
References
Evidencereferences
1.KrajewskiS,BrownJ,PhangPT,RavalM,BrownCJ.Impactofcomputedtomographyoftheabdomenon
clinicaloutcomesinpatientswithacuterightlowerquadrantpain:ametaanalysis.CanJSurg.201154:4353
ViewInArticle(refInSitu51650)

2.HlibczukV,DattaroJA,JinZ,FalzonL,BrownMD.Diagnosticaccuracyofnoncontrastcomputed
tomographyforappendicitisinadults:asystematicreview.AnnEmergMed.201055:519.e1
ViewInArticle(refInSitu40644)|CrossRef(http://dx.doi.org/10.1016%2Fj.annemergmed.2009.06.509)

3.vanRandenA,BipatS,ZwindermanAH,UbbinkDT,StokerJ,BoermeesterMA.Acuteappendicitis:meta
analysisofdiagnosticperformanceofCTandgradedcompressionUSrelatedtoprevalenceofdisease.

Radiology.2008249:97106
ViewInArticle(refInSitu51651)|CrossRef(http://dx.doi.org/10.1148%2Fradiol.2483071652)

4.BargerRLJr,NandalurKR.Diagnosticperformanceofmagneticresonanceimaginginthedetectionof
appendicitisinadults:ametaanalysis.AcadRadiol.201017:12116
ViewInArticle(refInSitu51652)|CrossRef(http://dx.doi.org/10.1016%2Fj.acra.2010.05.003)

5.MuiLM,NgCS,WongSK,etal.Optimumdurationofprophylacticantibioticsinacutenonperforated
appendicitis.ANZJSurg.200575:4258
ViewInArticle(refInSitu51663)|CrossRef(http://dx.doi.org/10.1111%2Fj.14452197.2005.03397.x)

6.AnsaloniL,CatenaF,CoccoliniF,etal.Surgeryversusconservativeantibiotictreatmentinacuteappendicitis:
asystematicreviewandmetaanalysisofrandomizedcontrolledtrials.DigSurg.201128:21021
ViewInArticle(refInSitu51691)|CrossRef(http://dx.doi.org/10.1159%2F000324595)

7.SauerlandS,JaschinskiT,NeugebauerEAM.Laparoscopicversusopensurgeryforsuspectedappendicitis.
CochraneDatabaseSystRev.2010:CD001546
ViewInArticle(refInSitu51692)

8.LiX,ZhangJ,SangL,etal.Laparoscopicversusconventionalappendectomy:ametaanalysisofrandomized
controlledtrials.BMCGastroenterol.201010:129
ViewInArticle(refInSitu51693)|CrossRef(http://dx.doi.org/10.1186%2F1471230X10129)

9.AndersenBR,KallehaveFL,AndersenHK.Antibioticsversusplaceboforpreventionofpostoperative
infectionafterappendectomy.CochraneDatabaseSystRev.2003:CD001439
ViewInArticle(refInSitu51694)|CrossRef(http://dx.doi.org/10.1002%2F14651858.CD001439)

10.TaylorE,BerjisA,BoschT,HoehneF,OzaetaM.Theefficacyofpostoperativeoralantibioticsin
appendicitis:arandomizedprospectivedoubleblindedstudy.AmSurg.200470:85862
ViewInArticle(refInSitu51695)

Guidelines
TheAmericanCollegeofRadiology(http://www.acr.org)hasproducedthefollowing:
RosenMP,DingA,BlakeMA,etal.ACRAppropriatenessCriteria:rightlowerquadrantpainsuspected
appendicitis
(http://www.acr.org/%7E/media/ACR/Documents/AppCriteria/Diagnostic/RightLowerQuadrantPainSuspectedAppendicitis.pdf)

Reston,VA:AmericanCollegeofRadiology2010
WagnerLK,ApplegateK,FieldingJ,etalACRGuidelinesandStandardsCommittee.ACRpracticeguideline
forimagingpregnantorpotentiallypregnantadolescentsandwomenwithionizingradiation
(http://www.acr.org/%7E/media/ACR/Documents/PGTS/guidelines/Pregnant_Patients.pdf).Reston,Va:American

CollegeofRadiology2008
TheSurgicalInfectionSociety(http://www.sisna.org/)andtheInfectiousDiseasesSocietyofAmerica
(http://www.idsociety.org/)haveproducedthefollowing:
SolomkinJS,MazuskiJE,BradleyJS,etal.Diagnosisandmanagementofcomplicatedintraabdominalinfectionin
adultsandchildren:guidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica
(http://www.journals.uchicago.edu/doi/full/10.1086/649554).ClinInfectDis.201050:13364

TheSocietyofAmericanGastrointestinalandEndoscopicSurgeons(http://www.sages.org/)hasproducedthefollowing:

PearlJP,PriceRR,AwadZT,etalSAGESGuidelinesCommittee.Guidelinesfordiagnosis,treatment,anduseof
laparoscopyforsurgicalproblemsduringpregnancy(http://www.sages.org/publication/id/23/).SurgEndosc.

201125:347992

Furtherreading
McKayR,ShepherdJ.TheuseoftheclinicalscoringsystembyAlvaradointhedecisiontoperform
computedtomographyforacuteappendicitisintheED.AmJEmergMed.200725:48993
DaviesGM,DasbachEJ,TeutschS.TheburdenofappendicitisrelatedhospitalizationsintheUnitedStates
in1997.SurgInfect(Larchmt).20045:1605
AugustinT,BhendeS,ChavdaK,VanderMeerT,CagirB.CTscansandacuteappendicitis:afiveyear
analysisfromaruralteachinghospital.JGastrointestSurg.200913:130612
AugustinT,CagirB,VanderMeerTJ.Characteristicsofperforatedappendicitis:effectofdelayis
confoundedbyageandgender.JGastroSurg.201115:122331
LintulaH,KokkiH,PulkkinenJ,KettunenR,GrhnO,EskelinenM.Diagnosticscoreinacuteappendicitis.
Validationofadiagnosticscore(Lintulascore)foradultswithsuspectedappendicitis.LangenbecksArch
Surg.2010395:495500
LintulaH,KokkiH,KettunenR,EskelinenM.Appendicitisscoreforchildrenwithsuspectedappendicitis.A
randomizedclinicaltrial.LangenbecksArchSurg.2009394:9991004
AnderssonM,AnderssonRE.Theappendicitisinflammatoryresponsescore:atoolforthediagnosisof
acuteappendicitisthatoutperformstheAlvaradoscore.WorldJSurg.200832:18439
EnochssonL,GudbjartssonT,HellbergA,etal.TheFenyLindbergscoringsystemforappendicitis
increasespositivepredictivevalueinfertilewomenaprospectivestudyin455patientsrandomizedto
eitherlaparoscopicoropenappendectomy.SurgEndosc.200418:150913
ChenMM,CoakleyFV,KaimalA,LarosRKJr.Guidelinesforcomputedtomographyandmagnetic
resonanceimaginguseduringpregnancyandlactation.ObstetGynecol.2008112:33340
RaoPM,RheaJT,NovellineRA,MostafaviAA,McCabeCJ.Effectofcomputedtomographyoftheappendix
ontreatmentofpatientsanduseofhospitalresources.NEnglJMed.1998338:1416
FlumDR,MorrisA,KoepsellT,DellingerEP.Hasmisdiagnosisofappendicitisdecreasedovertime?A
populationbasedanalysis.JAMA.2001286:174853
SinghalR,TaylorJ,OwoniyiM,ElKhayatRH,TyagiSK,CorfieldAP.Theroleofappendectomyinthe
subsequentdevelopmentofinflammatoryboweldisease:aUKbasedstudy.IntJColorectalDis.
201025:50913
BickellNA,AufsesAHJr,RojasM,BodianC.Howtimeaffectstheriskofruptureinappendicitis.JAmColl
Surg.2006202:4016
BrattonSL,HaberkernCM,WaldhausenJH.Acuteappendicitisrisksofcomplications:ageandMedicaid
insurance.Pediatrics.2000106:758
BennettJ,BoddyA,RhodesM.Choiceofapproachforappendicectomy:ametaanalysisofopenversus
laparoscopicappendicectomy.SurgLaparoscEndoscPercutanTech.200717:24555
LeeSL,YaghoubianA,StarkR,ShekherdimianS.Equalaccesstohealthcaredoesnoteliminatedisparities

inthemanagementofadultswithappendicitis.JSurgRes.2011170:20913
RadfordSmithGL,EdwardsJE,PurdieDM,etal.Protectiveroleofappendicectomyononsetandseverity
ofulcerativecolitisandCrohn'sdisease.Gut.200251:80813
AnderssonMN,AnderssonRE.Causesofshorttermmortalityafterappendectomy:apopulationbased
casecontrolledstudy.AnnSurg.2011254:1037
SeetahalSA,BolorunduroOB,SookdeoTC,etal.Negativeappendectomy:a10yearreviewofanationally
representativesample.AmJSurg.2011201:4337
OldJL,DusingRW,YapW,DirksJ.Imagingforsuspectedappendicitis.AmFamPhysician.200571:718

Codes
ICD9code
540Acuteappendicitis
540.0Acuteappendicitiswithgeneralizedperitonitiswithperforation,peritonitis(generalized),or
rupturefulminating,gangrenous,obstructive.Cecitis(acute)withperforation,peritonitis
(generalized),rupture.Ruptureofappendix
540.1Acuteappendicitiswithperitonealabscess
540.9Acuteappendicitiswithoutmentionofperitonitis
541Appendicitis,unqualified
542Otherappendicitis
543Otherdiseasesoftheappendix

Currentcontributors
TomsAugustin,MD,MPH,ChiefResident,GeneralSurgery,MiltonS.HersheyMedicalCenter,Hershey,Pennsylvania

Copyright2016Elsevier,Inc.Allrightsreserved.