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APPENDIX patient was discharged a month later in good condition.

DR. NGALOB EPIDEMIOLOGY
The most common abdominal -Lifetime risk:
EMERGENCY surgery is on the o Males: 8.6% (Higher incidence than females)
appendix. The most common More commonly constipated (leading to FECALITH
abdominal surgery is still OBSTRUCTION) vs females because of: Increased
cholecystectomy. metabolism, Laziness in drinking water
The standard surgery for the o Females: 6.7%
appendix is open surgery and -Highest incidence: 2ND 3RD DECADES of life (11 to 29 y/o)
not laparoscopy.
ETIOLOGY
ANATOMY -Main etiologic factor: OBSTRUCTION
In adults: o Adults: FECALITH
-Range of Length: 1-30cm Most dominant cause of obstruction
-Average length: 6-9cm
-Blood supply: o Children: LYMPHOID
Appendiceal/appendicular HYPERPLASIA (Book:
artery which can arise from hypertrophy)
any of the following: Due to the presence of
-ILEOCOLIC ARTERY (most common, 60-70%) Peyers patches in the
-Posterior cecal terminal ileum and
artery proximal cecum which is
-Anterior cecal artery absent in adults.
-Ileal artery from the This is secondary to a
Ileocolic artery viral/bacterial infection 2 weeks before
-The appendiceal presentation of illness.
artery cannot be
seen because it is PATHOGENESIS
embedded in the 1. Proximal obstruction
mesoappendix. Leads to closed loop obstruction
When ever you do Results in appendiceal distention
appendectomy, the o Stimulates VISCERAL nerve endings (C-FIBERS)
blood supply should also be removed. In any surgery, if you Results in vague, dull, DIFFUSE abdominal
remove an organ, you have to remove the blood supply. pain
Otherwise, it would just bleed. o Causes reflex nausea and vomiting

1. Most common origin of the appendicial artery: - Ileocolic 2. Intraluminal pressure increases and exceeds venous
Artery pressure
2. Differential Diagnosis for a 7-year-old boy that presents with -Impedes venous return
signs of appendicitis -Results in vascular CONGESTION
- Lymphoid Hyperplasia (1st stage of appendicitis)
-Appendix makes contact with
- Adult: Fecalith peritoneum: shift of pain to RLQ
3. Paraneoplasm, is not a fate of Appendicitis -Activation of A-DELTA FIBERS in
4. Normal isolates in appendectomy, except: the PARIETAL wall which transmit
- Staphylococcus aureus LOCALIZED pain
-GROSSLY: appendix is engorged
- E.coli and erythematous due to stasis of
- Bacteroides MOST COMMON venous blood
- Fusobacterium INITIAL LATER
5. Prime Symptom of appendicitis? PAIN Diffuse pain Localized: RLQ Pain
Visceral Parietal
6. Following are common physical exam findings in C fibers A delta fibers
Appendicitis, except: Murpheys sign
3. With continuous intraluminal secretion and bacterial
PHYSIOLOGY multiplication, inflammatory cascade is activated
Before: erroneously believed to be a vestigial organ with no -Mobilization of inflammatory cells including WBCs
known function -Results in SUPPURATION (2ND STAGE OF APPENDICITIS)
Now: an IMMUNOLOGIC ORGAN that actively -GROSSLY: appendix appears purulent
participates in the secretion of immunoglobulins,
particularly Ig A 4. Further distention will exceed arterial pressure
-Arrest of arterial blood flow
ACUTE APPENDICITIS -Tissues start to die
AMYANDS HERNIA: appendix within a hernia sac -Results in GANGRENE/NECROSIS (3RD STAGE OF
-The first known appendectomy was performed in 1736 by APPENDICITIS)
CLAUDIUS AMYAND in London. He operated on an 11-year- -GROSSLY: Tissues become brownish-blackish with
old boy with a scrotal hernia and a fecal fistula. Within the characteristic rotten meat odor
hernia sac, Amyand found a perforated appendix surrounded
by omentum. The appendix and omentum were amputated. The 5. The area with the poorest blood supply will suffer the

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_______________________________________________________ SURGERY II
most: FUSOBACTERIUM
-ANTI-MESENTERIC BORDER
Opposite the mesoappendix, is the area with the poorest CLINICAL PRESENTATION
blood supply. SYMPTOMS
-Further necrosis, further distention, further bacterial 1. Prime symptom: PAIN
multiplication Periumbilical, vague, dull, diffuse
-Results in RUPTURE/PERFORATION (4TH STAGE OF due to C-fibers
APPENDICITIS) 2. Pain will eventually localize to the RLQ
-GROSSLY: necrotic and mangled appendix with an obvious -Due to A-delta fibers when the appendix makes contact with
area of perforation, sometimes unidentifiable the peritoneal wall.
-In rare instances, pain can be elsewhere which depends on the
What part of the appendix is most susceptible to length of the appendix and what area it makes contact with.
perforation? 3. Nausea, vomiting and ANOREXIA
Antimesenteric border just distal to the point of obstruction -Absence of anorexia questions the diagnosis. 90% of the time
Any part beyond the obstruction is a possible point of rupture appendicitis presents with anorexia.
-Diarrhea
Already a late sign of appendicitis (ruptured)
More common in pediatric patients

SIGNS
1. Vital Signs:
Early: Normal
Late: Fever, tachycardia, tachypnea, hypotension
o Indicative of septic shock
Antimesenteric border
2. Physical Findings:
7. Which of the following statement is true regarding appendix -G/S:
in the pelvis: -weak looking
-walks slowly with a limping gait: The appendix is jarred
- Classical appendicitis symptoms can be absent
(causes pain) every time the patient walks prompting the
8. Sexually active female with RLQ pain who is presently patient to walk slowly.
menstruating, what is your most likely differential? -prefers supine position more than lateral decubitus or prone
- Rules out pregnancy, considerPID wherein there is increased contact of the appendix to the
9. Best tool for appendicitis peritoneal wall which causes more pain.
Abdomen:
- History and PE, in any case, kahithindi Appendicitis, the best
-Tenderness at, or near, the McBurneys point
tool is Hx and PE
-Line is drawn from the ASIS to the umbilicus
10. True of Alvardado scoring, except: -The lateral 1/3 is the McBurneys point
- Walanamang Right shift of leukocytes -Most common location of the base of the appendix

STAGES OF ACUTE APPENDICITIS On deep palpation, there is guarding at the RLQ:

1. Congestion -Gently press then release.
2. Suppuration -Dont keep doing this because you might rupture the appendix
3. Gangrene/Necrosis Palpation of the LLQ will cause pain in
(+) Rovsings sign
4. Rupture the RLQ
Flex the right leg then INTERNALLY
(+) Obturators test
FATES OF A RUPTURED APPENDIX: 3Ps ROTATE
PERITONITIS Patient is supine and the thigh is lifted
(+) Psoas test
PERIAPPENDICEAL ABSCESS: ruptured appendix is
encapsulated (+) Dunphys test Pain on COUGHING
PHLEGMON (+) Heel jarring Pain on STOMPING
Or combination of the above -Obturator & Psoas sign cannot be present at the same time
-Contents will spill intra-abdominally, causing irritation and because the appendix only adheres to the either the psoas /
inflammation of the peritoneum. (PERITONITIS) obturator or none at all.
-Pocket/s of purulent material form around the appendix -When the APPENDIX IS WITHIN THE PELVIS, ABDOMINAL
causing localized irritation and formation of abscess or FINDINGS CAN BE ABSENT
abscesses. (PERIAPPENDICEAL ABSCESS)
-A complex of necrotic debris, abscess and omentum forms LABORATORY FINDINGS
around the RUPTURED appendix forming a palpable tumor on CBC
the RLQ area. (PHLEGMON PHENOMENON) -An important part but not necessary in the diagnosis of acute
appendicitis
MICROBIOLOGY -Becomes necessary when findings are EQUIVOCAL
-SI: MC E.coli -Early: mild elevation of WBC with neutrophilia
-Colon: MC Bacteroides -Late: <4,000 (septic) or >12,000 with neutrophilia
-Appendix is at the junction of the ileum & the colon hence
share the bacteria of both. IMAGING
-Normal appendix: E.COLI & BACTEROIDES
-There is no superior imaging in the diagnosis of acute
-Pathologic appendix: E.COLI & BACTEROIDES +
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appendicitis a. Anatomic location of the inflamed appendix
-Ultrasound and CT can be helpful but CLINICAL b. Stage of the process
EVALUATION IS STILL MORE ACCURATE c. Patients age
THE BEST DIANOSTIC TOOL IN ACUTE APPENDICITIS: d. Patients gender
HISTORY & PE
1. Pediatric patients:
11. DDx of appendicitis depends on the following, except: ACUTE MESENTERIC ADENITIS
- Location, correct -Almost always, there is a history of URTI
-Tenderness not as sharp as acute appendicitis
- Patients sex, correct -Lymphadenopathies may be noted in the inguinal area
- Gender, correct -CBC: viral picture (low WBC, elevated lymphocytes) self-
- ANTIBIOTICS, of course, it will not dictate the differential limiting, no need to operate
diagnosis -Acute mesenteric adenitis is the disease most often confused
12. DDX in pediatric appendicitis except: with acute appendicitis in children. Almost invariably, an upper
respiratory tract infection is present or has recently subsided.
- Acute mesenteric Adenitis The pain usually is diffuse, and tenderness is not as sharply
localized as in appendicitis. Voluntary guarding is sometimes
13. The ff are true in the diagnosis of Acute mesenteric present, but true rigidity is rare. Generalized lymphadenopathy
adenitis in pediatric patients, except: may be noted. Laboratory procedures are of little help in arriving
- Almost always there is a history of LRTI, its not LOWER at the correct diagnosis, although a relative lymphocytosis,
its UPPER when present, suggests mesenteric adenitis. Observation for
14. True in the elderly, except: several hours is appropriate if the diagnosis of mesenteric
adenitis is suspected, as it is a self-limited disease.
- Findings are equivocal when patients undergo abdominal
xray, not Xray should be CT-scan 2. Elderly patients (>60 y/o):
15. Monogamous patient with missed menstruation for 2
-70 y/o: appendix obliterates and a diagnosis of appendicitis
months now, what is your most common differential diagnosis
becomes questionable
of Acute Appendicitis in this case is
-Perforated malignancy or diverticulitis
- Ectopic pregnancy -Impossible to distinguish from appendicitis
16. In appendicitis localized pain to the right lower quadrant -ATYPICAL PRESENTATION
from a diffused pain is due to: -If EQUIVOCAL, CT SCAN WARRANTED
- Irritation of the peritoneum and activation of the A delta -Diverticulitis or perforating carcinoma of the cecum or of a
fibers portion of the sigmoid that overlies the right lower abdomen may
be impossible to distinguish from appendicitis. These entities
CLINICAL SCORING should be considered, particularly in older patients. CT scanning
ALVARADO SCORE: M-A-N-T-R-E-L-S is often helpful in making a diagnosis in older patients with right
o E = elevated temperature lower quadrant pain and atypical clinical presentations. In
patients successfully managed conservatively, interval
The clinical diagnosis of appendicitis is a subjective estimate of surveillance of the colon (colonoscopy or barium enema) may
the probability of appendicitis based on multiple variables that be warranted.
individually are weak discriminators; however, used in
conjunction, they possess a high predictive value. This process 3. Female patients:
can be made more objective using clinical scoring systems, -In descending order of frequency:
which are based on variables with proven discriminating power -PID
and assigned a proper weight. -ruptured ovarian cyst
The Alvarado score is the most widespread scoring system. -twisted ovarian tumor or cyst
It is especially useful for RULING OUT APPENDICITIS and -ruptured ectopic pregnancy
selecting patients for further diagnostic workup. -Diseases of the female internal reproductive organs that may
erroneously be diagnosed as appendicitis are, in approximate
descending order of frequency, pelvic inflammatory disease,
ruptured Graafian follicle, twisted ovarian cyst or tumor,
endometriosis, and ruptured ectopic pregnancy. As a result, the
rate of misdiagnosis remains higher among female patients.

MANAGEMENT
DEFINITELY SURGICAL!!
Patient preparation is of utmost importance:
1. Hydration: If you open up the patient, the patient will
lose 0.5L-1L
2. Antibiotic/s: for E. coli & Bacteroides
Metronidazole and Cephalosporins
<3 pts: unlikely appendicitis
Or broad spectrum antibiotics: Meropenem &
4-6 pts: consider further imaging
Piperazin + Tazobactam
>7: High likelihood of appendicitis
3. Stabilize if unstable
>7: Probability is high; anywhere below that is 4. Adequate warming: To increase the blood supply by
questionable observe preventing vasoconstriction. Hypothermia equates to
mortality in septic patients.
DIFFERENTIAL DIAGNOSES 5. CONSENT
depends on 4 major factors:
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SPECIAL CIRCUMSTANCES
17. 45-year-old male, with RLQ pain and anorexia, with 1. Can a patient have another episode of appendicitis
previous appendectomy two years ago: after appendectomy? YES
- Stump appendicitis -STUMP APPENDICITIS: incomplete removal of the
appendix (not removed from the base). Retained
18. You were called by your resident for an intraop referral for
appendix after appendectomy tends to inflame
again.
INCIDENTAL ELECTIVE
-Improper ligation: not at the base
UNPLANNED PLANNED -There is a space where obstruction can occur, where fluid and
scheduled for a different
scheduled for bacteria can accumulate and exponentially multiply
procedure -The correct way is to tie at the base then ligate, leaving a
appendectomy
decision to remove the small stump
eg. Patient requested to
appendix happened during 2. Incidental vs elective appendectomy
also have her appendix
that procedure -UNPLANNED vs PLANNED
removed when she has her
eg. the tip of the appendix was -Incidental: No plan to remove the appendix in the first place
Oophorocystectomy
found during TAHBSO -Elective: scheduled/planned
a patient who will undergo hysterectomy:
- Unplanned procedure, so this becomes an Incidental NEOPLASMS OF THE APPENDIX
appendectomy 1. Carcinoid MOST COMMON
-Firm, yellow, bulbar mass, usually at the TIP
- Elective appendectomy is a planned surgery
-May be seen at the base
19. Intrapoeratively, the appendix is yellowish and hard, tumor -Firm, yellow, bulbar mass in the appendix should raise the
was 1 cm at the tip. What is your treatment? suspicion of an appendiceal carcinoid. The appendix is the most
- Appendectomy only common site of gastrointestinal carcinoid, followed by the small
bowel and rectum.
SPECIAL POPULATIONS -TREATMENT: APPENDECTOMY (LOCATION: TIP ONLY)
1. In the VERY young vs. RIGHT HEMICOLECTOMY (LOCATION: ELSEWHERE)
-Very difficult to diagnose appendicitis because patient cant -If the mass is AT THE TIP, SIMPLE APPENDECTOMY is
express self enough
-High perforation rate -If the bulbar tip is anywhere aside from the tip, do right hemi
-The establishment of a diagnosis of acute appendicitis is more colectomy because there is possibility of seeding on the cecum
difficult in young children than in the adult. The inability of young 2. Adenocarcinoma
children to give an accurate history, diagnostic delays by both -Aggressive cancer of the appendix
parents and physicians, and the frequency of gastrointestinal -may present like acute appendicitis
distress in children are all contributing factors to the -or may be seen incidentally during an unrelated surgery
misdiagnosis and delay in diagnosis. The more rapid -The most common mode of presentation for appendiceal
progression to rupture and the inability of the underdeveloped carcinoma is that of acute appendicitis. Patients also may
greater omentum to contain a rupture lead to significant present with ascites or a palpable mass, or the neoplasm may
morbidity rates in children. Children <5 years of age have a be discovered during an operative procedure for an unrelated
negative appendectomy rate of 25% and an appendiceal cause. The recommended treatment for all patients with
perforation rate of 45%. adenocarcinoma of the appendix is a formal right
hemicolectomy.
2. In the elderly (>70 y/o) -TREATMENT: Right hemicolectomy
-Appendicitis is NOT the primary consideration even if
Patients present w/ classical signs of appendicitis 1. Treatment of choice for adenocarcinoma of the appendix:
-Compared with younger adults, elderly patients with right hemicolectomy
appendicitis often pose a more difficult diagnostic problem 2. Average length of the appendix in adults:
because of the atypical presentation, expanded differential 6-9 cm
diagnosis, and communication difficulty. 3. Main etiologic factor in the development of acute
-These factors may be responsible for the disproportionately appendicitis: Obstruction
high perforation rate seen in the elderly. In the general
4. A fate of a ruptured appendix described as spillage of
population, perforation rates range from 20% to 30%, compared
appendiceal contents causing irritation of the peritoneum:
with 50% to 70% in the elderly.107 In addition, the perforation
Peritonitis
rate appears to increase with age greater than 80 years
5. A complex of necrotic debris, pus and omentum that forms
3. In the pregnant around the ruptured appendix
-MC SURGICAL EMERGENCY IN PREGNANCY creating a palpable tumor on the RLQ area: Phlegmon
-Very difficult to do appendectomy because the appendix is 6. The most commonly isolated organism in appendectomy
displaced SUPERIORLY AND LATERALLY due to the specimens: Bacteroides/Anareobes
enlargement of the uterus
-Appendectomy of the pregnant 7. In acute appendicitis, the point of maximal tenderness is
-Depends on the trimester, depending on the size of the gravid also known as: McBurneys Point
uterus 8. In acute mesenteric adenitis in pediatric patients, there is
-Go superior and lateral, open at the point of the maximal almost a history of this disease: URTI
tenderness 9. The highest incidence of appendicitis occurs in theses
-Most likely that is where the tip of the appendix is located decades: 2nd 3rd decade
-Incision is higher between RUQ and RLQ and more lateral
-RISK OF ABORTION: 4-7%

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10. Test used to strengthen the impression of appendicitis by No adnexal tenderness
Less likely patient is not pregnant
deeply palpating the LLQ causing pain on the right lower palpable
quadrant: Rovsings sign In all presentations of abdominal
11. & 12. The two criteria in the Alvarado scoring scale given 2 pain, a rectal exam is ideally a
points: RLQ tenderness, Leukocytosis must unless the patient refuses.
Rectal exam
When the abdominal exam is
13. Treatment of choice for carcinoid of the appendix tip:
unremarkable or equivocal, a rectal
Appendectomy
exam should be requested,
PBL 1: ACUTE APPENDICITIS Neutrophils elevated Active acute infection present
CASE
A 22-year-old female office worker presents with a 2- Rebound Tenderness
day history of increasingly severe abdominal pain. The pain Denotes peritonitis
began as a vague and dull abdominal discomfort, and after 24 Not limited to appendicitis
hours migrated to the right lower quadrant where it has Occurs not because of the inflamed organ, but it often
remained. Pain was noted to have increasing severity. She indicates that the peritoneum, or the inner most covering
has vomited three times and has had poor appetite since of the abdominal wall is already affected
then. Bowel movements are normal. There are no urinary Indicates a more severe condition, longer duration, and
symptoms. Her last menstrual period was two weeks ago. She more severe infection
is not sexually active. There was no history of uncommon food
intake for the past 2 weeks. No medications being taken. No 1. What is your impression? What are your differential
unusual activities. On physical examination, the patient has a diagnoses? Give bases for each differential.
temperature of 38.3 C and is in moderate abdominal distress. Impression: Appendicitis
There is significant guarding and direct tenderness on the DDx:
right lower quadrant, and slight tenderness without guarding a. Ovarian Torsion
in the left lower quadrant. On bimanual vaginal examination, Ovaries torted: Length will shorten can adhere to the
there were no discharges, no tenderness on motion of cervix; no peritoneum (esp. when ovaries are leaking: can have
adnexal masses are palpable. On rectal exam, there was noted peritonitis but unlikely)
right pararectal tenderness. Rest of PE was unremarkable. Ovarian torsion can manifest as a vague diffused
abdominal pain (since it is a visceral organ) and can
Laboratory Tests localize in the right lower quadrant when it has torted
Complete blood count: WBC: 15; Neutrophils: 89 (both
Good differential
elevated), the rest is unremarkable
b. Typhoid Ileitis
U/A: unremarkable
Possible but unlikely
Key Points: Does not commonly present with migratory pain
Pain increasing in c. Diverticulitis
Increase in fibers that are affected Right sided: rare
severity
Normal bowel Most likely not a bowel disease, Most commonly occurs in the left
movements obstruction or IBD Weak differential
No urinary symptoms R/O UTI or stone d. Tubo-ovarian Abscess
Relative: some will be honest, Complication of PID. Must establish PID first.
some will not be. Females are tend Weak differential. History is not consistent with PID.
Not sexually active
to be more honest with female Nothing in the PE refers to an infection of the
doctors
reproductive organs
No history of Patient did not take anything
However, it can be considered as a differential
uncommon food intake unusual to her diet. R/O food
for the past 2 weeks poisoning because the history is subjective but less likely
No medications taken R/O drug induced abdominal pain e. PID
Eg. Mountain climbing, other Less likely: no manifestations
strenuous activities f. Ruptured Ovarian Cyst
No unusual activities Ordinary cyst will exhibit no pain
R/O trauma induced abdominal
pain Pain is sudden in ruptured cyst (Mixing of the fluid from
>38oC is high grade (can mean the cyst into the peritoneum)
38.3oC dissemination into the circulation) g. Leaking Ovarian Cyst
fever = ongoing infection Pathology is gradual
Rate the pain: Possible but unlikely
Moderate abdominal 1-3: mild
stress 4-6: moderate 2. If the patient is a male, would it make your primary
>7: severe diagnosis stronger? Why?
Slight tenderness In the natural course of an -Yes. Differential diagnoses are narrowed in a male patient.
without guarding in the abdominal pain, where it is most High probability of appendicitis if it is a male patient because
left lower quadrant painful is the affected area differentials falling under a female patient will be eliminated.
Congruent with no sexual history. If
No discharges on
the patient denies sexual contact 3. If your patient is 70 y/o female, would your impression
bimanual vaginal
but presents with discharges, the change? What would be your impression then?
examination
history becomes questionable -Elderly patients will unlikely develop acute appendicitis
No tenderness on because the appendix has obliterated.
No PID
motion of cervix -Possible differentials would be: Malignancy or diverticulitis
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o Impossible to distinguish from appendicitis
o Atypical presentation 9. After 4 hours of observation, your patient developed
o If equivocal, CT scan is warranted fever, tachycardia, and severe abdominal pain. On PE,
there was generalized tenderness. What is your next
plan of action? Why?
4. Had your patient been an 11 y/o male or female, Surgery is indicated for the ff reasons:
what other differentials will you consider and o Fever, tachycardia, and severe abdominal pain
why? which are presentations of sepsis
Acute Mesenteric adenitis o Generalized tenderness is a presentation of acute
-most common differential diagnosis among children abdomen
-Presence of URTI, 2 weeks prior to the presentation of signs More advanced pathology
and symptoms, will strengthen the diagnosis of adenitis Generalized tenderness, even direct and rebound
-Usually will not present with rebound tenderness but may are indications for surgery
present with direct tenderness
-May also present with elevated WBC but not as high as in acute 10. What are the fates of a ruptured appendix? Describe
appendicitis each.
Remember the 3 Ps: can happen all at the the same time at a
5. If this patient had sexual intercourse 2 weeks prior to very late stage
admission, how would that change your differential 1. Peritonitis bacteria contaminates the peritoneum as a
diagnosis? Give bases. result of spillage from an intraabdominal viscus causing
-Ectopic pregnancy irritation and inflammation
-Implantation occurs at 6 days - 2 weeks: the patient had sexual 2. Phlegmon matted loops of bowel adherent to the
contact 2 weeks prior which makes the diagnosis more likely. adjacent appendix; a complex of necrotic debris,
-Most commonly affected: Fallopian Tube abscess, and omentum forms around the ruptured
-The probability is highest at the time it implants. appendix forming a palpable tumor on the RLQ area
-Sexual History is very important. 3. Periappendiceal abscess collection of a purulent
-Pelvic Inflammatory Disease (PID) material with a capsule
-Tuboovarian abscess

6. Which other laboratories and imaging studies (if any)

would be useful for this patient?
-Abdominopelvic Ultrasound useful in visualizing and
confirming gynecologic differentials
-Confirms ectopic pregnancy, PID & Tuboovarian abscess
-Better request for charity patients since it diagnoses all 3
-Pregnancy test only confirms ectopic pregnancy; may be
negative in early stages

7. If your patient had 2 different sexual partners a week

before the events occurred, would it change your
impression?
-No. Differentials are the same but the order of the differentials
may change
-PID is primarily considered if there is practice of contraception
-Ectopic Pregnancy is considered more if there is no use of
contraception

8. What is the Alvarado Scoring System? Describe? What

is the score of this patient?
Patients
CRITERIA Score
score
Migratory right iliac fossa pain 1 1
Anorexia 1 1
Nausea and vomiting 1 1
Tenderness: Right iliac fossa 2 2
Rebound tenderness 1 0
Elevated temperature (>37oC) 1 1
Leukocytosis (> 10x109 cells/L) 2 2
Shift to the left of neutrophils 1 1
TOTAL 10 9

<3 LOW LIKELIHOOD of appendicitis

4-6 consider further imaging
>7 HIGH LIKELIHOOD of appendicitis

INTERPRETATION: The patient has a high likelihood of

appendicitis.

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