Thissiteisintendedforhealthcareprofessionals

AppendicitisClinicalPresentation
Updated:Dec27,2015
Author:SandyCraig,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...

PRESENTATION

History
Variationsinthepositionoftheappendix,ageofthepatient,anddegreeofinflammationmakethe
clinicalpresentationofappendicitisnotoriouslyinconsistent.Statisticsreportthat1of5casesof
appendicitisismisdiagnosedhowever,anormalappendixisfoundin1540%ofpatientswhohave
anemergencyappendectomy.
Niwaetalreportedaninterestingcaseofayoungwomanwithrecurrentpaininwhowasreferredfor
appendicitis,treatedwithantibiotics,andwasfoundtohaveanappendicealdiverticulitisassociated
withararepelvicpseudocystatlaparotomyafter12months.[15]Herconditionwasprobablydueto
diverticularperforationofthepseudocyst.

Symptoms
Theclassichistoryofanorexiaandperiumbilicalpainfollowedbynausea,rightlowerquadrant(RLQ)
pain,andvomitingoccursinonly50%ofcases.Nauseaispresentin6192%ofpatientsanorexiais
presentin7478%ofpatients.Neitherfindingisstatisticallydifferentfromfindingsinpatientswho
presenttotheemergencydepartmentwithotheretiologiesofabdominalpain.Inaddition,when
vomitingoccurs,itnearlyalwaysfollowstheonsetofpain.Vomitingthatprecedespainissuggestive
ofintestinalobstruction,andthediagnosisofappendicitisshouldbereconsidered.Diarrheaor
constipationisnotedinasmanyas18%ofpatientsandshouldnotbeusedtodiscardthepossibility
ofappendicitis.
Themostcommonsymptomofappendicitisisabdominalpain.Typically,symptomsbeginas
periumbilicalorepigastricpainmigratingtotherightlowerquadrant(RLQ)oftheabdomen.Thispain
migrationisthemostdiscriminatingfeatureofthepatient'shistory,withasensitivityandspecificityof
approximately80%,apositivelikelihoodratioof3.18,andanegativelikelihoodratioof0.5.[3]Patients
usuallyliedown,flextheirhips,anddrawtheirkneesuptoreducemovementsandtoavoid
worseningtheirpain.Later,aworseningprogressivepainalongwithvomiting,nausea,andanorexia
aredescribedbythepatient.Usually,afeverisnotpresentatthisstage.
Thedurationofsymptomsislessthan48hoursinapproximately80%ofadultsbuttendstobelonger
inelderlypersonsandinthosewithperforation.Approximately2%ofpatientsreportdurationofpain
inexcessof2weeks.Ahistoryofsimilarpainisreportedinasmanyas23%ofcases,butthishistory
ofsimilarpain,inandofitself,shouldnotbeusedtoruleoutthepossibilityofappendicitis.
Inadditiontorecordingthehistoryoftheabdominalpain,obtainacompletesummaryoftherecent
personalhistorysurroundinggastroenterologic,genitourinary,andpneumologicconditions,aswellas
considergynecologichistoryinfemalepatients.Aninflamedappendixneartheurinarybladderor
uretercancauseirritativevoidingsymptomsandhematuriaorpyuria.Cystitisinmalepatientsisrare

intheabsenceofinstrumentation.Considerthepossibilityofaninflamedpelvicappendixinmale
patientswithapparentcystitis.Alsoconsiderthepossibilityofappendicitisinpediatricoradultpatients
whopresentwithacuteurinaryretention.[16]

PhysicalExamination
Itisimportanttorememberthatthepositionoftheappendixisvariable.Of100patientsundergoing3
dimensional(3D)multidetectorcomputedtomography(MDCT)scanning,thebaseoftheappendix
waslocatedattheMcBurneypointinonly4%ofpatientsin36%,thebasewaswithin3cmofthe
pointin28%,itwas35cmfromthatpointand,in36%ofpatients,thebaseoftheappendixwas
morethan5cmfromtheMcBurneypoint.[17]
Themostspecificphysicalfindingsinappendicitisarereboundtenderness,painonpercussion,
rigidity,andguarding.AlthoughRLQtendernessispresentin96%ofpatients,thisisanonspecific
finding.Rarely,leftlowerquadrant(LLQ)tendernesshasbeenthemajormanifestationinpatientswith
situsinversusorinpatientswithalengthyappendixthatextendsintotheLLQ.Tendernesson
palpationintheRLQovertheMcBurneypointisthemostimportantsigninthesepatients.
Acarefulphysicalexamination,notlimitedtotheabdomen,mustbeperformedinanypatientwith
suspectedappendicitis.Gastrointestinal(GI),genitourinary,andpulmonarysystemsmustbestudied.
Maleinfantsandchildrenoccasionallypresentwithaninflamedhemiscrotumduetomigrationofan
inflamedappendixorpusthroughapatentprocessusvaginalis.Thisisofteninitiallymisdiagnosedas
acutetesticulartorsion.Inaddition,performarectalexaminationinanypatientwithanunclearclinical
picture,andperformapelvicexaminationinallwomenwithabdominalpain.
AccordingtotheAmericanCollegeofEmergencyPhysicians(ACEP)2010clinicalpolicyupdate,
clinicalsignsandsymptomsshouldbeusedtostratifypatientriskandtochoosenextstepsfortesting
andmanagement.[10,11]

Accessorysigns
Inaminorityofpatientswithacuteappendicitis,someothersignsmaybenoted.However,their
absencenevershouldbeusedtoruleoutappendicealinflammation.TheRovsingsign(RLQpainwith
palpationoftheLLQ)suggestsperitonealirritationintheRLQprecipitatedbypalpationataremote
location.Theobturatorsign(RLQpainwithinternalandexternalrotationoftheflexedrighthip)
suggeststhattheinflamedappendixislocateddeepintherighthemipelvis.Thepsoassign(RLQpain
withextensionoftherighthiporwithflexionoftherighthipagainstresistance)suggeststhatan
inflamedappendixislocatedalongthecourseoftherightpsoasmuscle.
TheDunphysign(sharppainintheRLQelicitedbyavoluntarycough)maybehelpfulinmakingthe
clinicaldiagnosisoflocalizedperitonitis.Similarly,RLQpaininresponsetopercussionofaremote
quadrantoftheabdomen,ortofirmpercussionofthepatient'sheel,suggestsperitonealinflammation.
TheMarklesign,painelicitedinacertainareaoftheabdomenwhenthestandingpatientdropsfrom
standingontoestotheheelswithajarringlanding,wasstudiedin190patientsundergoing
appendectomyandfoundtohaveasensitivityof74%.[4]

Rectalexamination
Thereisnoevidenceinthemedicalliteraturethatthedigitalrectalexamination(DRE)providesuseful
informationintheevaluationofpatientswithsuspectedappendicitishowever,failuretoperforma
rectalexaminationisfrequentlycitedinsuccessfulmalpracticeclaims.In2008,Sedlaketalstudied

577patientswhounderwentDREaspartofanevaluationforsuspectedappendicitisandfoundno
valueasameansofdistinguishingpatientswithandwithoutappendicitis.[18]

AppendicitisandPregnancy
Theincidenceofappendicitisisunchangedinpregnancyrelativetothegeneralpopulation,butthe
clinicalpresentationismorevariablethanatothertimes.
Duringpregnancy,theappendixmigratesinacounterclockwisedirectiontowardtherightkidney,
risingabovetheiliaccrestatabout4.5months'gestation.RLQpainandtendernessdominateinthe
firsttrimester,butinthelatterhalfofpregnancy,rightupperquadrant(RUQ)orrightflankpainmust
beconsideredapossiblesignofappendicealinflammation.
Nausea,vomiting,andanorexiaarecommoninuncomplicatedfirsttrimesterpregnancies,buttheir
reappearancelateringestationshouldbeviewedwithsuspicion.

DiagnosticScoring
Severalinvestigatorshavecreateddiagnosticscoringsystemstopredictthelikelihoodofacute
appendicitis.Inthesesystems,afinitenumberofclinicalvariablesiselicitedfromthepatientand
eachisgivenanumericvaluethen,thesumofthesevaluesisused.
ThebestknownofthesescoringsystemsistheMANTRELSscore,whichtabulatesmigrationofpain,
anorexia,nauseaand/orvomiting,tendernessintheRLQ,reboundtenderness,elevatedtemperature,
leukocytosis,andshifttotheleft(seeTable1).[19]
Table1.MANTRELSScore(OpenTableinanewwindow)
Characteristic

Score

M=MigrationofpaintotheRLQ

A=Anorexia

N=Nauseaandvomiting

T=TendernessinRLQ

R=Reboundpain

E=Elevatedtemperature

L=Leukocytosis

S=ShiftofWBCstotheleft

Total

10

Source:Alvarado.[19]
RLQ=rightlowerquadrantWBCs=whitebloodcells
Clinicalscoringsystemsareattractivebecauseoftheirsimplicityhowever,nonehasbeenshown
prospectivelytoimproveontheclinician'sjudgmentinthesubsetofpatientsevaluatedinthe
emergencydepartment(ED)forabdominalpainsuggestiveofappendicitis.TheMANTRELSscore,in
fact,wasbasedonapopulationofpatientshospitalizedforsuspectedappendicitis,whichdiffers
markedlyfromthepopulationseenintheED.
Inreviewingtherecordsof150EDpatientswhounderwentabdominopelviccomputedtomography
(CT)scanningtoruleoutappendicitis,McKayandShepherdsuggestedthatpatientswithan
MANTRELSscoreof03couldbedischargedwithoutimaging,thatthosewithscoresof7orabove
receivesurgicalconsultation,andthosewithscoresof46undergoCTevaluation.[20]The
investigatorsfoundthatpatientswithaMANTRELSscoreof3orlowerhada3.6%incidenceof
appendicitis,patientswithscoresof46hada32%incidenceofappendicitis,andpatientswithscores
of710hada78%incidenceofappendicitis.[20]
Inanotherstudy,SchneideretalconcludedthattheMANTRELSscorewasnotsufficientlyaccurateto
beusedasthesolemethodfordeterminingtheneedforappendectomyinthepediatricpopulation.
[21] Theseinvestigators,studied588patientsaged321yearsandfoundthataMANTRELSscoreof
7orgreaterhadapositivepredictivevalueof65%andanegativepredictivevalueof85%.

Scoringsystemsandcomputeraideddiagnosis
Computeraideddiagnosisconsistsofusingretrospectivedataofclinicalfeaturesofpatientswith
appendicitisandothercausesofabdominalpainandthenprospectivelyassessingtheriskof
appendicitis.Computeraideddiagnosiscanachieveasensitivitygreaterthan90%whilereducing
ratesofperforationandnegativelaparotomybyasmuchas50%.
However,theprincipledisadvantagestothismethodarethateachinstitutionmustgenerateitsown
databasetoreflectcharacteristicsofitslocalpopulation,andspecializedequipmentandsignificant
initiationtimearerequired.Inaddition,computeraideddiagnosisisnotwidelyavailableinUSEDs.

StagesofAppendicitis
Thestagesofappendicitiscanbedividedintoearly,suppurative,gangrenous,perforated,
phlegmonous,spontaneousresolving,recurrent,andchronic.

Earlystageappendicitis
Intheearlystageofappendicitis,obstructionoftheappendiceallumenleadstomucosaledema,
mucosalulceration,bacterialdiapedesis,appendicealdistentionduetoaccumulatedfluid,and
increasingintraluminalpressure.Thevisceralafferentnervefibersarestimulated,andthepatient
perceivesmildvisceralperiumbilicalorepigastricpain,whichusuallylasts46hours.

Suppurativeappendicitis
Increasingintraluminalpressureseventuallyexceedcapillaryperfusionpressure,whichisassociated
withobstructedlymphaticandvenousdrainageandallowsbacterialandinflammatoryfluidinvasionof

thetenseappendicealwall.Transmuralspreadofbacteriacausesacutesuppurativeappendicitis.
Whentheinflamedserosaoftheappendixcomesincontactwiththeparietalperitoneum,patients
typicallyexperiencetheclassicshiftofpainfromtheperiumbilicustotherightlowerabdominal
quadrant(RLQ),whichiscontinuousandmoreseverethantheearlyvisceralpain.

Gangrenousappendicitis
Intramuralvenousandarterialthrombosesensue,resultingingangrenousappendicitis.

Perforatedappendicitis
Persistingtissueischemiaresultsinappendicealinfarctionandperforation.Perforationcancause
localizedorgeneralizedperitonitis.

Phlegmonousappendicitisorabscess
Aninflamedorperforatedappendixcanbewalledoffbytheadjacentgreateromentumorsmallbowel
loops,resultinginphlegmonousappendicitisorfocalabscess.

Spontaneouslyresolvingappendicitis
Iftheobstructionoftheappendiceallumenisrelieved,acuteappendicitismayresolvespontaneously.
[22,23] Thisoccursifthecauseofthesymptomsislymphoidhyperplasiaorwhenafecalithisexpelled
fromthelumen.

Recurrentappendicitis
Theincidenceofrecurrentappendicitisis10%.Thediagnosisisacceptedassuchifthepatient
underwentsimilaroccurrencesofRLQpainatdifferenttimesthat,afterappendectomy,were
histopathologicallyproventobetheresultofaninflamedappendix.

Chronicappendicitis
Chronicappendicitisoccurswithanincidenceof1%andisdefinedbythefollowing:(1)thepatient
hasahistoryofRLQpainofatleast3weeksdurationwithoutanalternativediagnosis(2)after
appendectomy,thepatientexperiencescompletereliefofsymptoms(3)histopathologically,the
symptomswereproventobetheresultofchronicactiveinflammationoftheappendicealwallor
fibrosisoftheappendix.
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