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AcuteAppendicitis:ReviewandUpdateNovember1,1999AmericanAcademyofFamilyPhysicians

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AcuteAppendicitis:ReviewandUpdate
D.MIKEHARDIN,JR.,M.D.,
TexasA&MUniversityHealthScienceCenter,Temple,Texas
Appendicitisiscommon,withalifetimeoccurrenceof7percent.Abdominalpainandanorexiaarethe
predominantsymptoms.Themostimportantphysicalexaminationfindingisrightlowerquadranttenderness
topalpation.Acompletebloodcountandurinalysisaresometimeshelpfulindeterminingthediagnosisand
supportingthepresenceorabsenceofappendicitis,whileappendicealcomputedtomographicscansand
ultrasonographycanbehelpfulinequivocalcases.Delayindiagnosingappendicitisincreasestheriskof
perforationandcomplications.Complicationandmortalityratesaremuchhigherinchildrenandtheelderly.
(AmFamPhysician199960:202734.)

Appendicitisisthemostcommonacutesurgicalconditionoftheabdomen. Approximately7percentofthe
1

populationwillhaveappendicitisintheirlifetime,2withthepeakincidenceoccurringbetweentheagesof10
and30years.3
Despitetechnologicadvances,thediagnosisofappendicitisisstillbasedprimarilyonthepatient'shistoryand
thephysicalexamination.Promptdiagnosisandsurgicalreferralmayreducetheriskofperforationand
preventcomplications.4Themortalityrateinnonperforatedappendicitisislessthan1percent,butitmaybeas
highas5percentormoreinyoungandelderlypatients,inwhomdiagnosismayoftenbedelayed,thusmaking
perforationmorelikely.1

Pathogenesis
Theappendixisalongdiverticulumthatextendsfromthe
inferiortipofthececum.5Itsliningisinterspersedwith
lymphoidfollicles.3Mostofthetime,theappendixhasan
intraperitoneallocation(eitheranteriororretrocecal)and,
thus,maycomeincontactwiththeanteriorparietal
peritoneumwhenitisinflamed.Upto30percentofthe
time,theappendixmaybe"hidden"fromtheanterior
peritoneumbybeinginapelvic,retroilealorretrocolic
(retroperitonealretrocecal)position.6The"hidden"position
oftheappendixnotablychangestheclinicalmanifestations
ofappendicitis.
Obstructionofthenarrowappendiceallumeninitiatesthe
clinicalillnessofacuteappendicitis.Obstructionhas
multiplecauses,includinglymphoidhyperplasia(relatedto
viralillnesses,includingupperrespiratoryinfection,

TABLE1
CommonSymptomsof
Appendicitis

Commonsymptoms*

Frequency
(%)

Abdominalpain
Anorexia
Nausea
Vomiting
Painmigration

~100
~100
90
75
50

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mononucleosis,gastroenteritis),fecaliths,parasites,foreign
bodies,Crohn'sdisease,primaryormetastaticcancerand
carcinoidsyndrome.Lymphoidhyperplasiaismorecommon
inchildrenandyoungadults,accountingfortheincreased
incidenceofappendicitisintheseagegroups.1,5

HistoryandPhysicalExamination

Classicsymptomsequence
50
(vagueperiumbilicalpainto
anorexia/nausea/unsustained
vomitingtomigrationofpainto
rightlowerquadranttolowgrade
fever)

*Onsetofsymptomstypicallywithinpast24to
36hours.
Informationfromreferences3through5.

Abdominalpainisthemostcommonsymptomof
appendicitis.3Inmultiplestudies,35specificcharacteristics
oftheabdominalpainandotherassociatedsymptomshave
provedtobereliableindicatorsofacuteappendicitis(Table
1).Athoroughreviewofthehistoryoftheabdominalpainandofthepatient'srecentgenitourinary,
gynecologicandpulmonaryhistoryshouldbeobtained.

Anorexia,nauseaandvomitingaresymptomsthatarecommonlyassociatedwithacuteappendicitis.The
classichistoryofpainbeginningintheperiumbilicalregionandmigratingtotherightlowerquadrantoccurs
inonly50percentofpatients.1Durationofsymptomsexceeding24to36hoursisuncommoninnonperforated
appendicitis.1

TABLE2
SignificantLikelihoodRatiosforSymptomsandSignsofAcute
Appendicitis

Symptom/sign

Positivelikelihoodratio(LR+)

Rightlower
8.0
quadrant(RLQ)pain
Painmigration
3.2
Painbefore
vomiting
Anorexia,nausea
andvomiting*
Rigidity

2.8

Psoassign

2.38

Rebound
tenderness
Fever
Guardingandrectal
tenderness*

1.1to6.3

MuchlowerLR+thanRLQpain,pain
migrationandpainbeforevomiting
3.76

Symptom/sign

Negative
likelihood
ratio(LR)

RLQpain

0to0.28

Nosimilarpain
previously||
Painmigration

0.3

Guarding

0to0.54

0.5

Rebound
0to0.86
tenderness
Fever,rigidityand
psoassign

1.9
MuchlowerLR+thanrigidity,psoassignand
reboundtenderness

NOTE:LRistheamountbywhichtheoddsofadiseasechangewithnewinformation,asfollows:
Likelihoodratio Degreeofchangeinprobability
>10or<0.1

Large(oftenconclusive)

5to10or0.1to0.2 Moderate
2to5or0.2to0.5 Small(butsometimesimportant)
1to2or0.5to1

Small(rarelyimportant)

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*ThesesymptomsandsignshavemuchlowerLR+.
Ratiosarepresentedinrangesforsignsandsymptomsthathadwidelyvaryingresultsinstudies.
FeverhadonlyborderlineLR+.
Thatis,theabsenceofRLQpainsignificantlylowerstheoddsofhavingappendicitis.
||Thatis,thehistoryofexperiencingasimilarpainpreviouslylowerstheoddsofhavingappendicitis.
ThesesignshavehigherLR.
Informationfromreferences7,8and19

Inarecentmetaanalysis,7likelihoodratioswerecalculatedformanyofthesesymptoms(Table2).A
likelihoodratioistheamountbywhichtheoddsofadiseasechangewithnewinformation(e.g.,physical
examinationfindings,laboratoryresults).8Thischangecanbepositiveornegative.Symptomssuchas
anorexia,nauseaandvomitingcommonlyoccurinacuteappendicitishowever,thepresenceofthese
symptomsdoesnotnecessarilyincreasethelikelihoodofappendicitisnordoestheirabsencedecreasethe
likelihoodofthediagnosis.Moreover,othersymptomshavemorenotablepositiveandnegativelikelihood
ratios(Table2).
Acareful,systematicexaminationoftheabdomenis
essential.Whilerightlowerquadranttendernessto
palpationisthemostimportantphysicalexamination
finding,othersignsmayhelpconfirmthediagnosis
(Table3).Theabdominalexaminationshouldbegin
withinspectionfollowedbyauscultation,gentle
palpation(beginningatasitedistantfromthepain)
and,finally,abdominalpercussion.Therebound
tendernessthatisassociatedwithperitonealirritation
hasbeenshowntobemoreaccuratelyidentifiedby
percussionoftheabdomenthanbypalpationwith
quickrelease.1

TABLE3
CommonSignsofAppendicitis
Rightlowerquadrantpainonpalpation(thesingle
mostimportantsign)
Lowgradefever(38C[or100.4F])absenceof
feverorhighfevercanoccur
Peritonealsigns
Localizedtendernesstopercussion
Guarding
Otherconfirmatoryperitonealsigns(absenceof
thesesignsdoesnotexcludeappendicitis)
Psoassignpainonextensionofrightthigh
(retroperitonealretrocecalappendix)
Obturatorsignpainoninternalrotationofrightthigh
(pelvicappendix)
Rovsing'ssignpaininrightlowerquadrantwith
palpationofleftlowerquadrant
Dunphy'ssignincreasedpainwithcoughing
Flanktendernessinrightlowerquadrant
(retroperitonealretrocecalappendix)
Patientmaintainshipflexionwithkneesdrawnupfor
comfort

Aspreviouslynoted,thelocationoftheappendix
varies.Whentheappendixishiddenfromtheanterior
peritoneum,theusualsymptomsandsignsofacute
appendicitismaynotbepresent.Painandtenderness
canoccurinalocationotherthantherightlower
quadrant.6Aretrocecalappendixinaretroperitoneal
locationmaycauseflankpain.Inthiscase,stretching
theiliopsoasmusclecanelicitpain.Thepsoassignis
elicitedinthismanner:thepatientliesontheleftside
whiletheexaminerextendsthepatient'srightthigh
(Figures1aand1b).Incontrast,apatientwithapelvic Informationfromreferences3through5.
appendixmayshownoabdominalsigns,buttherectal
examinationmayelicittendernessintheculdesac.In
addition,anobturatorsign(painonpassiveinternal
rotationoftheflexedrightthigh)maybepresentinapatientwithapelvicappendix3(Figures2aand2b).
Figure1A

FIGURE1A.Thepsoassign.Painonpassive
extensionoftherightthigh.Patientliesonleftside.
Examinerextendspatient'srightthighwhileapplying
counterresistancetotherighthip(asterisk).
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FIGURE2A.Theobturatorsign.Painonpassiveinternal
rotationoftheflexedthigh.Examinermoveslowerleglaterally
whileapplyingresistancetothelateralsideoftheknee
(asterisk)resultingininternalrotationofthefemur.

FIGURE1B.Anatomicbasisforthepsoassign:
inflamedappendixisinaretroperitoneallocationin
contactwiththepsoasmuscle,whichisstretchedby
thismaneuver.

FIGURE2B.Anatomicbasisfortheobturatorsign:inflamed
appendixinthepelvisisincontactwiththeobturatorinternus
muscle,whichisstretchedbythismaneuver.

Thedifferentialdiagnosisofappendicitisisbroad,butthepatient'shistoryandtheremainderofthephysical
examinationmayclarifythediagnosis(Table4).Becausemanygynecologicconditionscanmimic
appendicitis,apelvicexaminationshouldbeperformedonallwomenwithabdominalpain.Giventhebreadth
ofthedifferentialdiagnosis,thepulmonary,genitourinaryandrectalexaminationsareequallyimportant.
Studieshaveshown,however,thattherectalexaminationprovidesusefulinformationonlywhenthediagnosis
isunclearand,thus,canbereservedforuseinsuchcases.5

LaboratoryandRadiologicEvaluation
Ifthepatient'shistoryandthephysicalexaminationdo
notclarifythediagnosis,laboratoryandradiologic
evaluationsmaybehelpful.Acleardiagnosisof
appendicitisobviatestheneedforfurthertestingand
shouldpromptimmediatesurgicalreferral.
LaboratoryTests

TABLE4
DifferentialDiagnosisofAcute
Appendicitis
Gastrointestinal
Abdominalpain,

Gynecologic Pulmonary
Ectopic
Pleuritis

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Thewhitebloodcell(WBC)countiselevated(greater
than10,000permm3[1003109perL])in80percent
ofallcasesofacuteappendicitis.9Unfortunately,the
WBCiselevatedinupto70percentofpatientswith
othercausesofrightlowerquadrantpain.10Thus,an
elevatedWBChasalowpredictivevalue.SerialWBC
measurements(over4to8hours)insuspectedcases
mayincreasethespecificity,astheWBCcountoften
increasesinacuteappendicitis(exceptincasesof
perforation,inwhichitmayinitiallyfall).5
Inaddition,95percentofpatientshaveneutrophilia1
and,intheelderly,anelevatedbandcountgreaterthan
6percenthasbeenshowntohaveahighpredictive
valueforappendicitis.9Ingeneral,however,theWBC
countanddifferentialareonlymoderatelyhelpfulin
confirmingthediagnosisofappendicitisbecauseof
theirlowspecificities.

causeunknown
Cholecystitis
Crohn'sdisease
Diverticulitis
Duodenalulcer
Gastroenteritis
Intestinal
obstruction
Intussusception
Meckel's
diverticulitis
Mesenteric
lymphadenitis
Necrotizing
enterocolitis
Neoplasm
(carcinoid,
carcinoma,
lymphoma)
Omentaltorsion
Pancreatitis
Perforatedviscus
Volvulus

pregnancy
Endometriosis
Ovariantorsion
Pelvic
inflammatory
disease
Ruptured
ovariancyst
(follicular,
corpus
luteum)
Tuboovarian
abscess
Systemic
Diabetic
ketoacidosis
Porphyria
Sicklecell
disease
Henoch
Schnlein
purpura

Pneumonia
(basilar)
Pulmonary
infarction
Genitourinary
Kidneystone
Prostatitis
Pyelonephritis
Testicular
torsion
Urinarytract
infection
Wilms'tumor
Other
Parasitic
infection
Psoasabscess
Rectussheath
hematoma

Amorerecentlysuggestedlaboratoryevaluationis
determinationoftheCreactiveproteinlevel.An
ReprintedwithpermissionfromGraffeoCS,
elevatedCreactiveproteinlevel(greaterthan0.8mg
CounselmanFL.Appendicitis.EmergMedClinNorth
perdL)iscommoninappendicitis,butstudiesdisagree
Am199614:65371.
onitssensitivityandspecificity.4,5AnelevatedC
reactiveproteinlevelincombinationwithanelevated
WBCcountandneutrophiliaarehighlysensitive(97to
100percent).Therefore,ifallthreeofthesefindingsareabsent,thechanceofappendicitisislow.5
Inpatientswithappendicitis,aurinalysismaydemonstratechangessuchasmildpyuria,proteinuriaand
hematuria,1butthetestservesmoretoexcludeurinarytractcausesofabdominalpainthantodiagnose
appendicitis.
RadiologicEvaluation
Theoptionsforradiologicevaluationofpatientswithsuspected
appendicitishaveexpandedinrecentyears,enhancingand
sometimesreplacingpreviouslyusedradiologicstudies.
Plainradiographs,whileoftenrevealingabnormalitiesinacute
appendicitis,lackspecificityandaremorehelpfulindiagnosing
othercausesofabdominalpain.Likewise,bariumenemaisnow
usedinfrequentlybecauseoftheadvancesinabdominalimaging.5
Ultrasonographyandcomputedtomographic(CT)scansare
helpfulinevaluatingpatientswithsuspectedappendicitis.11
Ultrasonographyisappropriateinpatientsinwhichthediagnosisis FIGURE3.Ultrasonogramshowing
equivocalbyhistoryandphysicalexamination.Itisespeciallywell longitudinalsection(arrows)ofinflamed
suitedinevaluatingrightlowerquadrantorpelvicpaininpediatric appendix.
andfemalepatients.Anormalappendix(6mmorlessindiameter)
mustbeidentifiedtoruleoutappendicitis.Aninflamedappendixusuallymeasuresgreaterthan6mmin
diameter(Figure3),isnoncompressibleandtenderwithfocalcompression.Otherrightlowerquadrant
conditionssuchasinflammatoryboweldisease,cecaldiverticulitis,Meckel'sdiverticulum,endometriosisand
pelvicinflammatorydiseasecancausefalsepositiveultrasonographyresults.12
CT,specificallythetechniqueofappendicealCT,ismore
accuratethanultrasonography(Table5).AppendicealCT
consistsofafocused,helical,appendicealCTaftera
Gastrografinsalineenema(withorwithoutoralcontrast)
andcanbeperformedandinterpretedwithinonehour.

TABLE5
ComparisonofUltrasoundand

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Intravenouscontrastisunnecessary.12TheaccuracyofCTis
dueinparttoitsabilitytoidentifyanormalappendixbetter
thanultrasonography.13Aninflamedappendixisgreaterthan
6mmindiameter,buttheCTalsodemonstrates
periappendicealinflammatorychanges14(Figures4and5).If
appendicealCTisnotavailable,standardabdominal/pelvic
CTwithcontrastremainshighlyusefulandmaybemore
accuratethanultrasonography.12

AppendicealCTEvaluationof
SuspectedAppendicitis
Appendiceal
Comparison computed
graded
tomographic
ultrasound
scan
Sensitivity
Specificity
Use

Treatment
Thestandardformanagementofnonperforatedappendicitis
remainsappendectomy.Becauseprompttreatmentof
appendicitisisimportantinpreventingfurthermorbidityand
mortality,amarginoferrorinoverdiagnosisisacceptable.
Currently,thenationalrateofnegativeappendectomiesis
approximately20percent.15Somestudieshaveinvestigated
nonoperativemanagementwithparenteralantibiotic
treatment,but40percentofthesepatientseventually
requiredappendectomy.3

Advantages

Appendectomymaybeperformedbylaparotomy(usually
throughalimitedrightlowerquadrantincision)or
laparoscopy.Diagnosticlaparoscopymaybehelpfulin
equivocalcasesorinwomenofchildbearingage,while
therapeuticlaparoscopymaybepreferredincertainsubsets
ofpatients(e.g.,women,obesepatients,athletes).16
Whilelaparoscopicinterventionhastheadvantagesof
decreasedpostoperativepain,earlierreturntonormal
activityandbettercosmeticresults,itsdisadvantagesinclude
greatercostandlongeroperativetime.4Openappendectomy
mayremaintheprimaryapproachtotreatmentuntilfurther
costandbenefitanalysesareconducted.

FIGURE4.Computedtomographicscanshowing
crosssectionofinflamedappendix(A)with
appendicolith(a).

85%
92%
Evaluate
patientswith
equivocal
diagnosisof
appendicitis
Safe
Relatively
inexpensive
Canruleout
pelvicdisease
infemales
Betterfor
children

Disadvantages Operator
dependent
Technically
inadequate
studiesdueto
gas
Pain

90to100%
95to97%
Evaluate
patientswith
equivocal
diagnosisof
appendicitis
Moreaccurate
Better
identifies
phlegmonand
abscess
Better
identifies
normal
appendix
Cost
Ionizing
radiation
Contrast

Informationfromreferences11,13,20.

FIGURE5.Computedtomographicscan
showingenlargedandinflamedappendix(A)
extendingfromthececum(C).

Complications
Appendicealruptureaccountsforamajorityofthecomplications
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ofappendicitis.Factorsthatincreasetherateofperforationare
delayedpresentationtomedicalcare,17ageextremes(youngand
old)18andhiddenlocationofappendix.6Abriefperiodofin
hospitalobservation(lessthansixhours)inequivocalcasesdoes
notincreasetheperforationrateandmayimprovediagnostic
accuracy.18

Theclassichistoryofpainbeginning
intheperiumbilicalregionand
migratingtotherightlowerquadrant
occursinonly50percentof
patients.

Diagnosisofaperforatedappendixisusuallyeasier(althoughimmediatelyafterrupture,thepatient's
symptomsmaytemporarilysubside).Thephysicalexaminationfindingsaremoreobviousifperitonitis
generalizes,withamoregeneralizedrightlowerquadranttendernessprogressingtocompleteabdominal
tenderness.Anilldefinedmassmaybefeltintherightlowerquadrant.Feverismorecommonwithrupture,
andtheWBCcountmayelevateto20,000to30,000permm3(200to3003109perL)withaprominentleft
shift.3
Aperiappendicealabscessmaybetreatedimmediatelybysurgeryorbynonoperativemanagement.4
NonoperativemanagementconsistsofparenteralantibioticswithobservationorCTguideddrainage,followed
byintervalappendectomysixweekstothreemonthslater.1

SpecialConsiderations
Whileappendicitisisuncommoninyoungchildren,itposes
specialdifficultiesinthisagegroup.Youngchildrenareunableto
relateahistory,oftenhaveabdominalpainfromothercausesand
mayhavemorenonspecificsignsandsymptoms.Thesefactors
contributetoaperforationrateashighas50percentinthis
group.1

Thetechniqueofappendiceal
computedtomographyismore
accuratethanultrasonographyin
confirmingthediagnosisof
appendicitis.

Inpregnancy,thelocationoftheappendixbeginstoshift
significantlybythefourthtofifthmonthsofgestation.Commonsymptomsofpregnancymaymimic
appendicitis,andtheleukocytosisofpregnancyrenderstheWBCcountlessuseful.Whilethematernal
mortalityrateislow,theoverallfetalmortalityrateis2to8.5percent,risingtoashighas35percentin
perforationwithgeneralizedperitonitis.Asinnonpregnantpatients,appendectomyisthestandardfor
treatment.3
Elderlypatientshavethehighestmortalityrates.Theusualsignsandsymptomsofappendicitismaybe
diminished,atypicalorabsentintheelderly,whichleadstoahigherrateofperforation.Morefrequent
perforationcombinedwithahigherincidenceofothermedicalproblemsandlessreservetofightinfection
contributetoamortalityrateofupto5percentormore.1

FinalComment
Promptdiagnosisofappendicitisensurestimelytreatmentandpreventscomplications.Becauseabdominal
painisacommonpresentingsymptominoutpatientcare,familyphysiciansserveanimportantroleinthe
diagnosisofappendicitis.Obviouscasesofappendicitisrequireurgentreferral,whileequivocalcaseswarrant
furtherevaluationand,manytimes,surgicalconsultation.
TheauthorthanksGlenCryer,DepartmentofPublications,ScottandWhiteMemorialHospital,Temple,
Tex.,forhelpwiththemanuscript.
Figures3through5wereprovidedbyMichaelL.Nipper,M.D.,DepartmentofRadiology,ScottandWhite
MemorialHospital,Temple,Tex.

TheAuthor
D.MIKEHARDIN,JR.,M.D.,
isanassistantprofessorintheDepartmentofFamilyMedicineatScott&WhiteClinicandMemorial
Hospital,Bellmead,Tex.,affiliatedwithTexasA&MUniversityHealthScienceCenterinTemple.Dr.Hardin
graduatedfromtheUniversityofTexasMedicalSchoolatHoustonandcompletedaresidencyinfamily
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AcuteAppendicitis:ReviewandUpdateNovember1,1999AmericanAcademyofFamilyPhysicians

practiceattheMcLennanCountyMedicalEducationandResearchFoundation,Waco,Tex.
AddresscorrespondencetoD.MikeHardin,Jr.,M.D.,556NorthLoop340,Bellmead,TX76705.Reprints
arenotavailablefromtheauthor.

REFERENCES
1.LiuCD,McFaddenDW.Acuteabdomenandappendix.In:GreenfieldLJ,etal.,eds.Surgery:scientificprinciplesand
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JEpidemiol1990132:91025.
3.SchwartzSI.Appendix.In:SchwartzSI,ed.Principlesofsurgery.6thed.NewYork:McGrawHill,1994:130718.
4.WilcoxRT,TraversoLW.Havetheevaluationandtreatmentofacuteappendicitischangedwithnewtechnology?SurgClin
NorthAm199777:135570.
5.GraffeoCS,CounselmanFL.Appendicitis.EmergMedClinNorthAm199614:65371.
6.GuidrySP,PooleGV.Theanatomyofappendicitis.AmSurg199460:6871.
7.WagnerJM,McKinneyWP,CarpenterJL.Doesthispatienthaveappendicitis?JAMA1996276:158994.
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10.CalderJD,GajrajH.Recentadvancesinthediagnosisandtreatmentofacuteappendicitis.BrJHospMed199554:12933.
11.RaoPM,FeltmoteCM,RheaJT,SchulickAH,NovellineRA.Helicalcomputedtomographyindifferentiatingappendicitis
andacutegynecologicconditions.ObstetGynecol199993:41721.
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13.RaoPM,RheaJT,NovellineRA,McCabeCJ,LawrasonJN,BergerDL,etal.HelicalCTtechniqueforthediagnosisof
appendicitis:prospectiveevaluationofafocusedappendixCTexamination.Radiology1997202:13944.
14.PaulmanAA,HuebnerDM,ForrestTS.Sonographyinthediagnosisofacuteappendicitis.AmFamPhysician199144:465
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15.RaoPM,RheaJT,NovellineRA,MostafaviAA,McCabeCJ,etal.Effectofcomputedtomographyoftheappendixon
treatmentofpatientsanduseofhospitalresources.NEnglJMed1998338:1416.
16.GeisWP,MillerCE,etal.Laparoscopicappendectomyforacuteappendicitis:rationaleandtechnicalaspects.Contemp
Surg199240:139.
17.TempleCL,HuchcroftSA,TempleWJ.Thenaturalhistoryofappendicitisinadults:aprospectivestudy.AnnSurg
1995221:27881.
18.RicciMA,TrevisaniMF,BeckWC.Acuteappendicitis:afiveyearreview.AmSurg199157:3015.
19.JaeschkeR,GuyattGH,SackettDL.Users'guidestothemedicalliterature.III.Howtouseanarticleaboutadiagnostictest.
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Copyright1999bytheAmericanAcademyofFamilyPhysicians.
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