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Acuteappendicitisinadults:ClinicalmanifestationsanddifferentialdiagnosisUpToDate

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Acuteappendicitisinadults:Clinicalmanifestationsanddifferentialdiagnosis
Author: RonaldFMartin,MD
SectionEditor: MartinWeiser,MD
DeputyEditor: WenliangChen,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Sep2016.|Thistopiclastupdated:Feb05,2016.
INTRODUCTIONAppendicitis,aninflammationofthevestigialvermiformappendix,isoneofthemost
commoncausesoftheacuteabdomenandoneofthemostfrequentindicationsforanemergentabdominal
surgicalprocedureworldwide[1,2].
Theclinicalmanifestationsanddiagnosisofappendicitisinadultswillbereviewedhere.Themanagementof
appendicitisinadultsandappendicitisinpregnancyandchildrenarediscussedseparately.(See"Managementof
acuteappendicitisinadults"and"Acuteappendicitisinpregnancy"and"Acuteappendicitisinchildren:Clinical
manifestationsanddiagnosis".)
ANATOMYThevermiformappendixislocatedatthebaseofthececum,neartheileocecalvalvewherethe
taeniacoliconvergeonthececum(figure1)[3,4].Theappendixisatruediverticulumofthececum.Incontrastto
acquireddiverticulardisease,whichconsistsofaprotuberanceofasubsetoftheentericwalllayers,the
appendicealwallcontainsallofthelayersofthecolonicwall:mucosa,submucosa,muscularis(longitudinaland
circular),andtheserosalcovering[5].
Theappendicealorificeopensintothececum.Itsbloodsupply,theappendicealartery,isaterminalbranchofthe
ileocolicartery,whichtraversesthelengthofthemesoappendixandterminatesatthetipoftheorgan(figure2)
[4].
Theattachmentoftheappendixtothebaseofthececumisconstant.However,thetipmaymigratetothe
retrocecal,subcecal,preileal,postileal,andpelvicpositions.Thesenormalanatomicvariationscancomplicatethe
diagnosisasthesiteofpainandfindingsontheclinicalexaminationwillreflecttheanatomicpositionofthe
appendix.
ThepresenceofBandTlymphoidcellsinthemucosaandsubmucosaofthelaminapropriamaketheappendix
histologicallydistinctfromthececum[5].Thesecellscreatealymphoidpulpthataidsimmunologicfunctionby
increasinglymphoidproductssuchasIgAandoperatingaspartofthegutassociatedlymphoidtissuesystem[3].
Lymphoidhyperplasiacancauseobstructionoftheappendixandleadtoappendicitis.Thelymphoidtissue
undergoesatrophywithage[6].
EPIDEMIOLOGYAppendicitisoccursmostfrequentlyinthesecondandthirddecadesoflife.Theincidenceis
approximately233/100,000populationandishighestinthe10to19yearoldagegroup[7].Itisalsohigher
amongmen(maletofemaleratioof1.4:1),whohavealifetimeincidenceof8.6percentcomparedwith6.7
percentforwomen[7].
PATHOGENESISThenaturalhistoryofappendicitisissimilartothatofotherinflammatoryprocessesinvolving
hollowvisceralorgans.Initialinflammationoftheappendicealwallisfollowedbylocalizedischemia,perforation,
andthedevelopmentofacontainedabscessorgeneralizedperitonitis.
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Appendicealobstructionhasbeenproposedastheprimarycauseofappendicitis[3,811].Obstructionis
frequentlyimplicatedbutnotalwaysidentified.Astudyofpatientswithappendicitisshowedthattherewas
elevatedintraluminalpressureinonlyonethirdofthepatientswithnonperforatedappendicitis[12].
Appendicealobstructionmaybecausedbyfecaliths(hardfecalmasses),calculi,lymphoidhyperplasia,infectious
processes,andbenignormalignanttumors.However,somepatientswithafecalithhaveahistologicallynormal
appendixandthemajorityofpatientswithappendicitisdonothaveafecalith[13,14].
Whenobstructionoftheappendixisthecauseofappendicitis,theobstructionleadstoanincreaseinluminaland
intramuralpressure,resultinginthrombosisandocclusionofthesmallvesselsintheappendicealwall,andstasis
oflymphaticflow.Astheappendixbecomesengorged,thevisceralafferentnervefibersenteringthespinalcord
atT8T10arestimulated,leadingtovaguecentralorperiumbilicalabdominalpain[8].Welllocalizedpainoccurs
laterinthecoursewheninflammationinvolvestheadjacentparietalperitoneum.
Themechanismofluminalobstructionvariesdependinguponthepatient'sage.Intheyoung,lymphoidfollicular
hyperplasiaduetoinfectionisthoughttobethemaincause.Inolderpatients,luminalobstructionismorelikelyto
becausedbyfibrosis,fecaliths,orneoplasia(carcinoid,adenocarcinoma,ormucocele).Inendemicareas,
parasitescancauseobstructioninanyagegroup.(See"Canceroftheappendixandpseudomyxomaperitonei".)
Onceobstructed,thelumenbecomesfilledwithmucusanddistends,increasingluminalandintramuralpressure.
Thisresultsinthrombosisandocclusionofthesmallvessels,andstasisoflymphaticflow.Aslymphaticand
vascularcompromiseprogress,thewalloftheappendixbecomesischemicandthennecrotic.
Bacterialovergrowthoccurswithinthediseasedappendix.Aerobicorganismspredominateearlyinthecourse,
whilemixedinfectionismorecommoninlateappendicitis[15].Commonorganismsinvolvedingangrenousand
perforatedappendicitisincludeEscherichiacoli,Peptostreptococcus,Bacteroidesfragilis,andPseudomonas
species[16].Intraluminalbacteriasubsequentlyinvadetheappendicealwallandfurtherpropagateaneutrophilic
exudate.Theinfluxofneutrophilscausesafibropurulentreactionontheserosalsurface,irritatingthesurrounding
parietalperitoneum[6].Thisresultsinstimulationofsomaticnerves,causingpainatthesiteofperitonealirritation
[5].
Duringthefirst24hoursaftersymptomsdevelop,approximately90percentofpatientsdevelopinflammationand
perhapsnecrosisoftheappendix,butnotperforation.Thetypeofluminalobstructionmaybeapredictorof
perforationofanacutelyinflamedappendix.Fecalithsweresixtimesmorecommonthantruecalculiinthe
appendix,butcalculiweremoreoftenassociatedwithperforatedappendicitisorperiappendicealabscess(45
percent)thanwerefecaliths(19percent).Thisispresumablyduetotherigidityoftruecalculiascomparedwith
thesofter,morecrushablefecaliths[13].
Oncesignificantinflammationandnecrosisoccur,theappendixisatriskofperforation,whichleadstolocalized
abscessformationordiffuseperitonitis.Thetimecoursetoperforationisvariable.Onestudyshowedthat20
percentofpatientsdevelopedperforationlessthan24hoursaftertheonsetofsymptoms[17].Sixtyfivepercent
ofpatientsinwhomtheappendixperforatedhadsymptomsforlongerthan48hours.
CLINICALFEATURES
Clinicalmanifestations
HistoryAbdominalpainisthemostcommonsymptom,andisreportedinnearlyallconfirmedcasesof
appendicitis[18,19].Theclinicalpresentationofacuteappendicitisisdescribedasaconstellationofthefollowing
classicsymptoms:
Rightlowerquadrant(rightanterioriliacfossa)abdominalpain
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Anorexia
Nauseaandvomiting
Intheclassicpresentation,thepatientdescribestheonsetofabdominalpainasthefirstsymptom.Thepainis
typicallyperiumbilicalinnaturewithsubsequentmigrationtotherightlowerquadrantastheinflammation
progresses[18].Althoughconsideredaclassicsymptom,migratorypainoccursonlyin50to60percentof
patientswithappendicitis[8,20].Nauseaandvomiting,iftheyoccur,usuallyfollowtheonsetofpain.Fever
relatedsymptomsgenerallyoccurlaterinthecourseofillness.
Inmanypatients,initialfeaturesareatypicalornonspecific,andcaninclude:
Indigestion
Flatulence
Bowelirregularity
Diarrhea
Generalizedmalaise
Becausetheearlysymptomsofappendicitisareoftensubtle,patientsandcliniciansmayminimizetheir
importance.Thesymptomsofappendicitisvarydependinguponthelocationofthetipoftheappendix(figure1)
(see'Anatomy'above).Forexample,aninflamedanteriorappendixproducesmarked,localizedpainintheright
lowerquadrant,whilearetrocecalappendixmaycauseadullabdominalache[21].Thelocationofthepainmay
alsobeatypicalinpatientswhohavethetipoftheappendixlocatedinthepelvis,whichcancausetenderness
belowMcBurney'spoint.Suchpatientsmaycomplainofurinaryfrequencyanddysuriaorrectalsymptoms,such
astenesmusanddiarrhea.
PhysicalexaminationTheearlysignsofappendicitisareoftensubtle.Lowgradefeverreaching101.0F
(38.3C)maybepresent.Thephysicalexaminationmaybeunrevealingintheveryearlystagesofappendicitis
sincethevisceralorgansarenotinnervatedwithsomaticpainfibers.
However,astheinflammationprogresses,involvementoftheoverlyingparietalperitoneumcauseslocalized
tendernessintherightlowerquadrantandcanbedetectedontheabdominalexamination.Rectalexamination,
althoughoftenadvocated,hasnotbeenshowntoprovideadditionaldiagnosticinformationincasesof
appendicitis[22].Inwomen,rightadnexalareatendernessmaybepresentonpelvicexamination,and
differentiatingbetweentendernessofpelvicoriginversusthatofappendicitismaybechallenging.Highgrade
fever(>101.0F/38.3C)occursasinflammationprogresses.(See"Causesofabdominalpaininadults".)
Patientswitharetrocecalappendixmaynotexhibitmarkedlocalizedtendernessintherightlowerquadrantsince
theappendixdoesnotcomeintocontactwiththeanteriorparietalperitoneum(figure1)[21].Therectaland/or
pelvicexaminationismorelikelytoelicitpositivesignsthantheabdominalexamination.Tendernessmaybemore
prominentonpelvicexamination,andmaybemistakenforadnexaltenderness.
Severalfindingsonphysicalexaminationhavebeendescribedtofacilitatediagnosis,butthesefindingspredated
definitiveimagingforappendicitis,andthewidevariationintheirsensitivityandspecificitysuggeststhattheybe
usedwithcautiontobroaden,ornarrow,adifferentialdiagnosis.Therearenophysicalfindings,takenaloneorin
concert,thatdefinitivelyconfirmadiagnosisofappendicitis.
Commonlydescribedphysicalsignsinclude:
McBurney'spointtendernessisdescribedasmaximaltendernessat1.5to2inchesfromtheanterior
superioriliacspine(ASIS)onastraightlinefromtheASIStotheumbilicus[23](sensitivity50to94percent
specificity75to86percent[2426]).
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Rovsing'ssignreferstopainintherightlowerquadrantwithpalpationoftheleftlowerquadrant.Thissignis
alsocalledindirecttendernessandisindicativeofrightsidedlocalperitonealirritation[27](sensitivity22to
68percentspecificity58to96percent[25,2830]).
Thepsoassignisassociatedwitharetrocecalappendix.Thisismanifestedbyrightlowerquadrantpainwith
passiverighthipextension.Theinflamedappendixmaylieagainsttherightpsoasmuscle,causingthe
patienttoshortenthemusclebydrawinguptherightknee.Passiveextensionoftheiliopsoasmusclewith
hipextensioncausesrightlowerquadrantpain(sensitivity13to42percentspecificity79to97percent
[28,31,32]).
Theobturatorsignisassociatedwithapelvicappendix.Thistestisbasedontheprinciplethattheinflamed
appendixmaylayagainsttherightobturatorinternusmuscle.Whentheclinicianflexesthepatient'srighthip
andkneefollowedbyinternalrotationoftherighthip,thiselicitsrightlowerquadrantpain,(sensitivity8
percentspecificity94percent[31]).Thesensitivityislowenoughthatexperiencedcliniciansnolonger
performthisassessment.
LaboratoryfindingsAmildleukocytosis(whitebloodcellcount>10,000cells/microL)ispresentinmost
patientswithacuteappendicitis[33].Approximately80percentofpatientshavealeukocytosisandaleftshift
(increaseintotalWBCcount,bands[immatureneutrophils],andneutrophils)inthedifferential[3436].The
sensitivityandspecificityofanelevatedwhitebloodcell(WBC)countinacuteappendicitisis80percentand55
percentrespectively.
AcuteappendicitisisunlikelywhentheWBCcountisnormal,exceptintheveryearlycourseoftheillness[36
38].Incomparison,meanWBCcountsarehigherinpatientswithagangrenous(necrotic)orperforatedappendix
[39]:
Acute14,5007,300cells/microL
Gangrenous17,1003,900cells/microL
Perforated17,9002,100cells/microL(see'Perforatedappendix'below)
Mildelevationsinserumbilirubin(totalbilirubin>1.0mg/dL)havebeennotedtobeamarkerforappendiceal
perforationwithasensitivityof70percentandaspecificityof86percent[40].Thiscomparesfavorablywitha
sensitivityandspecificityofanelevatedWBCof80percentand55percentrespectively.
Imagingstudies
ComputedtomographyfindingsThefollowingfindingssuggestacuteappendicitisonstandard
abdominalcomputedtomography(CT)scanningwithcontrastincluding(image1andimage2)[4143]:
Enlargedappendicealdiameter>6mmwithanoccludedlumen
Appendicealwallthickening(>2mm)
Periappendicealfatstranding
Appendicealwallenhancement
Appendicolith(seeninapproximately25percentofpatients)
UltrasoundfindingsThemostaccurateultrasoundfindingforacuteappendicitisisanappendiceal
diameterof>6mm(image3andimage4)[8,44,45].
PlainradiographfindingsPlainradiographsareusuallynothelpfulforestablishingthediagnosisof
appendicitis(image5).However,thefollowingradiographicfindingshavebeenassociatedwithacute
appendicitis:
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Rightlowerquadrantappendicolith
Localizedrightlowerquadrantileus
Lossofthepsoasshadow
Freeair(occasionally)
Deformityofcecaloutline
Rightlowerquadrantsofttissuedensity
MagneticresonanceimagingMagneticresonanceimaging(MRI)canassistwiththeevaluationofacute
abdominalandpelvicpainduringpregnancy(image6)[46,47].Anormalappendixisvisualizedasatubular
structurelessthanorequalto6mmindiameterandfilledwithairand/ororalcontrastmaterial[48].Anenlarged
fluidfilledappendix(>7mmindiameter)isconsideredanabnormalfinding,whileanappendixwithadiameterof
6to7mmisconsideredaninconclusivefinding[48].(See"Approachtoabdominalpainandtheacuteabdomen
inpregnantandpostpartumwomen"and"Acuteappendicitisinpregnancy".)
DIFFERENTIALDIAGNOSISAvarietyofinflammatoryandinfectiousconditionsintherightlowerquadrant
canmimicthesignsandsymptomsofacuteappendicitis.(See"Causesofabdominalpaininadults".)
PerforatedappendixDuringthefirst24hoursaftertheonsetofabdominalpainandassociatedsymptoms,
approximately90percentofpatientsdevelopinflammationandperhapsnecrosisoftheappendix,butnot
perforation.Oncesignificantinflammationandnecrosisoccur,theappendixisatriskforperforation,whichleads
tolocalizedabscessformationordiffuseperitonitis.Thetimecoursetoperforationisvariable.Onestudyshowed
that20percentofpatientsdevelopedperforationlessthan24hoursaftertheonsetofsymptoms[17].Sixtyfive
percentofpatientsinwhomtheappendixperforatedhadsymptomsforlongerthan48hours.
Aperforatedappendixmustbeconsideredinapatientwhosetemperatureexceeds103.0F(39.4C),theWBC
countisgreaterthan15,000cells/microL,andimagingstudiesrevealafluidcollectionintherightlowerquadrant.
(See'Pathogenesis'aboveand'Laboratoryfindings'aboveand"Acuteappendicitisinadults:Diagnostic
evaluation",sectionon'Imaging'and'Imagingstudies'above.)
CecaldiverticulitisCecaldiverticulitisusuallyoccursinyoungadultsandpresentswithsignsandsymptoms
thatcanbevirtuallyidenticaltothoseofacuteappendicitis.Rightsideddiverticulitisoccursinonly1.5percentof
patientsinWesterncountries,butismorecommoninAsianpopulations(accountingforasmanyas75percentof
casesofdiverticulitis).Patientswithrightsideddiverticulitistendtobeyoungerthanthosewithleftsideddisease
andoftenaremisdiagnosedwithacuteappendicitis.Computedtomographic(CT)scanningoftheabdomenwith
IVandoralcontrastisthediagnostictestofchoiceinpatientssuspectedofhavingacutediverticulitis.(See
"Clinicalmanifestationsanddiagnosisofacutediverticulitisinadults"and"Acutecolonicdiverticulitis:Medical
management",sectionon'Rightsided(cecal)diverticulitis'.)
Meckel'sdiverticulitisMeckel'sdiverticulitispresentsinafashionsimilartoacuteappendicitis.AMeckel's
diverticulumisacongenitalremnantoftheomphalomesentericductandislocatedonthesmallintestinetwofeet
fromtheileocecalvalve[49,50].Meckel'sdiverticulitisshouldbeincludedinthedifferentialdiagnosis,asthesmall
bowelmaymigrateintotherightlowerquadrantandmimicthesymptomsofappendicitis.Ifaninflamedappendix
isnotfoundonabdominalexplorationforacuteappendicitis,thesurgeonshouldsearchforaninflamedMeckel's
diverticulum.(See"Meckelsdiverticulum",sectionon'Clinicalpresentations'.)
AcuteileitisAcuteileitis,duemostcommonlytoanacuteselflimitedbacterialinfection(Yersinia,
Campylobacter,Salmonella,andothers),shouldbeconsideredwhenacutediarrheaisaprominentsymptom.
Otherclinicalmanifestationsofacuteyersiniosisincludeabdominalpain,fever,nauseaand/orvomiting.
Yersiniosiscannotbereadilydistinguishedclinicallyfromothercausesofacutediarrheathatpresentwiththese
symptoms.However,localizationofabdominalpaintotherightlowerquadrantalongwithacutediarrheamaybe
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adiagnosticclueforyersiniosis.(See"ClinicalmanifestationsanddiagnosisofYersiniainfections",sectionon
'Acuteyersiniosis'.)
Acuteyersiniosispresentingwithrightlowerabdominalpain,fever,vomiting,leukocytosis,andunderstated
diarrheamaybeconfusedwithacuteappendicitis.Atsurgery,findingsincludevisibleinflammationaroundthe
appendixandterminalileumandinflammationofthemesentericlymphnodestheappendixitselfisgenerally
normal.Yersiniacanbeculturedfromtheappendixandinvolvedlymphnodes.(See"Clinicalmanifestationsand
diagnosisofYersiniainfections",sectionon'Pseudoappendicitis'.)
Crohn'sdiseaseCrohn'sdiseasecanpresentwithsymptomssimilartoappendicitis,particularlywhen
localizedtothedistalileum.Fatigue,prolongeddiarrheawithabdominalpain,weightloss,andfever,withor
withoutgrossbleeding,arethehallmarksofCrohn'sdisease.AnacuteexacerbationofCrohnsdiseasecan
mimicacuteappendicitisandmaybeindistinguishablebyclinicalevaluationandimaging.
Crohn'sdiseaseshouldbesuspectedinpatientswhohavepersistentpainaftersurgery,especiallyiftheappendix
ishistologicallynormal.(See"Clinicalmanifestations,diagnosisandprognosisofCrohndiseaseinadults".)
GynecologicandobstetricalconditionsThefollowinggynecologicdiseasesmaypresentwithsymptoms
and/orclinicalfindingsthatareincludedinthedifferentialofacuteappendicitis:
TuboovarianabscessAtuboovarianabscess(TOA)isaninflammatorymassinvolvingthefallopian
tube,ovary,and,occasionally,otheradjacentpelvicorgans(eg,bowel,bladder).Theseabscessesarefound
mostcommonlyinreproductiveagewomenandtypicallyresultfromuppergenitaltractinfection.Tuboovarian
abscessisusuallyacomplicationofpelvicinflammatorydisease.Theclassicpresentationincludesacutelower
abdominalpain,fever,chills,andvaginaldischarge.However,feverisnotpresentinallpatients,somepatients
reportonlylowgradenocturnalfeversorchills,andnotallwomenpresentinanacutefashion.Clinicalhistory
andCTimagingcanhelpdifferentiateTOAfromacuteappendicitis(picture1).(See"Epidemiology,clinical
manifestations,anddiagnosisoftuboovarianabscess",sectionon'Clinicalpresentation'.)
PelvicinflammatorydiseaseLowerabdominalpainisthecardinalpresentingsymptominwomenwith
pelvicinflammatorydisease(PID),althoughthecharacterofthepainmaybequitesubtle.Therecentonsetof
painthatworsensduringcoitusorwithjarringmovementmaybetheonlypresentingsymptomofPIDtheonset
ofpainduringorshortlyaftermensesisparticularlysuggestive.Onphysicalexamination,onlyaboutonehalfof
patientswithPIDhavefever.Abdominalexaminationrevealsdiffusetendernessgreatestinthelowerquadrants,
whichmayormaynotbesymmetrical.Reboundtendernessanddecreasedbowelsoundsarecommon.On
pelvicexamination,thefindingofapurulentendocervicaldischargeand/oracutecervicalmotionandadnexal
tendernesswithbimanualexaminationisstronglysuggestiveofPID.ClinicalhistoryandCTimagingcanhelp
differentiatePIDfromacuteappendicitis(See"Pelvicinflammatorydisease:Clinicalmanifestationsand
diagnosis".)
RupturedovariancystRuptureofanovariancystisacommonoccurrenceinwomenofreproductiveage
andmaybeassociatedwiththesuddenonsetofunilaterallowerabdominalpain.Therightlowerquadrantis
mostcommonlyaffected,possiblybecausetherectosigmoidcolonprotectstheleftovaryfromtheeffectsof
abdominaltrauma.Thepainoftenbeginsduringstrenuousphysicalactivity,suchasexerciseorsexual
intercourse,andmaybeaccompaniedbylightvaginalbleedingduetoadropinsecretionofovarianhormones
andsubsequentendometrialsloughing.Bloodfromtherupturesitemayseepintotheovary,whichcancause
painfromstretchingoftheovariancortex,oritmayflowintotheabdomen,whichhasanirritanteffectonthe
peritoneum.Serousormucinousfluidreleaseduponcystruptureisnotveryirritatingthepatientmayremain
asymptomaticdespiteaccumulationofalargevolumeofintraperitonealfluid.Ontheotherhand,spillageof
sebaceousmaterialuponruptureofadermoidcystcausesamarkedgranulomatousreactionandchemical
peritonitis,whichisusuallyquitepainful.IntraabdominalhemorrhagemaybeassociatedwithCullen'ssign(ie,
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periumbilicalecchymoses).ClinicalhistoryandCTimagingcanhelpdifferentiatearupturedovariancystfrom
acuteappendicitis(image7andimage8).(See"Evaluationandmanagementofrupturedovariancyst".)
MittelschmerzMittelschmerzreferstomidcyclepaininanovulatorywomancausedbynormalfollicular
enlargementjustpriortoovulationortonormalfollicularbleedingatovulation.Thepainistypicallymildand
unilateralitoccursmidwaybetweenmenstrualperiodsandlastsforafewhourstoacoupleofdays.Fluidor
bloodisreleasedfromtherupturedeggfollicleandcancauseirritationoftheliningoftheabdominalwall.(See
"Physiologyofthenormalmenstrualcycle".)
OvarianandfallopiantubetorsionOvariantorsionreferstothetwistingoftheovaryonitsligamentous
supports,oftenresultinginimpedanceofitsbloodsupply(picture2).Isolatedfallopiantubetorsionisuncommon
(picture3).Expedientdiagnosisisimportanttopreserveovarianfunctionandpreventadversesequelae.
However,thediagnosiscanbechallengingbecausethesymptomsarerelativelynonspecific.
Themostcommonsymptomofovariantorsionissuddenonsetlowerabdominalpain,oftenassociatedwith
wavesofnauseaandvomiting.Fever,althoughanuncommonfindinginovariantorsion,maybeamarkerof
necrosis,particularlyinthesettingofanincreasedwhitebloodcellcount.ClinicalhistoryandCTimagingcanhelp
differentiatethediagnosisfromacuteappendicitis(picture4).(See"Ovarianandfallopiantubetorsion".)
EndometriosisEndometriosisisdefinedasthepresenceofendometrialglandsandstromaatextrauterine
sites.Theseectopicendometrialimplantsareusuallylocatedinthepelvis,butcanoccurnearlyanywhereinthe
body(picture5).
Commonsymptomsofendometriosisincludepelvicpain(whichisusuallychronicandoftenmoresevereduring
mensesoratovulation),dysmenorrhea,deepdyspareunia,cyclicalbowelorbladdersymptoms,abnormal
menstrualbleeding,andinfertility.Thereareoftennoabnormalfindingsonphysicalexaminationwhenfindings
arepresent,themostcommonistendernessuponpalpationoftheposteriorfornix.Ultrasoundismostlyuseful
fordiagnosingovarianendometriomasitlacksadequateresolutionforvisualizingadhesionsandsuperficial
peritoneal/ovarianimplants,whicharemorecommonthanendometriomas.(See"Endometriosis:Pathogenesis,
clinicalfeatures,anddiagnosis".)
OvarianhyperstimulationsyndromeOvarianhyperstimulationsyndrome(OHSS)isaniatrogenic
complicationofovulationinductiontherapy,andmaybeaccompaniedbyormistakenforcystrupture.Clinical
findingsincludebloating,nausea,vomiting,diarrhea,lethargy,shortnessofbreath,andrapidweightgain.
Severeovarianhyperstimulationsyndromeischaracterizedbylargeovariancysts,ascites,and,insomepatients,
pleuraland/orpericardialeffusion,electrolyteimbalance(hyponatremia,hyperkalemia),hypovolemia,and
hypovolemicshock.Markedhemoconcentration,increasedbloodviscosity,andthromboembolicphenomena,
includingdisseminatedintravascularcoagulation,occurinthemostseverecases.(See"Pathogenesis,clinical
manifestations,anddiagnosisofovarianhyperstimulationsyndrome".)
EctopicpregnancyEctopicpregnancyhasclinicalsymptomsandsonographicfeaturessimilartothoseof
arupturedovariancyst.Inwomenwithacutepelvicpainorabnormalvaginalbleeding,apositivepregnancytest
stronglysuggeststhepresenceofanectopicpregnancyifanintrauterinepregnancycannotbevisualized
sonographically.Ifanintrauterinepregnancyisvisualized,thenpelvicpainandintraperitonealfluidcouldbedue
toarupturedovariancyst(eg,corpusluteumcyst,thecaluteincyst)orheterotopicpregnancy.(See"Ectopic
pregnancy:Clinicalmanifestationsanddiagnosis",sectionon'Heterotopicpregnancy'.)
AcuteendometritisAcuteendometritisoccursafteranobstetricaldeliveryor,rarely,afteraninvasive
uterineprocedure.Thediagnosisislargelybaseduponthepresenceoffever,gradualonsetofuterine
tenderness,fouluterinedischarge,andleukocytosisinanatrisksetting.(See"Postpartumendometritis"and
"Endometritisunrelatedtopregnancy".)
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Urologicconditions
RenalcolicPainisthemostcommonsymptomandvariesfromamildandbarelynoticeableacheto
discomfortthatissointensethatitrequiresparenteralanalgesics.Thepaintypicallywaxesandwanesinseverity,
anddevelopsinwavesorparoxysmsthatarerelatedtomovementofthestoneintheureterandassociated
ureteralspasm.Paroxysmsofseverepainusuallylast20to60minutes.Painisthoughttooccurprimarilyfrom
urinaryobstructionwithdistentionoftherenalcapsule.(See"Diagnosisandacutemanagementofsuspected
nephrolithiasisinadults"and"Acutemanagementofnephrolithiasisinchildren".)
TesticulartorsionTesticulartorsionisaurologicemergencythatismorecommoninneonatesand
postpubertalboys,althoughitcanoccuratanyage.Testiculartorsionresultsfrominadequatefixationofthe
testistothetunicavaginalis.Iffixationofthelowerpoleofthetestistothetunicavaginalisisinsufficientlybroad
basedorabsent,thetestismaytorse(twist)onthespermaticcord,potentiallyproducingischemiafromreduced
arterialinflowandvenousoutflowobstruction.(See"Causesofscrotalpaininchildrenandadolescents",section
on'Testiculartorsion'and"Evaluationoftheacutescrotuminadults",sectionon'Testiculartorsion'.)
EpididymitisEpididymitisoccursmorefrequentlyamonglateadolescents,butalsooccursinyoungerboys
whodenysexualactivityandisthemostcommoncauseofscrotalpaininadultsintheoutpatientsetting.Several
factorsmaypredisposepostpubertalboystodevelopsubacuteepididymitis,includingsexualactivity,heavy
physicalexertion,anddirecttrauma(eg,bicycleormotorcycleriding).Bacterialepididymitisinprepubertalboysis
associatedwithstructuralanomaliesoftheurinarytract.Inacuteinfectiousepididymitis,palpationreveals
indurationandswellingoftheinvolvedepididymiswithexquisitetenderness.Moreadvancedcasesoftenpresent
withtesticularswellingandpain(epididymoorchitis)withscrotalwallerythemaandareactivehydrocele.(See
"Causesofscrotalpaininchildrenandadolescents",sectionon'Epididymitis'and"Evaluationoftheacute
scrotuminadults",sectionon'Epididymitis'.)
TorsionoftheappendixtestisorappendixepididymisTheappendixtestisisasmallvestigialstructure
ontheanterosuperioraspectofthetestis(anembryologicremnantoftheMllerianductsystem).Theappendix
epididymisisavestigialremnantoftheWolffianductthatislocatedattheheadoftheepididymis.The
pedunculatedshapeoftheseappendagespredisposesthemtotorsion,whichcanproducescrotalpainthat
rangesfrommildtosevere.Mostcasesoftorsionoftheappendixtestisoccurbetweentheagesof7and14
years,andrarelyoccurinadults.(See"Causesofscrotalpaininchildrenandadolescents",sectionon'Torsionof
theappendixtestisorappendixepididymis'and"Evaluationoftheacutescrotuminadults",sectionon'Torsionof
theappendixtestis'.)
TREATMENTThemanagementofacuteappendicitisinchildrenandadultsisdiscussedindetailseparately.
(See"Acuteappendicitisinchildren:Management"and"Managementofacuteappendicitisinadults".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandare
comfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patienteducation:Appendicitisinadults(TheBasics)").
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SUMMARYANDRECOMMENDATIONSAppendicitisisoneofthemostcommoncausesoftheacute
abdomenandoneofthemostfrequentindicationsforanemergentabdominalsurgicalprocedureworldwide.
Thetipoftheappendixcanbefoundinaretrocecalorpelviclocation,aswellasmedial,lateral,anterior,or
posteriortothececum.Anatomicvariabilitycancomplicatethediagnosis,asclinicalpresentationwillreflect
theanatomicpositionoftheappendix.(See'Anatomy'above.)
Appendicealobstructionplaysaroleinthepathogenesisofappendicitis,butitisnotrequiredforthe
developmentofappendicitis.(See'Pathogenesis'above.)
Theclassicsymptomsofappendicitisincluderightlowerquadrantabdominalpain,anorexia,fever,nausea,
andvomiting.Theabdominalpainisinitiallyperiumbilicalinnaturewithsubsequentmigrationtotheright
lowerquadrantastheinflammationprogresses(see'Clinicalmanifestations'above).Patientswith
appendicitiscanalsopresentwithatypicalornonspecificsymptoms,suchasindigestion,flatulence,bowel
irregularity,andgeneralizedmalaiseandnotallpatientswillhavemigratoryabdominalpain.
Thedifferentialdiagnosisofrightlowerquadrantabdominalpainincludesinflammatorydiseaseprocesses
(eg,Crohnsdisease,rupturedcyst),infectiousdiseases(eg,acuteileitis,tuboovarianabscess),and
obstetricalconditions(eg,ectopicpregnancy).(See'Differentialdiagnosis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.WilliamsGR.PresidentialAddress:ahistoryofappendicitis.Withanecdotesillustratingitsimportance.Ann
Surg1983197:495.
2.Fitz,RH.Perforatinginflammationofthevermiformappendixwithspecialreferencetoitsearlydiagnosis
andtreatment.AmJMedSci188692:321.
3.Jaffe,BM,Berger,DH.TheAppendix.In:SchwartzPrinciplesofSurgery,8thed,Schwartz,SI,Brunicardi,
CF(Ed),McGrawHillHealthPub.Division,NewYork2005.
4.BuschardK,KjaeldgaardA.Investigationandanalysisoftheposition,fixation,lengthandembryologyofthe
vermiformappendix.ActaChirScand1973139:293.
5.Mulholland,MW,Lillemoe,KD,Doherty,GM,etal.Greenfield'sSurgery,4thed,LippincottWilliams&
Wilkins,Philadelphia,PA2005.
6.Kumar,V,Abbas,AK,Fausto,N.RobbinsandCotran:PathologicBasisofDisease,7thed,Saunders
Elsevier,Philadelphia,PA2007.
7.AddissDG,ShafferN,FowlerBS,TauxeRV.Theepidemiologyofappendicitisandappendectomyinthe
UnitedStates.AmJEpidemiol1990132:910.
8.BirnbaumBA,WilsonSR.Appendicitisatthemillennium.Radiology2000215:337.
9.BurkittDP.Theaetiologyofappendicitis.BrJSurg197158:695.
10.ButlerC.Surgicalpathologyofacuteappendicitis.HumPathol198112:870.
11.MirandaR,JohnstonAD,O'LearyJP.Incidentalappendectomy:frequencyofpathologicabnormalities.Am
Surg198046:355.
12.ArnbjrnssonE,BengmarkS.Obstructionoftheappendixlumeninrelationtopathogenesisofacute
appendicitis.ActaChirScand1983149:789.
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13.NiteckiS,KarmeliR,SarrMG.Appendicealcalculiandfecalithsasindicationsforappendectomy.Surg
GynecolObstet1990171:185.
14.JonesBA,DemetriadesD,SegalI,BurkittDP.Theprevalenceofappendicealfecalithsinpatientswithand
withoutappendicitis.AcomparativestudyfromCanadaandSouthAfrica.AnnSurg1985202:80.
15.LauWY,TeohChanCH,FanST,etal.Thebacteriologyandsepticcomplicationofpatientswith
appendicitis.AnnSurg1984200:576.
16.BennionRS,BaronEJ,ThompsonJEJr,etal.Thebacteriologyofgangrenousandperforated
appendicitisrevisited.AnnSurg1990211:165.
17.TempleCL,HuchcroftSA,TempleWJ.Thenaturalhistoryofappendicitisinadults.Aprospectivestudy.
AnnSurg1995221:278.
18.LeeSL,WalshAJ,HoHS.Computedtomographyandultrasonographydonotimproveandmaydelaythe
diagnosisandtreatmentofacuteappendicitis.ArchSurg2001136:556.
19.RaoPM,RheaJT,NovellineRA,etal.HelicalCTtechniqueforthediagnosisofappendicitis:prospective
evaluationofafocusedappendixCTexamination.Radiology1997202:139.
20.ChungCH,NgCP,LaiKK.Delaysbypatients,emergencyphysicians,andsurgeonsinthemanagementof
acuteappendicitis:retrospectivestudy.HongKongMedJ20006:254.
21.GuidrySP,PooleGV.Theanatomyofappendicitis.AmSurg199460:68.
22.TakadaT,NishiwakiH,YamamotoY,etal.TheRoleofDigitalRectalExaminationforDiagnosisofAcute
Appendicitis:ASystematicReviewandMetaAnalysis.PLoSOne201510:e0136996.
23.McBurney,C.Experiencewithearlyoperativeinterferenceincasesofdiseaseofthevermiformappendix.
NYMedJ188950:676.
24.GolledgeJ,TomsAP,FranklinIJ,etal.Assessmentofperitonisminappendicitis.AnnRCollSurgEngl
199678:11.
25.AnderssonRE,HuganderAP,GhaziSH,etal.Diagnosticvalueofdiseasehistory,clinicalpresentation,and
inflammatoryparametersofappendicitis.WorldJSurg199923:133.
26.LaneR,GrabhamJ.Ausefulsignforthediagnosisofperitonealirritationintherightiliacfossa.AnnRColl
SurgEngl199779:128.
27.Rovsing,NT.IndirektesHervorrufendestypischenSchmerzesanMcBurney'sPunkt.EinBeitragzur
diagnostikderAppendicitisundTyphlitis.ZentralblattfrChirurgie,Leipzig,190734:1257.
28.IzbickiJR,KnoefelWT,WilkerDK,etal.Accuratediagnosisofacuteappendicitis:aretrospectiveand
prospectiveanalysisof686patients.EurJSurg1992158:227.
29.AlshehriMY,IbrahimA,AbuaishaN,etal.Valueofreboundtendernessinacuteappendicitis.EastAfrMed
J199572:504.
30.JahnH,MathiesenFK,NeckelmannK,etal.Comparisonofclinicaljudgmentanddiagnostic
ultrasonographyinthediagnosisofacuteappendicitis:experiencewithascoreaideddiagnosis.EurJSurg
1997163:433.
31.BerryJJr,MaltRA.Appendicitisnearitscentenary.AnnSurg1984200:567.
32.JohnH,NeffU,KelemenM.Appendicitisdiagnosistoday:clinicalandultrasonicdeductions.WorldJSurg
199317:243.
33.Silen,W.Cope'sEarlyDiagnosisoftheAcuteAbdomen,19thedition,OxfordUniversityPress1996.p.70.
34.ColemanC,ThompsonJEJr,BennionRS,SchmitPJ.Whitebloodcellcountisapoorpredictorofseverity
ofdiseaseinthediagnosisofappendicitis.AmSurg199864:983.
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35.TehraniHY,PetrosJG,KumarRR,ChuQ.Markersofsevereappendicitis.AmSurg199965:453.
36.ThompsonMM,UnderwoodMJ,DookeranKA,etal.RoleofsequentialleucocytecountsandCreactive
proteinmeasurementsinacuteappendicitis.BrJSurg199279:822.
37.GrnroosJM,GrnroosP.LeucocytecountandCreactiveproteininthediagnosisofacuteappendicitis.Br
JSurg199986:501.
38.BrJSurg199986:501.
39.GurayaSY,AlTuwaijriTA,KhairyGA,MurshidKR.Validityofleukocytecounttopredicttheseverityof
acuteappendicitis.SaudiMedJ200526:1945.
40.SandM,BecharaFG,HollandLetzT,etal.Diagnosticvalueofhyperbilirubinemiaasapredictivefactorfor
appendicealperforationinacuteappendicitis.AmJSurg2009198:193.
41.RaoPM,RheaJT,NovellineRA.SensitivityandspecificityoftheindividualCTsignsofappendicitis:
experiencewith200helicalappendicealCTexaminations.JComputAssistTomogr199721:686.
42.WhitleyS,SookurP,McLeanA,PowerN.TheappendixonCT.ClinRadiol200964:190.
43.ChoiD,ParkH,LeeYR,etal.Themostusefulfindingsfordiagnosingacuteappendicitisoncontrast
enhancedhelicalCT.ActaRadiol200344:574.
44.KesslerN,CytevalC,GallixB,etal.Appendicitis:evaluationofsensitivity,specificity,andpredictivevalues
ofUS,DopplerUS,andlaboratoryfindings.Radiology2004230:472.
45.JeffreyRBJr,LaingFC,TownsendRR.Acuteappendicitis:sonographiccriteriabasedon250cases.
Radiology1988167:327.
46.SpallutoLB,WoodfieldCA,DeBenedectisCM,LazarusE.MRimagingevaluationofabdominalpainduring
pregnancy:appendicitisandothernonobstetriccauses.Radiographics201232:317.
47.OtoA,ErnstRD,GhulmiyyahLM,etal.MRimaginginthetriageofpregnantpatientswithacuteabdominal
andpelvicpain.AbdomImaging200934:243.
48.PedrosaI,LevineD,EyvazzadehAD,etal.MRimagingevaluationofacuteappendicitisinpregnancy.
Radiology2006238:891.
49.LeeTH,KimJO,KimJJ,etal.AcaseofintussusceptedMeckel'sdiverticulum.WorldJGastroenterol2009
15:5109.
50.BanliO,KarakoyunR,AltunH.IleoilealintussusceptionduetoinvertedMeckel'sdiverticulum.ActaChir
Belg2009109:516.
Topic1386Version25.0

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GRAPHICS
Variationsinthepositionoftheappendix

Graphic64911Version2.0

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Bloodsupplytothecolonandrectum

ThebloodsupplytothecolonoriginatesfromtheSMAandtheIMA.TheSMAarises
approximately1cmbelowtheceliacarteryandrunsinferiorlytowardthececum,terminating
astheileocolicartery.TheSMAgivesrisetotheinferiorpancreaticoduodenalartery,several
jejunalandilealbranches,themiddlecolicartery,andtherightcolicartery.Asageneralrule,
themiddlecolicarteryarisesfromtheproximalSMAandsuppliesbloodtotheproximalto
midtransversecolon.However,itoccasionallyprovidesthepredominantbloodflowtothe
splenicflexure.Therightcolicarteryariseseitherfromacommontrunkwith,orjustbelow,
themiddlecolicartery,andsuppliesbloodtothemiddistalascendingcolon.Theileocolic
arterysuppliesbloodtothedistalileum,cecum,andproximalascendingcolon.
TheIMAarisesapproximately6to7cmbelowtheSMA.TheIMAgivesrisetotheleftcolic
arteryandsigmoidarteriescontinuingasthesuperiorrectal(hemorrhoidal)artery.Itis
largelyresponsibleforsupplyingblooddistaltothetransversecolon.
SMA:superiormesentericarteryIMA:inferiormesentericartery.
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CTscannormalappendix

CTscandepictsanormalappendix.Thefigureontheleftshowsanappendiceallumencontainingairand
wallthicknessof3mm(arrow).Thefigureontherightshowsthetipofthenormalappendix(arrowhead)
thatmeasures6mmandnoassociatedinduration.
CT:computedtomography.
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CTscanacuteappendicitis

TheCTscanwasobtainedusingoralandintravenouscontrastfromapatientwhopresentedwithright
lowerquadrantabdominalpain.Thesefiguresshowaninflammedappendixthatmeasures21mmin
diameterandcontainsanappendicolithandfluidthatislikelypurulent.
(A)Showsanappendicolithintheappendixusinganarrow.
(B)Showstheappendicolith,anoverlayoforangetoshowfluidinsidetheappendix,andayellowarrow
indicatesfreefluid.
(C)Showstheenlargedappendixandfluidwithoutanoverlay.
(D)Showsacoloredoverlay:redcircledepictstheenhancingappendicealwallorangedepictstheintra
appendicealfluidyellowdepictsthefreefluid.
CT:computedtomography.
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Normalappendixbyultrasoundimaging

Thegrayscaleultrasound(A,andmagnifiedinB)andDopplerimage(C)oftheappendixareprojectedin
thetransverseplane.ImagesAandBshowanormalappendixmeasuringalmost6mminmaximum
transversedimension(arrow).Theappendixwascompressibleandnohyperemiawasdemonstrated(arrow)
ontheDopplerimage(C).Thesefindingsareconsistentwithanormalappendixbyultrasound.
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Acuteappendicitisultrasound

Thepatientisa19yearoldfemalewhopresentedtotheemergencydepartmentwithrightlowerquadrant
pain.Thegrayscaleultrasoundoftheappendixisprojectedinthelongitudinal(A)andtransverseplanes
(B).Anoncompressibleappendixmeasuresalmost20mmindiameter,consistentwithadiagnosisofacute
appendicitis.Theechogenicmucosalandsubmucosalportionsofthewallhavebecomediscontinuous
(arrows)suggestingdisruptionasaresultofsloughing.Luminalair(arrowheads)resultsinposterior
shadowing.
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Appendicolithonabdominalfilms

Thisplainfilmoftheabdomenrevealsa1.2cmcalcificdensity,anappendicolith.
Thepatientpresentedwithrightlowerquadrantpainandwasdiagnosedwithacute
appendicitis.
Graphic83461Version1.0

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Magneticresonanceimageofappendicitisinpregnancy

T2weightedmagneticresonanceimageofawomanwithappendicitisat9weeks
ofgestation.Theappendixwasfluidfilledandmeasured7mm(arrow).The
gestationalsac(gs)isseenlowerinthepelvis.
CourtesyofDeborahLevine,MD.
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Tuboovarianabscess

Grossintraoperativephotographofalefttuboovarianabscessinapatientwith
pelvicinflammatorydisease.
CourtesyofMitchelHoffman,MD.
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Rupturedovariancyst

Computedtomography.Arrowsindicatefreebloodwithinperitonealcavity
surroundingliverandspleen.
CourtesyofWilliamJMann,Jr,MD.
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Adnexalmass

Computedtomography.Arrowindicatespoorlydefinedadnexalmass,whichatexploration
wasrupturedcorpusluteumcystandclot.
CourtesyofWilliamJMann,Jr,MD.
Graphic72345Version2.0

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Ovarianandtubaltorsiondemonstratingmarked
vascularengorgementaswellasincreasedsizeand
distension

Anatomywasrestoredandbothstructuresweresalvageddespitenonviable
appearance.
Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6thed,
EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,Philadelphia
2012.Copyright2012LippincottWilliams&Wilkins.www.lww.com.
Graphic72645Version14.0

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Tubaltorsiondemonstratingseveredistensionofthe
distaltube

Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6thed,Emans
SJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,Philadelphia2012.
Copyright2012LippincottWilliams&Wilkins.www.lww.com.
Graphic82480Version12.0

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Enlargedleftovaryfoundtorseduponlaparotomy
demonstratingadark,duskyappearancesecondaryto
venouslymphaticcongestioninthesettingofcontinued
arterialperfusion

Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6thed,
EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,Philadelphia
2012.Copyright2012LippincottWilliams&Wilkins.www.lww.com.
Graphic61891Version14.0

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Peritonealendometriosis

Theperitoneuminthiswomanwithendometriosisisstuddedwithreddish,
irregularlyshapedimplants.
Reprintedwithpermission.Copyright1990SyntexLaboratories,Inc.Allrights
reserved.
Graphic61500Version1.0

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ContributorDisclosures
RonaldFMartin,MD Nothingtodisclose MartinWeiser,MD Nothingtodisclose WenliangChen,MD,
PhD Nothingtodisclose
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providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconformto
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