Signs and Symptoms
History
- Abdominal pain: Primary symptom
- Normal location:
- RLQ pain
- 35% of patients have appendix located within 5 cm of “normal” location
- Retrocecal appendix (28-68%):
- Back pain
- Flank pain
- Testicular pain
- Pelvic appendix (27-53%):
- Suprapubic pain
- Urinary or rectal symptoms
- Long appendix (<0.2%):
- Inflamed tip may cause pain in RUQ or LLQ
- Anorexia
- Vomiting
- Change in bowel habits: Diarrhea (33%), constipation (9-33%)
- Classic presentation (<75% adults):
- Initially periumbilical pain
- Anorexia (first symptom in 95%) and nausea
- Pain localizes to RLQ (1-12 hr after onset)
- Finally, vomiting and fever
Pediatric Considerations |
- Presentations often nonspecific and difficult to localize (<50% have classic presentation)
- Anorexia, vomiting, and diarrhea more common (half-eaten meal hours before complaints of pain may more accurately indicate duration of symptoms)
- Observe child before exam for subtle indicators of local inflammation:
- Limping gait
- Hesitation to move, climb, or jump
- Flexed right hip
|
Physical Exam
- Vital signs:
- Often normal
- Fever: Normal to mild elevation (<1°F) initially, increases with perforation
- Abdominal exam:
- Tenderness at McBurney point (1/3 of distance from right anterior iliac spine to umbilicus)
- Guarding:
- Voluntary guarding early owing to muscular resistance to palpation
- Involuntary guarding (rigidity) later as inflammation progresses and perforation occurs
- Rebound:
- Pain with any rapid movement of peritoneum (e.g., bumping stretcher)
- Specific signs (less useful in pediatrics):
- Rovsing sign: Pain in RLQ when palpating LLQ
- Psoas sign: Increased pain on extension of right hip with patient lying on her or his left side, owing to inflamed appendix touching iliopsoas muscle
- Obturator sign: Pain with passive internal rotation and flexion of right hip
- Rectal exam:
- Limited value: May localize tenderness/mass
- Pelvic exam:
- Important to differentiate gynecologic disease
- Vaginal discharge and /or adnexal tenderness or mass suggests gynecologic disease
- Cervical motion tenderness when present suggests PID, but can be seen in up to 25% of women with appendicitis
- Patient position:
- Supine or decubitus with legs (particularly the right) drawn up
- Prefer not to move
- Shuffling gait—known as “appy walk”
Pediatric Considerations |
| Almost all children have generalized abdominal tenderness with some rigidity |
Pregnancy Prophylaxis |
- Enlarging uterus displaces appendix upward and laterally
- Hyperemesis gravidarum and other nonsurgical causes of vomiting should not cause abdominal tenderness
|
Geriatric Considerations |
| Typical signs of peritonitis may be absent in elderly |
Essential Workup
- Suggestive history and physical exam sufficient to establish preoperative diagnosis and warrant surgical consultation
- Tests listed below may be used to assist in diagnosis
- Atypical cases: Repeat serial exams in conjunction with some of the tests listed below is effective, with decreased rates of negative appendectomies and no increase in rates of perforation
Diagnostic Tests & Interpretation
Lab
- CBC:
- WBC >10,000, with left shift (80%)
- Normal WBC does not exclude diagnosis
- C-reactive protein:
- Overall sensitivity 65-85%, specificity 35-85%
- May not be elevated early (<12 hr)
- Increased sensitivity with serial measurements
- Urinalysis:
- Generally normal
- Mild pyuria, bacteriuria, or hematuria (25-30%)
- Pyuria present if inflamed appendix lies near ureter or bladder
- Pregnancy test for females of child-bearing age
Imaging
- Unnecessary when diagnosis is clear
- Most helpful in female patients of childbearing age where diagnosis is often unclear
- Abdominal radiographs—not recommended
- US: Sensitivity 86-90%; specificity 85-95%:
- Noncompressible appendix 6 mm anteroposterior (AP) diameter
- Presence of appendicolith
- Periappendiceal fluid/mass
- Limited by obesity, bowel gas, retrocecal appendix, and operator
- Negative study of limited use
- CT: Sensitivity 94-100%; specificity 91-99%:
- Highest yield using oral contrast with focused appendiceal technique (5 mm cuts from 3 cm above cecum extending distally 12-15 cm)
- Fat strand ing (100%)
- Appendix 6 mm in diameter (93%)
- Focal cecal apical thickening
- Defines appendiceal masses (phlegmon vs. abscess)
- Best study for finding alternative diagnoses
- Nonvisualized appendix does not rule out appendicitis
- MRI: Sensitivity 90-100%, specificity 92-94%:
- Appendix 7 mm in diameter
- Periappendiceal fat strand ing
- Advantages: Lack of ionizing radiation, excellent safety profile of gadolinium contrast agents
- Disadvantages: High cost, limited availability, lengthy exam, lack of radiologist familiarity in appendicitis
- No gadolinium in early pregnancy (class C drug)
Pediatric Considerations |
| American College of Radiology recommends US followed by CT as needed for suspected appendicitis |
Diagnostic Procedures/Surgery
- Laparoscopy:
- Diagnostic and therapeutic use
- Gross pathology may be absent with positive microscopic findings
- Decreased risk of wound infections, decreased hospital LOS
- Open appendectomy
- Percutaneous drainage
Differential Diagnosis
- Gastroenteritis
- Meckel diverticulum
- Epiploic appendicitis
- Crohn disease
- Diverticulitis
- Volvulus
- Abdominal aortic aneurysm
- Intestinal obstruction
- UTI
- Pyelonephritis
- PID
- Ectopic pregnancy
- Ovarian cyst/torsion
- Tubo-ovarian abscess
- Endometriosis
- Renal stone
- Testicular torsion
- Mesenteric adenitis
- Henoch-Schönlein purpura
- Diabetic ketoacidosis
- Streptococcal pharyngitis (children)
- Biliary disease
Initial Stabilization/Therapy
- Airway, breathing, and circulation management (ABCs)
- Fluid resuscitation with LR or 0.9% NS
ED Treatment/Procedures
- IV fluids, correct electrolyte abnormalities
- Immediate surgical consult for convincing history and physical exam:
- Laparoscopic vs. open technique
- Negative appendectomy rate of 10% in males and 20% in females worldwide
- 5-10% in U.S. due to imaging, use of diagnostic laparoscopy
- Percutaneous drainage, IV antibiotics, bowel rest and possible interval appendectomy in 6-8 wk in appendiceal abscesses
- Perioperative antibiotics
- NPO
- Order CT if palpable mass is present in RLQ to define phlegmon versus abscess
- If diagnosis is uncertain, send serial labs, observe, and repeat exams (6-10% negative appendectomy rate with observation protocols)
- Analgesics:
- Administration of analgesics, including narcotics, does not adversely affect abdominal exam or mask pathology
Medication
- Ampicillin/sulbactam: 3 g (peds: 100-200 mg ampicillin/kg/24 hr) IV q6h
- Cefoxitin: 2 g (peds: 80-100 mg/kg/24 hr) IV q6h
- Ceftriaxone: 1 g (peds: 50-100 mg/kg) IV q24h
- Ciprofloxacin: 400 mg (peds: 20-40 mg/kg) IV q12h
- Ertapenem: 1 g IM/IV q24h
- Metronidazole: 500 mg (peds: 30-50 mg/kg/24 hr) IV q8-12h
- Morphine sulfate: 3-5 mg (peds: 0.1-0.2 mg/kg per dose q2-q4h) IV, titrated to effect
- Piperacillin/tazobactam: 3.375 g (peds: 150-300 mg/kg/d if <6 mo; 240-400 mg/kg/d if >6 mo) IV q6h
Disposition
Admission Criteria
- Surgical intervention of acute appendicitis
- Observation or further diagnostic workup if diagnosis is uncertain
Discharge Criteria
Patients with abdominal pain thought not to be appendicitis may be discharged if they meet the following criteria:
- Resolved or resolving symptoms
- Minimal or no abdominal tenderness
- No lab/radiologic abnormalities
- Able to tolerate PO intake
- Adequate social support and able to return if symptoms worsen
Follow-up Recommendations
24-48 hr recheck for patients discharged from the ED with abdominal pain of unclear etiology
- BairdDL, SimillisC, KontovounisiosC, et al. Acute appendicitis . BMJ. 2017;357:j1703.
- BhanguA, SoreideK, Di SaverioS, et al. Acute appendicitis: modern understand ing of pathogenesis, diagnosis, and management . Lancet. 2015;386:1278-1287.
- DiSaverioS, BirindelliA, KellyMD, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis . World J Emerg Surg. 2016;11:34.
- HarnossJC, ZelienkaI, ProbstP, et al. Antibiotic versus surgical therapy for uncomplicated appendicitis: Systematic review and meta-analysis of controlled trials . Ann Surg. 2017;265(5):889-900.
- MarzuilloP, GermaniC. Appendicitis in children less than five years old: A challenge for the general practitioner . World J Clin Pediatr. 2015;4(2):19-24.
See Also (Topic, Algorithm, Electronic Media Element)
The authors gratefully acknowledge Jennifer L. Kolodchak for his contribution to the previous edition of this chapter.