Which of the following clinical manifestations would be the most suggestive of acute appendicitis?
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Last updated: April 25, 2022 Show
SummaryAcute appendicitis is the acute inflammation of the appendix, typically due to an obstruction of the appendiceal lumen. It is the most common cause of acute abdomen requiring emergency surgical intervention in both children and adults. The characteristic features of acute appendicitis are periumbilical abdominal pain that migrates to the right lower quadrant (RLQ), anorexia, nausea, fever, and RLQ tenderness. When seen alongside neutrophilic leukocytosis, these features are sufficient to make a clinical diagnosis using appendicitis scoring systems to estimate the likelihood of appendicitis. Imaging (e.g., abdominal CT with IV contrast, abdominal ultrasonography) may be considered if the clinical diagnosis is uncertain. The current standard of management of acute uncomplicated appendicitis is appendectomy within 24 hours of diagnosis (laparoscopic or open) and antibiotics. Emergency appendectomy is indicated for patients with systemic complications. Nonoperative management (NOM), which includes bowel rest, antibiotics, and analgesics, is indicated in patients with an inflammatory appendiceal mass (phlegmon) or an appendiceal abscess, because surgical intervention is associated with a higher risk of complications in these patient groups. Interval appendectomy 6–8 weeks following resolution of the acute episode may be considered in these patients to prevent a recurrence or if there is concern for an underlying appendiceal tumor. DefinitionEpidemiologyReferences:[2][3] Epidemiological data refers to the US, unless otherwise specified. EtiologyPathophysiologyClinical features
The location of the pain may be variable as the appendix's location varies, especially in pregnant women. [9] ManagementThe following recommendations apply to adult patients and are consistent with the 2020 World Society of Emergency Surgery (WSES) appendicitis guidelines, the 2018 American Association for the Surgery of Trauma (AAST) appendicitis guidelines, and the 2010 American College of Emergency Physicians (ACEP) clinical policy on acute appendicitis. See “Appendicitis in children” for information about pediatric patients. [10][11][12] Diagnostic imaging is often performed for most patients. A selective and individualized approach is generally recommended to minimize patient exposure to radiation and expedite care. [10][11][15][16] Low likelihood of appendicitisPatients > 60 years old with RLQ pain have a higher risk of serious underlying illness and should be evaluated thoroughly (e.g., with appropriate diagnostic imaging) irrespective of their appendicitis risk score. [14][18] Moderate likelihood of appendicitisHigh likelihood of appendicitis [19]
Risk stratification toolsDiagnosticsAcute appendicitis is usually a clinical diagnosis based on history, physical examination, and laboratory studies. Imaging is recommended if the clinical diagnosis is uncertain. Laboratory studies [9][10]
A normal WBC count does not rule out acute appendicitis. Imaging [9][10][13][19][27]Decisions regarding the optimal timing and initial imaging modality should be based on individual patient factors (e.g., demographics, likelihood of appendicitis, risk of alternate diagnoses of concern, comorbidities), available resources, and local specialist preferences and hospital policy. [10][11][15][16] The combined use of appendicitis risk scores and an initial ultrasound abdomen can reduce the need for CT abdomen in certain patients with suspected appendicitis, however, this should be balanced with the risk of missing the diagnosis. [11][16][17][28] Abdominal ultrasoundMany institutions prefer ultrasound as the initial imaging modality, reserving CT scans for inconclusive ultrasound findings. [11][27] While abdominal ultrasound can confirm the diagnosis of acute appendicitis, normal ultrasound findings do not reliably rule out appendicitis. [10] CT abdomen with IV contrastCT abdomen is the most accurate initial imaging modality for appendicitis. [10][12][27] MRI abdomen and pelvis [14][27][33]A normal MRI in a pregnant patient does not completely rule out the possibility of acute appendicitis. Consider diagnostic laparoscopy if clinical suspicion remains high. [11] TreatmentNonoperative managementAcute management checklistThis checklist is applicable to patients with confirmed acute appendicitis and those with a high likelihood of appendicitis according to any of the risk stratification tools for acute appendicitis.
Pathology
Differential diagnosesComplicationsPylephlebitis [57]
We list the most important complications. The selection is not exhaustive. PrognosisSpecial patient groupsThe diagnosis should not be based solely on the clinical score in children. [11] Individuals > 60 years of age have a higher risk of perforation! [14] Related One-Minute TelegramInterested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below. References
What is the clinical manifestation for acute appendicitis?Sudden pain that begins on the right side of the lower abdomen. Sudden pain that begins around your navel and often shifts to your lower right abdomen. Pain that worsens if you cough, walk or make other jarring movements. Nausea and vomiting.
What are the most predictive signs of acute appendicitis?Common Symptoms of Appendicitis
Anorexia, nausea and vomiting are symptoms that are commonly associated with acute appendicitis. The classic history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50 percent of patients.
What are the common clinical findings in a patient with appendicitis?The most specific physical findings in appendicitis are rebound tenderness, pain on percussion, rigidity, and guarding. Although RLQ tenderness is present in 96% of patients, this is a nonspecific finding.
What clinical manifestations represent the early symptoms of classic appendicitis?The classic symptoms of appendicitis include:. Pain in your lower right belly or pain near your navel that moves lower. This is usually the first sign.. Loss of appetite.. Nausea and vomiting soon after belly pain begins.. Swollen belly.. Fever of 99-102 F.. Can't pass gas.. |
