Last updated: April 25, 2022
Summary
Acute 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.
Definition
Epidemiology
References:[2][3]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
Pathophysiology
Clinical features
- Migrating abdominal
pain: most common and specific symptom
- Typically constant and rapidly worsens
- Most patients present within 48 hours of symptom onset.
- Initial diffuse periumbilical pain; : caused by the irritation of the visceral peritoneum [pain is referred to T8–T10 dermatomes] [6]
- Localizes to the RLQ within ∼ 12–24 hours; : caused by the irritation of the parietal peritoneum
- Associated nonspecific symptoms
- Nausea
- Anorexia
- Vomiting
- Low-grade fever
- Diarrhea
- Constipation
-
Clinical signs of appendicitis
- McBurney point tenderness [RLQ tenderness]
- RLQ guarding and/or rigidity
- Rebound tenderness [Blumberg sign], especially in the RLQ
- Rovsing sign: RLQ pain elicited on deep palpation of the LLQ [8]
- Psoas sign: can be performed in two different ways
- Obturator sign: RLQ pain on passive internal rotation of the right hip with the hip and knee flexed
- Hyperesthesia within Sherren triangle: formed by the anterior superior iliac spine, umbilicus, and symphysis pubis
- Lanz point tenderness: at the junction of the right third and left two-thirds of a line connecting both the anterior superior iliac spines
- Pain in the Pouch of Douglas: pain elicited by palpating the rectouterine pouch on rectal examination
- Baldwin sign: pain in the flank when flexing the right hip [suggests an inflamed retrocecal appendix]
The location of the pain may be variable as the appendix's location varies, especially in pregnant women. [9]
Management
The 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 appendicitis
Patients > 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 appendicitis
High likelihood of appendicitis [19]
- Associated scores: AIR score ≥ 9, Alvarado score ≥ 7–9
- Management: Urgent surgical consult for admission and definitive treatment required
- Begin empiric antibiotic therapy for acute appendicitis.
- Arrange preoperative CT abdomen as needed [e.g., for patients > 40 years old]. [11]
- Next steps
- Laparoscopic appendectomy within 24 hours for uncomplicated appendicitis [no signs of sepsis or complicated appendicitis]
- Emergency appendectomy for complicated appendicitis with systemic manifestations [e.g., generalized peritonitis or sepsis]
- Nonoperative management of
appendicitis
- Recommended for complicated appendicitis with an appendiceal phelgmon or appendiceal abscess
- Consider in select patients who present with early uncomplicated appendicitis in close consultation with a surgeon.
Risk stratification tools
Diagnostics
Acute 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]
- Routine
studies
- CBC: mild leukocytosis with left shift
- CRP: elevated [> 10 mg/L] [10]
- BMP: ↑ creatinine, electrolyte abnormalities may be present in patients with severe vomiting and diarrhea
- Urinalysis: typically normal in appendicitis; possible findings of mild pyuria and/or hematuria
- Tests to evaluate differential diagnoses
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 ultrasound
Many 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 contrast
CT 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]
Treatment
Nonoperative management
Acute management checklist
This 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.
- Urgent general surgery consult for consideration of appendectomy or nonoperative management [NOM]
- NPO
- IV fluid therapy
- Electrolyte repletion
- Parenteral analgesics [see “Pain management”] [53]
- Parenteral antiemetics as needed [see “Antiemetics”]
- Consider nasogastric tube insertion.
- Empiric antibiotic therapy for acute appendicitis
- Transfer to OR or admit to surgical ward
for definitive management.
- Emergency appendectomy
- Perforated appendicitis with signs of generalized peritonitis
- Septic shock
- Appendectomy within 24 hours: Uncomplicated appendicitis
- NOM
- Appendiceal mass
- Appendiceal abscess: percutaneous drainage if abscess > 4 cm
- Emergency appendectomy
Pathology
- The appendix is composed of the same four histological layers of the alimentary canal.
- See “Microscopic anatomy” in “Large intestine” for the histological features of a healthy appendix.
- Transmural neutrophilic infiltration is the characteristic histological feature of acute appendicitis.
- Blood vessel thrombosis, mucosal ulceration, and/or gangrene of the appendiceal wall may also be present.
Differential diagnoses
Complications
Pylephlebitis [57]
- Description: septic thrombosis of the portal vein or its branches
- Etiology: : a complication of intraabdominal sepsis [e.g., due to perforated appendicitis, diverticulitis, or necrotizing pancreatitis]
- Clinical features: fever, abdominal pain
- Diagnostics
- CT: filling defect in the portal vein or its branches
- Bacteremia
- Treatment: broad-spectrum antibiotics
- Prognosis: Thrombosis of the portal circulation can result in bowel infarction and death.
We list the most important complications. The selection is not exhaustive.
Prognosis
Special patient groups
The 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]
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