Highlights & Basics
- Acute appendicitis typically presents as acute abdominal pain starting in the mid-abdomen and later localizing to the right lower quadrant.
- Associated with fever, anorexia, nausea, vomiting, and elevation of the neutrophil count.
- Diagnosis is usually made clinically. If investigation is required, computed tomography scan or ultrasonography may show dilatation of the appendix outer diameter to more than 6 mm.
- Definitive treatment is surgical appendectomy. A nonoperative, antibiotic-only approach may be feasible in select patient populations.
Quick Reference
History & Exam
Key Factors
abdominal pain
anorexia
nausea and vomiting
right lower quadrant tenderness
tense rigid abdomen
hypotension and tachycardia
palpable mass
Other Factors
age of occurrence
fever
flushed face and a fetor
diminished bowel sounds
tachycardia
loose stool
constipation
Rovsing sign
psoas sign
obturator sign
Diagnostics Tests
1st Tests to Order
CBC
CRP
abdominal and pelvic CT scan
Other Tests to consider
abdominal ultrasound
urinalysis
urinary pregnancy test
abdominal and pelvic MRI in pregnancy
Emerging Tests
Neutrophil-to-lymphocyte ratio
serum sodium
pentraxin-3
serum amyloid A
platelet indices
Treatment Options
acute
uncomplicated acute appendicitis
appendectomy + supportive care
intravenous antibiotic therapy
antibiotic-only therapy
ill with perforation or abscess
ill with perforation or abscess
perforation
abscess
Definition
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Diagnostic Approach
History
- Retrocecal appendix may cause flank or back pain
- Retroileal appendix may cause testicular pain due to irritation of the spermatic artery or ureter
- Pelvic appendix may cause suprapubic pain
- A long appendix with tip inflammation in the left lower quadrant may cause pain to that region.
Physical exam
Investigations
Tests to exclude other causes
Novel biomarkers
- Neutrophil-to-lymphocyte ratio. The simple ratio between neutrophils and lymphocytes measured in peripheral blood has been shown to have moderate predictive power for acute appendicitis and may be a useful adjunctive tool for diagnosis.[56]
- Pentraxin 3.[59]
- Serum amyloid A. One systematic review and meta-analysis showed that serum amyloid A has a sensitivity and specificity for acute appendicitis of 0.87 and 0.74 respectively.[60]
Risk Factors
History & Exam
Tests
Differential Diagnosis
Differentiating Signs/Symptoms
- Usually presents in children with a recent history of upper respiratory infection.
- Pain in the abdomen is usually diffuse with tenderness not localized to the right lower quadrant.
- Guarding may be present, but rigidity is usually absent.
- Generalized lymphadenopathy may be noted.
Differentiating Tests
- There is no specific test to confirm the diagnosis.
- Relative lymphocytosis in WBC differential counts is suggestive.
- Negative ultrasound or CT findings help exclude other diagnoses.
Viral gastroenteritis
Differentiating Signs/Symptoms
- Common in children; caused by viruses, bacteria, or toxin.
- Characterized by profuse watery diarrhea, nausea, and vomiting.
- Crampy abdominal pain often precedes the diarrhea, and no localizing signs are present.
- If caused by typhoid fever, intestinal perforation may cause localized abdominal pain and/or generalized and rebound tenderness. In this scenario, associated maculopapular rash, inappropriate bradycardia, and leukopenia will differentiate from appendicitis.
Differentiating Tests
- No specific test unless due to typhoid (Salmonella typhi from stool or blood will confirm the diagnosis).
Meckel diverticulitis
Differentiating Signs/Symptoms
- Usually asymptomatic.
- Clinical presentation of diverticulitis is similar to acute appendicitis.
Differentiating Tests
- Technetium pertechnetate scan may show the enhancement of diverticulum if gastric mucosa is present.
Intussusception
Differentiating Signs/Symptoms
- Occurs in young children (age <2 years).
- Sudden onset of colicky pain; between episodes of pain the child is calm.
- A sausage-shaped mass may be palpable in the right lower quadrant.
Differentiating Tests
- Barium enema may demonstrate the intussusception with a coil-spring sign at the point of bowel invagination.
Crohn disease
Differentiating Signs/Symptoms
- Young adult with fever, nausea, vomiting, diarrhea, right lower quadrant pain, and localized tenderness.
Differentiating Tests
- CT scan may show intra-abdominal abscess.
- Contrast study of the small bowel and colon may show stricture or a series of ulcers and fissures (cobblestone appearance) of mucosa.
Peptic ulcer disease
Differentiating Signs/Symptoms
- May or may not have a history of peptic ulcer disease.
- Pain is abrupt, severe in intensity, and may be localized to right lower quadrant.
Differentiating Tests
- Erect chest x-ray and abdominal x-ray may show free air under the diaphragm
Right-sided ureteric stone
Differentiating Signs/Symptoms
- Pain is usually colicky in nature and severe in intensity. May be referred to the labia, scrotum, or penis and associated with hematuria.
- Fever usually absent.
Differentiating Tests
- Urinalysis positive for blood.
- Leukocytosis usually absent.
- Abdominal x-rays or tomogram may show calcified stone.
- Pyelography and CT scan without oral and intravenous contrast confirm the diagnosis.
Cholecystitis
Differentiating Signs/Symptoms
- Pain and tenderness are usually in the right upper quadrant. In one third of patients the gallbladder can be palpable.[68]
Differentiating Tests
- Abdominal ultrasound shows thick wall with pericholecystic collection, and tenderness is present over gallbladder area (Murphy sign).
- Hepatobiliary iminodiacetic acid scan will show nonvisualization of gallbladder at >4 hours.
Urinary tract infection
Differentiating Signs/Symptoms
- Pain and tenderness is usually in suprapubic area associated with burning micturition.
- Acute right-sided pyelonephritis may present with fever, chills, and tenderness at the right costovertebral angle.
Differentiating Tests
- Urine microscopy and culture confirm presence of bacteria.
Differentiating Signs/Symptoms
- Most patients present with abrupt abdominal pain, fever, distension, and rebound tenderness.
- History of advanced cirrhosis or nephrosis.
Differentiating Tests
- CT scan may show fluid in the abdomen.
- Peritoneal fluid shows >500/microliter count and >25% polymorphonuclear leukocytosis.
Pelvic inflammatory disease
Differentiating Signs/Symptoms
- Occurs in females usually aged between 20 and 40 years.
- Presents with bilateral lower quadrant tenderness, usually within 5 days of the last menstrual period.
- Purulent discharge from cervical os.
Differentiating Tests
- Endocervical swab may confirm the pelvic inflammatory disease due to Chlamydia trachomatis.[69]
Differentiating Signs/Symptoms
- Midmenstrual cycle, brief period of lower abdominal pain not usually associated with nausea and vomiting and fever.
- Tenderness is usually diffuse, not localized.
Differentiating Tests
- Clinical diagnosis. No investigation indicated.
Ectopic pregnancy
Differentiating Signs/Symptoms
- Female within childbearing age presents with missed menstrual period, right lower quadrant pain, or pelvic pain with some degree of vaginal bleeding or spotting. Cervical motion tenderness may be present on pelvic examination.
Differentiating Tests
- Human chorionic gonadotropin hormone level is high in serum and in urine.
- Ultrasound reveals presence of mass in fallopian tubes.
Ovarian torsion
Differentiating Signs/Symptoms
- Female with right lower quadrant pain. Occasionally presents with mass in the right lower quadrant.
Differentiating Tests
- Ultrasonography shows ovarian cyst and decreased blood flow.
Cecal diverticulitis
Differentiating Signs/Symptoms
Differentiating Tests
- CT has a sensitivity and specificity of 99% for the diagnosis of acute diverticulitis; it may show an inflamed diverticulum or contrast-filled mass surround by colonic wall thickening, inflammation of the pericolic fat, localized edema, free fluid or extraluminal air.[70]
Criteria
- The AIR score or the AAS can be used to determine whether a patient is at high, intermediate or low risk of having appendicitis.
- High-risk patients who are aged <40 years, and have strong symptoms and signs of appendicitis, may go straight to surgery without imaging. However, local protocols should be checked as this varies in practice.
- Intermediate-risk patients may undergo further imaging and observation.
- Low-risk patients may be safely discharged without diagnostic imaging, as long as they have appropriate safety-netting.
- Women, aged 16-49 years = 1 point.
- All other patients = 3 points.
- Mild = 2 points.
- Moderate or severe = 4 points.
- ≥7.2 and <10.9 = 1 point.
- ≥10.9 and <14.0 = 2 points.
- ≥14.0 = 3 points.
- ≥62 and <75 = 2 points.
- ≥75 and <83 = 3 points.
- ≥83= 4 points.
- ≥4 and <11 = 2 points.
- ≥11 and <25 = 3 points.
- ≥25 and <83 = 5 points.
- ⩾83 = 1 point.
- ≥12 and <53 = 2 points.
- ≥53 and <152 = 2 points.
- ≥152 = 1 point.
Treatment Approach
Uncomplicated presentation
Complicated presentation
Surgical options
Antibiotic-only therapy
Outpatient laparoscopic appendectomy
Treatment Options
uncomplicated acute appendicitis
appendectomy + supportive care
Comments
- Once the diagnosis of acute appendicitis is made, patients should be given nothing by mouth.
- Intravenous fluids should be started.
- Appendectomy should be performed without delay, as early appendectomy reduces the chances of perforation and intra-abdominal abscess.
- There are 2 operative options for appendectomy: open and laparoscopic. In adults, the choice of appendectomy generally depends upon the experience of the surgeon.
- In pregnant patients, laparoscopic appendectomy should be preferred to open appendectomy when surgery is indicated and where expertize of laparoscopy is available.[121] [122] It is safe in terms of risk of fetal loss and preterm delivery.[121] [122] Compared to open surgery during pregnancy, laparoscopic appendectomy is associated with shorter length of hospital stay and lower incidence of surgical site infection.[122] Laparoscopy is technically safe and feasible during pregnancy.[7][121] [122] [123]
- Some patients with uncomplicated appendicitis may be discharged safely after laparoscopic appendectomy without hospitalization, provided that an ambulatory pathway with well-defined ERAS (Enhanced Recovery After Surgery) protocols and patient information/consent are locally established.[7] [126] ERAS implementation after laparoscopic appendectomy carries similar rates of morbidity and readmissions compared with conventional care.[127] Its potential benefits include earlier recovery after surgery and lower hospital and social costs.[7]
- Patients with higher APACHE (Acute Physiology and Chronic Health Evaluation) scores seem to be at higher risk of development of postoperative complications.Image
intravenous antibiotic therapy
Primary Options
- cefoxitin
2 g intravenously as a single dose 30-60 minutes before surgery
- cefoxitin
Comments
- A single preoperative dose of broad-spectrum antibiotic such as cefoxitin should be given to patients with uncomplicated appendicitis undergoing appendectomy. Postoperative antibiotics are not indicated for these patients.[7]
antibiotic-only therapy
Comments
- Antibiotics alone for the treatment of uncomplicated appendicitis can be successful in selected patients who wish to avoid surgery, and who accept the risk of up to 39% recurrence.[83] In such cases, it is recommended that the diagnosis of uncomplicated appendicitis be confirmed by imaging, and that patient expectations be managed via a shared decision-making process.[7][93] [95] [125]
- A conservative approach should be avoided in pregnant patients.[7]
ill with perforation or abscess
intravenous antibiotic therapy + supportive care
Primary Options
- cefoxitin
1-2 g intravenously every 8 hours
- cefoxitin
- meropenem
1 g intravenously every 8 hours
- meropenem
Comments
- These patients have evidence of perforation, mass, or abscess.
- Initial management includes keeping the patient nothing by mouth and starting intravenous fluids. Patients who are in shock should be given a bolus of intravenous fluid to help maintain a stable pulse rate and blood pressure.[97] See Shock .
- Following on, maintenance intravenous fluids should be given until the condition of the patient improves and an oral diet can be tolerated.
- Intravenous antibiotics (e.g., cefoxitin or piperacillin/tazobactam) should be started immediately. For more severe infections, a carbapenem antibiotic may be used as a single agent. Combination antibiotic regimens may also be used based on local sensitivities and protocols.[21]
- Antibiotics should be continued until the patient becomes afebrile and leukocytosis is corrected.[7]
- Patients with higher APACHE (Acute Physiology and Chronic Health Evaluation) scores seem to be at higher risk of development of postoperative complication.
perforation
appendectomy
Comments
- There are 2 operative options for appendectomy: open and laparoscopic. In adults, the choice of appendectomy generally depends upon the experience of the surgeon.
- Studies have shown laparoscopic appendectomy to have better cosmetic results, shorter length of hospital stay, reduced postoperative pain, and reduced risk of wound infection, when compared with open appendectomy.[112]
- Laparoscopic appendectomy is recommended for complicated and perforated appendicitis.[114] [115] It is also considered the safest approach in obese patients.[116] In pregnant patients, laparoscopic appendectomy should be preferred to open appendectomy when surgery is indicated and where expertize of laparoscopy is available.[121] [122] It is technically feasible and is safe in terms of risk of fetal loss and preterm delivery.[121] [122] Compared to open surgery during pregnancy, laparoscopic appendectomy is associated with shorter length of hospital stay and lower incidence of surgical site infection.[7] [123] [129]
abscess
drainage ± interval appendectomy
Comments
- Abscess usually occurs as a progression of the disease process, particularly after perforation.
- Presents with tender right lower quadrant mass, swinging fever, and leukocytosis. Ultrasonography or computed tomography (CT) scan will show the abscess.
- Initial treatment includes intravenous antibiotics and CT-guided or operative drainage of the abscess.
- If there is clinical improvement and the signs and symptoms are completely resolved, interval appendectomy may be unnecessary.[7] [98] [99] [100] [101] Interval appendectomy should be performed if the symptoms do not completely resolve and/or symptoms recur.[7] [13] Interval appendectomy is also recommended in all patients over 30 years old with complicated appendicitis initially treated nonoperatively; in addition any patient ages ≥40 years with uncomplicated appendicitis who has conservative management without interval appendectomy should undergo screening with colonoscopy and interval full-dose contrast-enhanced CT scan since the incidence of appendicular neoplasms is high.[7] [102] Interval appendectomy can also be used to identify patients who have underlying appendiceal neoplasm; interval appendectomy may reduce the future risk of appendiceal neoplasm, particularly in the context of complicated appendicitis.[103] [104] The risk of appendiceal neoplasm in patients treated with nonoperative management of complicated appendicitis is 11%, increasing to 16% in patients ages 50 years and older and 43% in patients ages over 80 years.[102] [105][106]
- For patients with phlegmon or abscess, management remains subject to debate. Latest evidence suggests that laparoscopic appendectomy is associated with fewer readmissions and fewer additional interventions than conservative management, provided advanced laparoscopic expertize is available.[7] [107] However, nonoperative management with antibiotics and, if available, percutaneous image-guided drainage is a reasonable alternative if the patient is stable and laparoscopic appendectomy is unavailable, although there is a lack of evidence for its use on a routine basis.[7]
Emerging Tx
Eravacycline
Meropenem/vaborbactam
Imipenem/cilastatin/relebactam
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
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Key Articles
Referenced Articles
Guidelines
Diagnostic
Summary
Recommendations on the diagnosis and management of acute appendicitis.Published by
American College of Emergency Physicians
Published
2023
Summary
Computed tomography scan of the abdomen and pelvis with intravenous contrast is usually appropriate to evaluate for suspected appendicitis in patients with right lower quadrant pain with fever and leukocytosis.Published by
American College of Radiology
Published
2022
Summary
Computed tomography scan of the abdomen and pelvis with intravenous contrast is usually appropriate to evaluate for abdominal abscesses, as well as a broad range of additional pathologies, in the setting of nonlocalized abdominal pain and fever.Published by
American College of Radiology
Published
2018
Summary
Provides recommendations for diagnosing acute appendicitis based on best available evidence and expert opinion.Published by
European Association for Endoscopic Surgery
Published
2016
Summary
Provides evidence-based recommendations for diagnosing non-traumatic acute abdomen.Published by
Japanese Society for Abdominal Emergency Medicine; Japan Radiological Society; Japanese Society of Hepato-Biliary-Pancreatic Surgery; Japan Primary Care Association
Published
2016
Summary
A thorough, detailed history and physical examination is the most important component of the diagnostic evaluation of a child with fever without source, or with fever of unknown origin.Published by
American College of Radiology
Published
2015
Summary
Emergency laparoscopic investigation can be used diagnostically to identify and treat the cause of acute abdominal pain in a number of conditions, including appendicitis. This approach is indicated if routine, noninvasive diagnostic procedures have failed to yield results.Published by
European Association for Endoscopic Surgery
Published
2006
Treatment
Summary
A tool to help clinicians to consider the various differential diagnoses and to implement appropriate management in children presenting with abdominal pain.Published by
Starship Child Health
Published
2022
Summary
Recommendations for clinical practice in the management of adult appendicitis.Published by
French Society of Digestive Surgery
Published
2021
Summary
Laparoscopic appendectomy should represent the first choice where laparoscopic skills are available. Antibiotic therapy can be successful in selected patients with uncomplicated appendicitis who wish to avoid surgery.Published by
World Society of Emergency Surgery
Published
2020
Summary
A tool to help clinicians to consider the various differential diagnoses and to implement appropriate management in children presenting with abdominal pain.Published by
World Society of Emergency Surgery
Published
2019
Summary
Open and laparoscopic appendectomies are viable surgical approaches. Antibiotics alone may be useful to treat patients with early, nonperforated appendicitis.Published by
World Society of Emergency Surgery
Published
2017