This document provides an overview of acute appendicitis, including its definition, symptoms, diagnostic considerations, stages of progression, and treatment options. Key points include: - Acute appendicitis is characterized by inflammation of the vermiform appendix and is a surgical emergency. - The classic symptoms of abdominal pain migrating to the right lower quadrant occur in only 50% of cases. - Diagnostic tools include physical exam, blood tests like WBC and CRP, urinalysis, and imaging like CT, MRI, or ultrasound. - Appendicitis progresses from early to suppurative to gangrenous stages if not treated surgically. - Appendectomy remains the definitive treatment, and

1. ACUTE APPENDICITIS :
EASY TO DIAGNOSE
DR FADI JALLAD
CONSULTANT GENERAL SURGERY
MD,FACS

2. DEFINITION
• ACUTE APPENDICITIS: A
SURGICAL EMERGENCY
CHARACTERISED BY
SYMPTOMS DUE TO THE
INFLAMMATION OF THE
VERMIFORM APPENDIX.

3. HISTORY
• THE CLASSIC HISTORY OF ANOREXIA AND PERIUMBILICAL PAIN FOLLOWED BY
NAUSEA, (RLQ) PAIN, AND VOMITING OCCURS IN ONLY 50% OF CASES.
• NAUSEA (61-92%)
• ANOREXIA (74-78%)
• VOMITING OCCURS, IT NEARLY ALWAYS FOLLOWS THE ONSET OF PAIN
• MIGRATING PAIN (SENSITIVITY AND SPECIFICITY OF 80%).

4. EXAMINATION
• USUALLY LIE DOWN, FLEX THEIR
HIPS, AND DRAW THEIR KNEES UP TO
REDUCE MOVEMENTS AND TO AVOID
WORSENING THEIR PAIN.
• LATER, A WORSENING PROGRESSIVE
PAIN ALONG WITH VOMITING,
NAUSEA, AND ANOREXIA ARE
DESCRIBED BY THE PATIENT.

5. DURATION OF SYMPTOMS
• DURATION OF SYMPTOMS IS LESS THAN 48 HOURS IN
APPROXIMATELY 80% OF ADULTS
• LONGER IN ELDERLY PERSONS AND IN THOSE WITH
PERFORATION.
• 2% OF PATIENTS REPORT DURATION OF PAIN IN
EXCESS OF 2 WEEKS

6. NON CLASSICAL PRESENTATION
• AN INFLAMED APPENDIX NEAR THE URINARY
BLADDER OR URETER CAN CAUSE IRRITATIVE
VOIDING SYMPTOMS AND HEMATURIA OR
PYURIA.
• CONSIDER THE POSSIBILITY OF AN INFLAMED
PELVIC APPENDIX IN MALE PATIENTS WITH
APPARENT CYSTITIS.
• CONSIDER THE POSSIBILITY OF
APPENDICITIS IN PEDIATRIC OR ADULT
PATIENTS WHO PRESENT WITH ACUTE
URINARY RETENTION.

7. EXAMINATION
• MCBURNEY POINT IN ONLY 4% OF PATIENTS
 36% THE BASE WAS WITHIN 3 CM OF THE POINT;
 28% IT WAS 3-5 CM FROM THAT POINT
 36% THE BASE OF THE APPENDIX WAS MORE THAN 5 CM
FROM THE MCBURNEY POINT. *
• REBOUND TENDERNESS, PAIN ON PERCUSSION, RIGIDITY,
AND GUARDING.
• RLQ TENDERNESS IS PRESENT IN 96% OF PATIENTS, THIS IS A
NONSPECIFIC FINDING.
• (LLQ) TENDERNESS HAS BEEN THE MAJOR MANIFESTATION IN
PATIENTS WITH SITUS INVERSUS OR IN PATIENTS WITH A
LENGTHY APPENDIX THAT EXTENDS INTO THE LLQ.
• OTO A, ERNST RD, MILESKI WJ, NISHINO TK, LE O, WOLFE GC, ET AL. LOCALIZATION OF APPENDIX WITH MDCT AND
INFLUENCE OF FINDINGS ON CHOICE OF APPENDECTOMY INCISION. AJR AM J ROENTGENOL. 2006 OCT. 187(4):987-90

8. ACCESSORY SIGNS
• THE ROVSING SIGN
• THE OBTURATOR SIGN (RLQ PAIN WITH
INTERNAL AND EXTERNAL ROTATION
OF THE FLEXED RIGHT HIP) SUGGESTS
THAT THE INFLAMED APPENDIX IS
LOCATED DEEP IN THE RIGHT
HEMIPELVIS.
• THE PSOAS SIGN
• THE DUNPHY SIGN (SHARP PAIN IN THE
RLQ ELICITED BY A VOLUNTARY
COUGH)
• THE MARKLE SIGN, PAIN ELICITED IN A
CERTAIN AREA OF THE ABDOMEN
WHEN THE STANDING PATIENT DROPS
FROM STANDING ON TOES TO THE
HEELS WITH A JARRING LANDING,

9. ALVARADO SCORE
• ACUTE APPENDICITIS: DIAGNOSTIC ACCURACY OF
ALVARADO SCORING SYSTEM
• ASIAN J SURG. 2013 OCT;36(4):144-9. DOI: 10.1016/J.ASJSUR.2013.04.004. EPUB 2013 MAY
28.MEMON ZA1, IRFAN S, FATIMA K, IQBAL MS, SAMI W.
• CONCLUSION: ALVARADO SCORE CAN BE USED
EFFECTIVELY IN OUR SETUP TO REDUCE THE
INCIDENCE OF NEGATIVE APPENDECTOMIES.
HOWEVER, ITS ROLE IN FEMALES WAS NOT
SATISFACTORY
• SCHNEIDER ET AL CONCLUDED THAT THE MANTRELS
SCORE WAS NOT SUFFICIENTLY ACCURATE TO BE
USED AS THE SOLE METHOD FOR DETERMINING THE
NEED FOR APPENDECTOMY IN THE PEDIATRIC
POPULATIONS
CHNEIDER C, KHARBANDA A, BACHUR R. EVALUATING APPENDICITIS SCORING SYSTEMS USING A
PROSPECTIVE PEDIATRIC COHORT. ANN EMERG MED. 2007 JUN. 49(6):778-84, 784.E1.

10. STAGES OF APPENDICITIS
• EARLY STAGE APPENDICITIS:
OBSTRUCTION OF THE APPENDICEAL LUMEN LEADS TO
MUCOSAL EDEMA, MUCOSAL ULCERATION, BACTERIAL
DIAPEDESIS, APPENDICEAL DISTENTION DUE TO
ACCUMULATED FLUID, AND INCREASING INTRALUMINAL
PRESSURE. THE VISCERAL AFFERENT NERVE FIBERS ARE
STIMULATED, AND THE PATIENT PERCEIVES MILD VISCERAL
PERIUMBILICAL OR EPIGASTRIC PAIN, WHICH USUALLY LASTS
4-6 HOURS.
• SUPPURATIVE APPENDICITIS:
 INCREASING INTRALUMINAL PRESSURES EVENTUALLY
EXCEED CAPILLARY PERFUSION PRESSURE, WHICH IS
ASSOCIATED WITH OBSTRUCTED LYMPHATIC AND VENOUS
DRAINAGE AND ALLOWS BACTERIAL AND INFLAMMATORY
FLUID INVASION OF THE TENSE APPENDICEAL WALL.
 TRANSMURAL SPREAD OF BACTERIA CAUSES ACUTE
SUPPURATIVE APPENDICITIS. WHEN THE INFLAMED SEROSA
OF THE APPENDIX COMES IN CONTACT WITH THE PARIETAL
PERITONEUM, PATIENTS TYPICALLY EXPERIENCE THE

11. • GANGRENOUS APPENDICITIS
INTRAMURAL VENOUS AND ARTERIAL THROMBOSIS
• PERFORATED APPENDICITIS.
• PHLEGMONOUS APPENDICITIS OR ABSCESS
• SPONTANEOUSLY RESOLVING APPENDICITIS IF THE
OBSTRUCTION OF THE APPENDICEAL LUMEN IS RELIEVED,
ACUTE APPENDICITIS MAY RESOLVE SPONTANEOUSLY.
( LYMPHOID HYPERPLASIA OR WHEN A FECALITH IS
EXPELLED FROM THE LUMEN)
• RECURRENT APPENDICITIS
 10%.
 THE DIAGNOSIS IS ACCEPTED AS SUCH IF THE PATIENT
UNDERWENT SIMILAR OCCURRENCES OF RLQ PAIN AT
DIFFERENT TIMES THAT, AFTER APPENDECTOMY, WERE
HISTOPATHOLOGICALLY PROVEN TO BE THE RESULT OF
AN INFLAMED APPENDIX.

12. CHRONIC APPENDICITIS
• INCIDENCE OF 1%
• DEFINED BY THE FOLLOWING:
(1) THE PATIENT HAS A HISTORY OF RLQ PAIN OF AT LEAST 3 WEEKS’ DURATION
WITHOUT AN ALTERNATIVE DIAGNOSIS.
(2) AFTER APPENDECTOMY, THE PATIENT EXPERIENCES COMPLETE RELIEF OF
SYMPTOMS.
(3) HISTOPATHOLOGICALLY, THE SYMPTOMS WERE PROVEN TO BE THE RESULT
OF CHRONIC ACTIVE INFLAMMATION OF THE APPENDICEAL WALL OR FIBROSIS
OF THE APPENDIX.

13. DIAGNOSTIC CONSIDERATIONS
• THE OVERALL ACCURACY FOR DIAGNOSING ACUTE APPENDICITIS IS
APPROXIMATELY 80%,
• MEAN NEGATIVE APPENDECTOMY RATE OF 20%.
• DIAGNOSTIC ACCURACY VARIES BY SEX, WITH A RANGE OF
 78-92% IN MALE PATIENTS
 58-85% IN FEMALE PATIENTS
• THE CLASSIC HISTORY OCCURS IN ONLY 50% OF CASES
• APPENDICITIS IN PATIENTS OLDER THAN 60 YEARS ACCOUNTS FOR 10% OF ALL
APPENDECTOMIES.

15. WBC
• 80-85% : (WBC) COUNT GREATER THAN 10,500 CELLS.
• NEUTROPHILIA GREATER THAN 75% OCCURS IN 78% OF
PATIENTS.
• LESS THAN 4% OF PATIENTS WITH APPENDICITIS HAVE A WBC
COUNT LESS THAN 10,500 CELLS AND NEUTROPHILIA LESS THAN
75%.

16. C-REACTIVE PROTEIN
• CRP LEVELS OF GREATER THAN 1 MG/DL ARE COMMONLY REPORTED IN
PATIENTS WITH APPENDICITIS,
• VERY HIGH LEVELS OF CRP IN PATIENTS WITH APPENDICITIS INDICATE
GANGRENOUS EVOLUTION OF THE DISEASE, ESPECIALLY IF IT IS ASSOCIATED
WITH LEUKOCYTOSIS AND NEUTROPHILIA.
• CRP NORMALIZATION OCCURS 12 HOURS AFTER ONSET OF SYMPTOMS.
• THIMSEN ET AL NOTED THAT A NORMAL CRP LEVEL AFTER 12 HOURS OF
SYMPTOMS WAS 100% PREDICTIVE OF BENIGN, SELF-LIMITED ILLNESS
THIMSEN DA, TONG GK, GRUENBERG JC. PROSPECTIVE EVALUATION OF C-REACTIVE PROTEIN IN PATIENTS SUSPECTED TO HAVE ACUTE
APPENDICITIS. AM SURG. 1989 JUL. 55(7):466-8.

17. URINALYSIS AND URINARY 5-HIAA
• MILD PYURIA MAY OCCUR
• SEVERE PYURIA IS A MORE COMMON FINDING IN URINARY TRACT INFECTIONS
(UTIS)
• BOLANDPARVAZ ET AL, MEASUREMENT OF THE URINARY 5-
HYDROXYINDOLEACETIC ACID (U-5-HIAA) LEVELS COULD BE AN EARLY
MARKER OF APPENDICITIS
BOLANDPARVAZ S, VASEI M, OWJI AA, ATA-EE N, AMIN A, DANESHBOD Y, ET AL. URINARY 5-HYDROXY INDOLE ACETIC ACID AS A TEST FOR EARLY DIAGNOSIS OF
ACUTE APPENDICITIS. CLIN BIOCHEM. 2004 NOV. 37(11):985-9.

18. COMPUTED TOMOGRAPHY SCANNING
• A LARGE, SINGLE CENTER STUDY FOUND THAT CT
HAS A HIGH RATE OF SENSITIVITY AND
SPECIFICITY (98.5% AND 98%).
PICKHARDT PJ, LAWRENCE EM, POOLER BD, BRUCE RJ. DIAGNOSTIC PERFORMANCE OF MULTIDETECTOR
COMPUTED TOMOGRAPHY FOR SUSPECTED ACUTE APPENDICITIS. ANN INTERN MED. 2011 JUN 21.
154(12):789-96
• LOW-DOSE ABDOMINAL CT ALLOWS FOR A 78%
REDUCTION IN RADIATION EXPOSURE COMPARED
TO TRADITIONAL ABDOMINOPELVIC CT AND MAY BE
PREFERABLE FOR DIAGNOSING CHILDREN AND
YOUNG ADULTS.
KIM K, KIM YH, KIM SY, KIM S, LEE YJ, KIM KP, ET AL. LOW-DOSE ABDOMINAL CT FOR EVALUATING
SUSPECTED APPENDICITIS. N ENGL J MED. 2012 APR 26. 366(17):1596-605

19. ULTRASONOGRAPHY
• TYPICALLY DEMONSTRATES A NO
COMPRESSIBLE TUBULAR
STRUCTURE OF 7-9 MM IN
DIAMETER

20. MAGNETIC RESONANCE IMAGING
• THE LACK OF IONIZING RADIATION MAKES IT
AN ATTRACTIVE MODALITY IN PREGNANT
PATIENTS.
• COBBEN ET AL SHOWED THAT MRI IS FAR
SUPERIOR TO TRANSABDOMINAL
ULTRASONOGRAPHY IN EVALUATING
PREGNANT PATIENTS WITH SUSPECTED
APPENDICITIS.
• COBBEN LP, GROOT I, HAANS L, BLICKMAN JG, PUYLAERT J. MRI FOR CLINICALLY SUSPECTED
APPENDICITIS DURING PREGNANCY. AJR AM J ROENTGENOL. 2004 SEP. 183(3):671-5.
• THE SENSITIVITY AND SPECIFICITY OF MRI
FOR APPENDICITIS APPEARS TO BE SIMILAR TO
THOSE OF COMPUTED TOMOGRAPHY (CT)
SCANNING
REPPLINGER MD, LEVY JF, PEETHUMNONGSIN E, ET AL. SYSTEMATIC REVIEW AND META-ANALYSIS OF THE
ACCURACY OF MRI TO DIAGNOSE APPENDICITIS IN THE GENERAL POPULATION. J MAGN RESON IMAGING.

21. MANAGEMENT
• APPENDECTOMY REMAINS
THE ONLY CURATIVE
TREATMENT OF
APPENDICITIS
• CONTROVERSIES EXIST
OVER THE NONOPERATIVE
MANAGEMENT OF ACUTE
APPENDICITIS.

22. URGENT VERSUS EMERGENT
APPENDECTOMY
• A RETROSPECTIVE STUDY SUGGESTED THAT THE RISK OF APPENDICEAL
RUPTURE IS MINIMAL IN PATIENTS WITH LESS THAN 24-36 HOURS OF
UNTREATED SYMPTOMS
BICKELL NA, AUFSES AH JR, ROJAS M, BODIAN C. HOW TIME AFFECTS THE RISK OF RUPTURE IN APPENDICITIS. J AM COLL SURG. 2006 MAR. 202(3):401-6
• RETROSPECTIVE STUDY SUGGESTED THAT APPENDECTOMY WITHIN 12-24
HOURS OF PRESENTATION IS NOT ASSOCIATED WITH AN INCREASE IN
HOSPITAL LENGTH OF STAY, OPERATIVE TIME, ADVANCED STAGES OF
APPENDICITIS, OR COMPLICATIONS COMPARED WITH APPENDECTOMY
PERFORMED WITHIN 12 HOURS OF PRESENTATION.
ABOU-NUKTA F, BAKHOS C, ARROYO K, KOO Y, MARTIN J, REINHOLD R, ET AL. EFFECTS OF DELAYING APPENDECTOMY FOR ACUTE APPENDICITIS
FOR 12 TO 24 HOURS. ARCH SURG. 2006 MAY. 141(5):504-6; DISCUSSION 506-7

23. LAPAROSCOPIC APPENDECTOMY
• ACCORDING TO THE 2010 SOCIETY OF AMERICAN GASTROINTESTINAL AND
ENDOSCOPIC SURGEONS (SAGES) GUIDELINE, THE INDICATIONS FOR
LAPAROSCOPIC APPENDECTOMY ARE IDENTICAL TO THOSE FOR OPEN
APPENDECTOMY.
THE 2010 SAGES GUIDELINE LISTS THE FOLLOWING CONDITIONS AS SUITABLE
FOR LAPAROSCOPIC APPENDECTOMY
 UNCOMPLICATED APPENDICITIS
 APPENDICITIS IN PEDIATRIC PATIENTS
 SUSPECTED APPENDICITIS IN PREGNANT WOMEN
ACCORDING TO THE SAGES GUIDELINE, LAPAROSCOPIC APPENDECTOMY MAY
BE THE PREFERRED APPROACH IN THE FOLLOWING CASES
 PERFORATED APPENDICITIS
 APPENDICITIS IN ELDERLY PATIENTS
 APPENDICITIS IN OBESE PATIENTS
[GUIDELINE] KORNDORFFER JR JR, FELLINGER E, REED W. SAGES GUIDELINE FOR LAPAROSCOPIC APPENDECTOMY. SURG ENDOSC. 2010 APR. 24(4):757-61.