Acute Appendicitis in Adults_ Clinical Manifestations and Differential Diagnosis

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16/05/2016 Acute appendicitis in adults: Clinical manifestations and differential diagnosis

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Official reprint from UpToDatewww.uptodate.com ©2016 UpToDate

Author Ronald F Martin, MD

Section Editor Martin Weiser, MD

Deputy Editor Wenliang Chen, MD, PhD

Acute appendicitis in adults: Clinical manifestations and differential diagnosis

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Apr 2016. | This topic last updated: Feb 05, 2016.

INTRODUCTION — Appendicitis, an inflammation of the vestigial vermiform appendix, is one of the most

common causes of the acute abdomen and one of the most frequent indications for an emergent abdominal

surgical procedure worldwide [1,2].

The clinical manifestations and diagnosis of appendicitis in adults will be reviewed here. The management of

appendicitis in adults and appendicitis in pregnancy and children are discussed separately. (See "Management

of acute appendicitis in adults" and "Acute appendicitis in pregnancy" and "Acute appendicitis in children:

Clinical manifestations and diagnosis".)

ANATOMY — The vermiform appendix is located at the base of the cecum, near the ileocecal valve where the

taenia coli converge on the cecum (figure 1) [3,4]. The appendix is a true diverticulum of the cecum. In contrast

to acquired diverticular disease, which consists of a protuberance of a subset of the enteric wall layers, the

appendiceal wall contains all of the layers of the colonic wall: mucosa, submucosa, muscularis (longitudinal

and circular), and the serosal covering [5].

The appendiceal orifice opens into the cecum. Its blood supply, the appendiceal artery, is a terminal branch of

the ileocolic artery, which traverses the length of the mesoappendix and terminates at the tip of the organ

(figure 2) [4].

The attachment of the appendix to the base of the cecum is constant. However, the tip may migrate to the

retrocecal, subcecal, preileal, postileal, and pelvic positions. These normal anatomic variations can complicate

the diagnosis as the site of pain and findings on the clinical examination will reflect the anatomic position of theappendix.

The presence of B and T lymphoid cells in the mucosa and submucosa of the lamina pro pria make the

appendix histologically distinct from the cecum [5]. These cells create a lymphoid pulp that aids immunologic

function by increasing lymphoid products such as IgA and operating as part of the gut-associ ated lymphoid

tissue system [3]. Lymphoid hyperplasia can cause obstruction of the appendix and lead to appendicitis. The

lymphoid tissue undergoes atrophy with age [6].

EPIDEMIOLOGY — Appendicitis occurs most frequently in the second and third decades of life. The incidence

is approximately 233/100,000 population and is highest in the 10 to 19 year-old age group [7]. It is also higher

among men (male to female ratio of 1.4:1), who have a lifetime incidence of 8.6 percent compared with 6.7percent for women [7].

PATHOGENESIS — The natural history of appendicitis is similar to that of other inflammatory processes

involving hollow visceral organs. Initial inflammation of the appendiceal wall is followed by localized ischemia,

perforation, and the development of a contained abscess or generalized peritonitis.

Appendiceal obstruction has been proposed as the primary cause of appendicitis [3,8-11]. Obstruction is

frequently implicated but not always identified. A study of patients with appendicitis showed that there was

elevated intraluminal pressure in only one-third of the patients with nonperforated appendicitis [ 12].

Appendiceal obstruction may be caused by fecaliths (hard fecal masses), calculi, lymphoid hyperplasia,

infectious processes, and benign or malignant tumors. However, some patients with a fecalith have a

histologically normal appendix and the majority of patients with appendicitis do not have a fecalith [ 13,14].

When obstruction of the appendix is the cause of appendicitis, the obstruction leads to an increase in luminal

and intramural pressure, resulting in thrombosis and occlusion of the small vessels in the appendiceal wall, and

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stasis of lymphatic flow. As the appendix becomes engorged, the visceral afferent nerve fibers entering the

spinal cord at T8-T10 are stimulated, leading to vague central or periumbilical abdominal pain [ 8]. Well-localized

pain occurs later in the course when inflammation involves the adjacent parietal peritoneum.

The mechanism of luminal obstruction varies depending upon the patient's age. In the young, lymphoid

follicular hyperplasia due to infection is thought to be the main cause. In older patients, luminal obstruction is

more likely to be caused by fibrosis, fecaliths, or neoplasia (carcinoid, adenocarcinoma, or mucocele). In

endemic areas, parasites can cause obstruction in any age group. (See "Cancer of the appendix and

pseudomyxoma peritonei".)

Once obstructed, the lumen becomes filled with mucus and distends, increasing luminal and intramural

pressure. This results in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. As

lymphatic and vascular compromise progress, the wall of the appendix becomes ischemic and then necrotic.

Bacterial overgrowth occurs within the diseased appendix. Aerobic organisms predominate early in the course,

while mixed infection is more common in late appendicitis [15]. Common organisms involved in gangrenous

and perforated appendicitis include Escherichia coli, Peptostreptococcus, Bacteroides fragilis, and

Pseudomonas species [16]. Intraluminal bacteria subsequently invade the appendiceal wall and further

propagate a neutrophilic exudate. The influx of neutrophils causes a fibropurulent reaction on the serosal

surface, irritating the surrounding parietal peritoneum [6]. This results in stimulation of somatic nerves, causing

pain at the site of peritoneal irritation [5].

During the first 24 hours after symptoms develop, approximately 90 percent of patients develop inflammation

and perhaps necrosis of the appendix, but not perforation. The type of luminal obstruction may be a predictor of

perforation of an acutely inflamed appendix. Fecaliths were six times more common than true calculi in the

appendix, but calculi were more often associated with perforated appendicitis or periappendiceal abscess (45

percent) than were fecaliths (19 percent). This is presumably due to the rigidity of true calculi as compared with

the softer, more crushable fecaliths [13].

Once significant inflammation and necrosis occur, the appendix is at risk of perforation, which leads to

localized abscess formation or diffuse peritonitis. The time course to perforation is variable. One study showed

that 20 percent of patients developed perforation less than 24 hours after the onset of symptoms [ 17]. Sixty-

five percent of patients in whom the appendix perforated had symptoms for longer than 48 hours.

CLINICAL FEATURES

Clinical manifestations

History — Abdominal pain is the most common symptom, and is reported in nearly all confirmed cases of

appendicitis [18,19]. The clinical presentation of acute appendicitis is described as a constellation of the

following classic symptoms:

In the classic presentation, the patient describes the onset of abdominal pain as the first symptom. The pain is

typically periumbilical in nature with subsequent migration to the right lower quadrant as the inflammation

progresses [18]. Although considered a classic symptom, migratory pain occurs only in 50 to 60 percent of

patients with appendicitis [8,20]. Nausea and vomiting, if they occur, usually follow the onset of pain. Fever-

related symptoms generally occur later in the course of illness.

In many patients, initial features are atypical or nonspecific, and can include:

Right lower quadrant (right anterior iliac fossa) abdominal pain●

Anorexia●

Nausea and vomiting●

Indigestion●Flatulence●

Bowel irregularity●

Diarrhea●

Generalized malaise●

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Because the early symptoms of appendicitis are often subtle, patients and clinicians may minimize their

importance. The symptoms of appendicitis vary depending upon the location of the tip of the appendix (figure 1)

(see 'Anatomy' above). For example, an inflamed anterior appendix produces marked, localized pain in the right

lower quadrant, while a retrocecal appendix may cause a dull abdominal ache [21]. The location of the pain

may also be atypical in patients who have the tip of the appendix located in the pelvis, which can cause

tenderness below McBurney's point. Such patients may complain of urinary frequency and dysuria or rectal

symptoms, such as tenesmus and diarrhea.

Physical examination — The early signs of appendicitis are often subtle. Low-grade fever reaching101.0°F (38.3°C) may be present. The physical examination may be unrevealing in the very early stages of

appendicitis since the visceral organs are not innervated with somatic pain fibers.

However, as the inflammation progresses, involvement of the overlying parietal peritoneum causes localized

tenderness in the right lower quadrant and can be detected on the abdominal examination. Rectal examination,

although often advocated, has not been shown to provide additional diagnostic information in cases of

appendicitis [22]. In women, right adnexal area tenderness may be present on pelvic examination, and

differentiating between tenderness of pelvic origin versus that of appendicitis may be challenging. High-grade

fever (>101.0°F/38.3°C) occurs as inflammation progresses. (See "Causes of abdominal pain in adults".)

Patients with a retrocecal appendix may not exhibit marked localized tenderness in the right lower quadrant

since the appendix does not come into contact with the anterior parietal peritoneum (figure 1) [21]. The rectal

and/or pelvic examination is more likely to elicit positive signs than the abdominal examination. Tenderness

may be more prominent on pelvic examination, and may be mistaken for adnexal tenderness.

Several findings on physical examination have been described to facilitate diagnosis, but these findings pre-

dated definitive imaging for appendicitis, and the wide variation in their sensitivity and specificity suggests that

they be used with caution to broaden, or narrow, a differential diagnosis. There are no physical findings, taken

alone or in concert, that definitively confirm a diagnosis of appendicitis.

Commonly described physical signs include:

Laboratory findings — A mild leukocytosis (white blood cell count >10,000 cells/microL) is present in most

patients with acute appendicitis [33]. Approximately 80 percent of patients have a leukocytosis and a left shift

(increase in total WBC count, bands [immature neutrophils], and neutrophils) in the differential [ 34-36]. The

sensitivity and specificity of an elevated white blood cell (WBC) count in acute appendicitis is 80 percent and

55 percent respectively.

Acute appendicitis is unlikely when the WBC count is normal, except in the very early course of the illness [36-

38]. In comparison, mean WBC counts are higher in patients with a gangrenous (necrotic) or perforated

McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus [23] (sensitivity 50 to 94

percent; specificity 75 to 86 percent [24-26]).

●

Rovsing's sign refers to pain in the right lower quadrant with palpation of the left lower quadrant. This sign

is also called indirect tenderness and is indicative of right-sided local peritoneal irritation [27] (sensitivity

22 to 68 percent; specificity 58 to 96 percent [ 25,28-30]).

●

The psoas sign is associated with a retrocecal appendix. This is manifested by right lower quadrant pain

with passive right hip extension. The inflamed appendix may lie against the right psoas muscle, causing

the patient to shorten the muscle by drawing up the right knee. Passive extension of the iliopsoas muscle

with hip extension causes right lower quadrant pain (sensitivity 13 to 42 percent; specificity 79 to 97percent [28,31,32]).

●

The obturator sign is associated with a pelvic appendix. This test is based on the principle that the

inflamed appendix may lay against the right obturator internus muscle. When the clinician flexes the

patient's right hip and knee followed by internal rotation of the right hip, this elicits right lower quadrant

pain, (sensitivity 8 percent; specificity 94 percent [31]). The sensitivity is low enough that experienced

clinicians no longer perform this assessment.

●

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appendix [39]:

Mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been noted to be a marker for appendiceal

perforation with a sensitivity of 70 percent and a specificity of 86 percent [40]. This compares favorably with a

sensitivity and specificity of an elevated WBC of 80 percent and 55 percent respectively.

Imaging studies

Computed tomography findings — The following findings suggest acute appendicitis on standard

abdominal computed tomography (CT) scanning with contrast including (image 1 and image 2) [41-43]:

Ultrasound findings — The most accurate ultrasound finding for acute appendicitis is an appendiceal

diameter of >6 mm (image 3 and image 4) [8,44,45].

Plain radiograph findings — Plain radiographs are usually not helpful for establishing the diagnosis of

appendicitis (image 5). However, the following radiographic findings have been associated with acute

appendicitis:

Magnetic resonance imaging — Magnetic resonance imaging (MRI) can assist with the evaluation of

acute abdominal and pelvic pain during pregnancy (image 6) [46,47]. A normal appendix is visualized as a

tubular structure less than or equal to 6 mm in diameter and filled with air and/or oral contrast material [48]. An

enlarged fluid-filled appendix (>7 mm in diameter) is considered an abnormal finding, while an appendix with a

diameter of 6 to 7 mm is considered an inconclusive finding [ 48]. (See "Approach to abdominal pain and the

acute abdomen in pregnant and postpartum women" and "Acute appendicitis in pregnancy".)

DIFFERENTIAL DIAGNOSIS — A variety of inflammatory and infectious conditions in the right lower quadrant can mimic the signs and symptoms of acute appendicitis. (See "Causes of abdominal pain in adults".)

Perforated appendix — During the first 24 hours after the onset of abdominal pain and associated symptoms,

approximately 90 percent of patients develop inflammation and perhaps necrosis of the appendix, but not

perforation. Once significant inflammation and necrosis occur, the appendix is at risk for perforation, which

leads to localized abscess formation or diffuse peritonitis. The time course to perforation is variable. One study

showed that 20 percent of patients developed perforation less than 24 hours after the onset of symptoms [ 17].

Sixty-five percent of patients in whom the appendix perforated had symptoms for longer than 48 hours.

A perforated appendix must be considered in a patient whose temperature exceeds 103.0°F (39.4°C), the WBC

count is greater than 15,000 cells/microL, and imaging studies reveal a fluid collection in the right lower quadrant. (See 'Pathogenesis' above and 'Laboratory findings' above and "Acute appendicitis in adults:

Diagnostic evaluation", section on 'Imaging' and 'Imaging studies' above.)

Cecal diverticulitis — Cecal diverticulitis usually occurs in young adults and presents with signs and

symptoms that can be virtually identical to those of acute appendicitis. Right-sided diverticulitis occurs in only

Acute − 14,500 ± 7,300 cells/microL●

Gangrenous − 17,100 ± 3,900 cells/microL●

Perforated − 17,900 ± 2,100 cells/microL (see 'Perforated appendix' below)●

Enlarged appendiceal diameter >6 mm with an occluded lumen●

Appendiceal wall thickening (>2 mm)●

Periappendiceal fat stranding●

Appendiceal wall enhancement●

Appendicolith (seen in approximately 25 percent of patients)●

Right lower quadrant appendicolith●

Localized right lower quadrant ileus●

Loss of the psoas shadow●

Free air (occasionally)●Deformity of cecal outline●

Right lower quadrant soft tissue density●

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1.5 percent of patients in Western countries, but is more common in Asian populations (accounting for as many

as 75 percent of cases of diverticulitis). Patients with right-sided diverticulitis tend to be younger than those

with left-sided disease and often are misdiagnosed with acute appendicitis. Computed tomographic (CT)

scanning of the abdomen with IV and oral contrast is the diagnostic test of choice in patients suspected of

having acute diverticulitis. (See "Clinical manifestations and diagnosis of acute diverticulitis in adults" and

"Nonoperative management of acute uncomplicated diverticulitis", section on 'Right-sided (cecal) diverticulitis' .)

Meckel's diverticulitis — Meckel's diverticulitis presents in a fashion similar to acute appendicitis. A Meckel's

diverticulum is a congenital remnant of the omphalomesenteric duct and is located on the small intestine twofeet from the ileocecal valve [49,50]. Meckel's diverticulitis should be included in the differential diagnosis, as

the small bowel may migrate into the right lower quadrant and mimic the symptoms of appendicitis. If an

inflamed appendix is not found on abdominal exploration for acute appendicitis, the surgeon should search for

an inflamed Meckel's diverticulum. (See "Meckel’s diverticulum", section on 'Clinical presentations'.)

Acute ileitis — Acute ileitis, due most commonly to an acute self-limited bacterial infection (Yersinia,

Campylobacter, Salmonella, and others), should be considered when acute diarrhea is a prominent symptom.

Other clinical manifestations of acute yersiniosis include abdominal pain, fever, nausea and/or vomiting.

Yersiniosis cannot be readily distinguished clinically from other causes of acute diarrhea that present with

these symptoms. However, localization of abdominal pain to the right lower quadrant along with acute diarrhea

may be a diagnostic clue for yersiniosis. (See "Clinical manifestations and diagnosis of Yersinia infections",section on 'Acute yersiniosis'.)

Acute yersiniosis presenting with right lower abdominal pain, fever, vomiting, leukocytosis, and understated

diarrhea may be confused with acute appendicitis. At surgery, findings include visible inflammation around the

appendix and terminal ileum and inflammation of the mesenteric lymph nodes; the appendix itself is generally

normal. Yersinia can be cultured from the appendix and involved lymph nodes. (See "Clinical manifestations

and diagnosis of Yersinia infections", section on 'Pseudoappendicitis'.)

Crohn's disease — Crohn's disease can present with symptoms similar to appendicitis, particularly when

localized to the distal ileum. Fatigue, prolonged diarrhea with abdominal pain, weight loss, and fever, with or

without gross bleeding, are the hallmarks of Crohn's disease. An acute exacerbation of Crohn’s disease canmimic acute appendicitis and may be indistinguishable by clinical evaluation and imaging.

Crohn's disease should be suspected in patients who have persistent pain after surgery, especially if the

appendix is histologically normal. (See "Clinical manifestations, diagnosis and prognosis of Crohn disease in

adults".)

Gynecologic and obstetrical conditions — The following gynecologic diseases may present with symptoms

and/or clinical findings that are included in the differential of acute appendicitis:

Tubo-ovarian abscess — A tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian

tube, ovary, and, occasionally, other adjacent pelvic organs (eg, bowel, bladder). These abscesses are found

most commonly in reproductive age women and typically result from upper genital tract infection. Tubo-ovarianabscess is usually a complication of pelvic inflammatory disease. The classic presentation includes acute

lower abdominal pain, fever, chills, and vaginal discharge. However, fever is not present in all patients, some

patients report only low-grade nocturnal fevers or chills, and not all women present in an acute fashion. Clinical

history and CT imaging can help differentiate TOA from acute appendicitis (picture 1). (See "Epidemiology,

clinical manifestations, and diagnosis of tuboovarian abscess", section on 'Clinical presentation' .)

Pelvic inflammatory disease — Lower abdominal pain is the cardinal presenting symptom in women with

pelvic inflammatory disease (PID), although the character of the pain may be quite subtle. The recent onset of

pain that worsens during coitus or with jarring movement may be the only presenting symptom of PID; the

onset of pain during or shortly after menses is particularly suggestive. On physical examination, only about

one-half of patients with PID have fever. Abdominal examination reveals diffuse tenderness greatest in the

lower quadrants, which may or may not be symmetrical. Rebound tenderness and decreased bowel sounds are

common. On pelvic examination, the finding of a purulent endocervical discharge and/or acute cervical motion

and adnexal tenderness with bimanual examination is strongly suggestive of PID. Clinical history and CT

imaging can help differentiate PID from acute appendicitis (See "Pelvic inflammatory disease: Clinical

http://www.uptodate.com/contents/pelvic-inflammatory-disease-clinical-manifestations-and-diagnosis?source=see_linkhttp://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-tuboovarian-abscess?source=see_link&sectionName=CLINICAL+PRESENTATION&anchor=H2672637#H2672637http://www.uptodate.com/contents/image?imageKey=PC%2F60914&topicKey=NEPH%2F828&rank=3%7E150&source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-prognosis-of-crohn-disease-in-adults?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-yersinia-infections?source=see_link&sectionName=Pseudoappendicitis&anchor=H89479916#H89479916http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-yersinia-infections?source=see_link&sectionName=Acute+yersiniosis&anchor=H89479838#H89479838http://www.uptodate.com/contents/meckels-diverticulum?source=see_link&sectionName=CLINICAL+PRESENTATIONS&anchor=H1124082204#H1124082204http://www.uptodate.com/contents/acute-appendicitis-in-adults-clinical-manifestations-and-differential-diagnosis/abstract/49,50http://www.uptodate.com/contents/nonoperative-management-of-acute-uncomplicated-diverticulitis?source=see_link&sectionName=Right-sided+%28cecal%29+diverticulitis&anchor=H432559362#H432559362http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-acute-diverticulitis-in-adults?source=see_link


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manifestations and diagnosis".)

Ruptured ovarian cyst — Rupture of an ovarian cyst is a common occurrence in women of reproductive

age and may be associated with the sudden onset of unilateral lower abdominal pain. The right lower quadrant

is most commonly affected, possibly because the rectosigmoid colon protects the left ovary from the effects of

abdominal trauma. The pain often begins during strenuous physical activity, such as exercise or sexual

intercourse, and may be accompanied by light vaginal bleeding due to a drop in secretion of ovarian hormones

and subsequent endometrial sloughing. Blood from the rupture site may seep into the ovary, which can cause

pain from stretching of the ovarian cortex, or it may flow into the abdomen, which has an irritant effect on theperitoneum. Serous or mucinous fluid released upon cyst rupture is not very irritating; the patient may remain

asymptomatic despite accumulation of a large volume of intraperitoneal fluid. On the other hand, spillage of

sebaceous material upon rupture of a dermoid cyst causes a marked granulomatous reaction and chemical

peritonitis, which is usually quite painful. Intraabdominal hemorrhage may be associated with Cullen's sign (ie,

periumbilical ecchymoses). Clinical history and CT imaging can help differentiate a ruptured ovarian cyst from

acute appendicitis (image 7 and image 8). (See "Evaluation and management of ruptured ovarian cyst".)

Mittelschmerz — Mittelschmerz refers to midcycle pain in an ovulatory woman caused by normal follicular

enlargement just prior to ovulation or to normal follicular bleeding at ovulation. The pain is typically mild and

unilateral; it occurs midway between menstrual periods and lasts for a few hours to a couple of days. Fluid or

blood is released from the ruptured egg follicle and can cause irritation of the lining of the abdominal wall. (See"Physiology of the normal menstrual cycle".)

Ovarian and fallopian tube torsion — Ovarian torsion refers to the twisting of the ovary on its

ligamentous supports, often resulting in impedance of its blood supply (picture 2). Isolated fallopian tube torsion

is uncommon (picture 3). Expedient diagnosis is important to preserve ovarian function and prevent adverse

sequelae. However, the diagnosis can be challenging because the symptoms are relatively nonspecific.

The most common symptom of ovarian torsion is sudden onset lower abdominal pain, often associated with

waves of nausea and vomiting. Fever, although an uncommon finding in ovarian torsion, may be a marker of

necrosis, particularly in the setting of an increased white blood cell count. Clinical history and CT imaging can

help differentiate the diagnosis from acute appendicitis (picture 4). (See "Ovarian and fallopian tube torsion".)

Endometriosis — Endometriosis is defined as the presence of endometrial glands and stroma at

extrauterine sites. These ectopic endometrial implants are usually located in the pelvis, but can occur nearly

anywhere in the body (picture 5).

Common symptoms of endometriosis include pelvic pain (which is usually chronic and often more severe

during menses or at ovulation), dysmenorrhea, deep dyspareunia, cyclical bowel or bladder symptoms,

abnormal menstrual bleeding, and infertility. There are often no abnormal findings on physical examination;

when findings are present, the most common is tenderness upon palpation of the posterior fornix. Ultrasound is

mostly useful for diagnosing ovarian endometriomas; it lacks adequate resolution for visualizing adhesions and

superficial peritoneal/ovarian implants, which are more common than endometriomas. (See "Endometriosis:

Pathogenesis, clinical features, and diagnosis".)

Ovarian hyperstimulation syndrome — Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic

complication of ovulation induction therapy, and may be accompanied by or mistaken for cyst rupture. Clinical

findings include bloating, nausea, vomiting, diarrhea, lethargy, shortness of breath, and rapid weight gain.

Severe ovarian hyperstimulation syndrome is characterized by large ovarian cysts, ascites, and, in some

patients, pleural and/or pericardial effusion, electrolyte imbalance (hyponatremia, hyperkalemia), hypovolemia,

and hypovolemic shock. Marked hemoconcentration, increased blood viscosity, and thromboembolic

phenomena, including disseminated intravascular coagulation, occur in the most severe cases. (See

"Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome".)

Ectopic pregnancy — Ectopic pregnancy has clinical symptoms and sonographic features similar to those

of a ruptured ovarian cyst. In women with acute pelvic pain or abnormal vaginal bleeding, a positive pregnancy

test strongly suggests the presence of an ectopic pregnancy if an intrauterine pregnancy cannot be visualized

sonographically. If an intrauterine pregnancy is visualized, then pelvic pain and intraperitoneal fluid could be due

http://www.uptodate.com/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-ovarian-hyperstimulation-syndrome?source=see_linkhttp://www.uptodate.com/contents/endometriosis-pathogenesis-clinical-features-and-diagnosis?source=see_linkhttp://www.uptodate.com/contents/image?imageKey=ENDO%2F61500&topicKey=NEPH%2F828&rank=3%7E150&source=see_linkhttp://www.uptodate.com/contents/ovarian-and-fallopian-tube-torsion?source=see_linkhttp://www.uptodate.com/contents/image?imageKey=OBGYN%2F61891&topicKey=NEPH%2F828&rank=3%7E150&source=see_linkhttp://www.uptodate.com/contents/image?imageKey=OBGYN%2F82480&topicKey=NEPH%2F828&rank=3%7E150&source=see_linkhttp://www.uptodate.com/contents/image?imageKey=OBGYN%2F72645&topicKey=NEPH%2F828&rank=3%7E150&source=see_linkhttp://www.uptodate.com/contents/physiology-of-the-normal-menstrual-cycle?source=see_linkhttp://www.uptodate.com/contents/evaluation-and-management-of-ruptured-ovarian-cyst?source=see_linkhttp://www.uptodate.com/contents/image?imageKey=OBGYN%2F72345&topicKey=NEPH%2F828&rank=3%7E150&source=see_linkhttp://www.uptodate.com/contents/image?imageKey=OBGYN%2F75150&topicKey=NEPH%2F828&rank=3%7E150&source=see_linkhttp://www.uptodate.com/contents/pelvic-inflammatory-disease-clinical-manifestations-and-diagnosis?source=see_link


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to a ruptured ovarian cyst (eg, corpus luteum cyst, theca lutein cyst) or heterotopic pregnancy. (See "Ectopic

pregnancy: Clinical manifestations and diagnosis", section on 'Heterotopic pregnancy'.)

Acute endometritis — Acute endometritis occurs after an obstetrical delivery or, rarely, after an invasive

uterine procedure. The diagnosis is largely based upon the presence of fever, gradual onset of uterine

tenderness, foul uterine discharge, and leukocytosis in an at-risk setting. (See "Postpartum endometritis" and

"Endometritis unrelated to pregnancy".)

Urologic conditions

Renal colic — Pain is the most common symptom and varies from a mild and barely noticeable ache to

discomfort that is so intense that it requires parenteral analgesics. The pain typically waxes and wanes in

severity, and develops in waves or paroxysms that are related to movement of the stone in the ureter and

associated ureteral spasm. Paroxysms of severe pain usually last 20 to 60 minutes. Pain is thought to occur

primarily from urinary obstruction with distention of the renal capsule. (See "Diagnosis and acute management

of suspected nephrolithiasis in adults" and "Acute management of nephrolithiasis in children".)

Testicular torsion — Testicular torsion is a urologic emergency that is more common in neonates and

postpubertal boys, although it can occur at any age. Testicular torsion results from inadequate fixation of the

testis to the tunica vaginalis. If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently

broad-based or absent, the testis may torse (twist) on the spermatic cord, potentially producing ischemia fromreduced arterial inflow and venous outflow obstruction. (See "Causes of scrotal pain in children and

adolescents", section on 'Testicular torsion' and "Evaluation of the acute scrotum in adults", section on

'Testicular torsion'.)

Epididymitis — Epididymitis occurs more frequently among late adolescents, but also occurs in younger

boys who deny sexual activity and is the most common cause of scrotal pain in adults in the outpatient setting.

Several factors may predispose postpubertal boys to develop subacute epididymitis, including sexual activity,

heavy physical exertion, and direct trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in

prepubertal boys is associated with structural anomalies of the urinary tract. In acute infectious epididymitis,

palpation reveals induration and swelling of the involved epididymis with exquisite tenderness. More advanced

cases often present with testicular swelling and pain (epididymo-orchitis) with scrotal wall erythema and a

reactive hydrocele. (See "Causes of scrotal pain in children and adolescents", section on 'Epididymitis' and

"Evaluation of the acute scrotum in adults", section on 'Epididymitis' .)

Torsion of the appendix testis or appendix epididymis — The appendix testis is a small vestigial

structure on the anterosuperior aspect of the testis (an embryologic remnant of the Müllerian duct system). The

appendix epididymis is a vestigial remnant of the Wolffian duct that is located at the head of the epididymis.

The pedunculated shape of these appendages predisposes them to torsion, which can produce scrotal pain that

ranges from mild to severe. Most cases of torsion of the appendix testis occur between the ages of 7 and 14

years, and rarely occur in adults. (See "Causes of scrotal pain in children and adolescents", section on 'Torsion

of the appendix testis or appendix epididymis' and "Evaluation of the acute scrotum in adults", section on

'Torsion of the appendix testis'.)

TREATMENT — The management of acute appendicitis in children and adults is discussed in detail

separately. (See "Acute appendicitis in children: Management" and "Management of acute appendicitis in

adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics”

and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6

grade reading level, and they answer the four or five key questions a patient might have about a given

condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read

materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth

information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these

topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on

th th

th th

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“patient info” and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS — Appendicitis is one of the most common causes of the acute

abdomen and one of the most frequent indications for an emergent abdominal surgical procedure worldwide.

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

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The tip of the appendix can be found in a retrocecal or pelvic location, as well as medial, lateral, anterior,

or posterior to the cecum. Anatomic variability can complicate the diagnosis, as clinical presentation will

reflect the anatomic position of the appendix. (See 'Anatomy' above.)

●

Appendiceal obstruction plays a role in the pathogenesis of appendicitis, but it is not required for the

development of appendicitis. (See 'Pathogenesis' above.)

●

The classic symptoms of appendicitis include right lower quadrant abdominal pain, anorexia, fever,

nausea, and vomiting. The abdominal pain is initially periumbilical in nature with subsequent migration to

the right lower quadrant as the inflammation progresses (see 'Clinical manifestations' above). Patients

with appendicitis can also present with atypical or nonspecific symptoms, such as indigestion, flatulence,

bowel irregularity, and generalized malaise; and not all patients will have migratory abdominal pain.

●

The differential diagnosis of right lower quadrant abdominal pain includes inflammatory disease processes

(eg, Crohn’s disease, ruptured cyst), infectious diseases (eg, acute ileitis, tubo-ovarian abscess), andobstetrical conditions (eg, ectopic pregnancy). (See 'Differential diagnosis' above.)

●

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45. Jeffrey RB Jr, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases.Radiology 1988; 167:327.

46. Spalluto LB, Woodfield CA, DeBenedectis CM, Lazarus E. MR imaging evaluation of abdominal painduring pregnancy: appendicitis and other nonobstetric causes. Radiographics 2012; 32:317.

47. Oto A, Ernst RD, Ghulmiyyah LM, et al. MR imaging in the triage of pregnant patients with acuteabdominal and pelvic pain. Abdom Imaging 2009; 34:243.

48. Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR imaging evaluation of acute appendicitis in pregnancy.Radiology 2006; 238:891.

49. Lee TH, Kim JO, Kim JJ, et al. A case of intussuscepted Meckel's diverticulum. World J Gastroenterol2009; 15:5109.

50. Banli O, Karakoyun R, Altun H. Ileo-ileal intussusception due to inverted Meckel's diverticulum. ActaChir Belg 2009; 109:516.

Topic 1386 Version 24.0

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GRAPHICS

Variations in the position of the appendix

Graphic 64911 Version 2.0


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Blood supply to the colon and rectum

The blood supply to the colon originates from the SMA and the IMA. The SMA

arises approximately 1 cm below the celiac artery and runs inferiorly toward the

cecum, terminating as the ileocolic artery. The SMA gives rise to the inferior

pancreaticoduodenal artery, several jejunal and ileal branches, the middle colic

artery, and the right colic artery. As a general rule, the middle colic artery arises

from the proximal SMA and supplies the proximal to mid-transverse colon.However, it occasionally provides the predominant blood flow to the splenic

flexure. The right colic artery arises either from a common trunk with, or just

below, the middle colic artery, and supplies blood to the mid-distal ascending

colon. The ileocolic artery supplies the distal ileum, cecum, and proximal

ascending colon.

The IMA arises approximately 6 to 7 cm below the SMA. The IMA gives rise to the

left colic artery and sigmoid arteries continuing as the superior rectal

(hemorrhoidal) artery. It is largely responsible for blood supply from the distal

transverse colon to the rectum.

SMA: superior mesenteric artery; IMA: inferior mesenteric artery.



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CT scan normal appendix

CT scan depicts a normal appendix. The figure on the left shows an appendiceal lumen

containing air and wall thickness of 3 mm (arrow). The figure on the right shows the tip of

the normal appendix (arrowhead) that measures 6 mm and no associated induration.

CT: computed tomography.



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CT scan acute appendicitis

The CT scan was obtained using oral and intravenous contrast from a patient who presented

with right lower quadrant abdominal pain. These figures show an inflammed appendix that

measures 21 mm in diameter and contains an appendicolith and fluid that is likely purulent.

(A) Shows an appendicolith in the appendix using an arrow.

(B) Shows the appendicolith, an overlay of orange to show fluid inside the appendix, and a

yellow arrow indicates free fluid.(C) Shows the enlarged appendix and fluid without an overlay.

(D) Shows a colored overlay: red circle depicts the enhancing appendiceal wall; orange

depicts the intra-appendiceal fluid; yellow depicts the free fluid.

CT: computed tomography.



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Normal appendix by ultrasound imaging

The gray scale ultrasound (A, and magnified in B) and Doppler image (C) of the appendix are

projected in the transverse plane. Images A and B show a normal appendix measuring almost

6 mm in maximum transverse dimension (arrow). The appendix was compressible and no

hyperemia was demonstrated (arrow) on the Doppler image (C). These findings are consistent

with a normal appendix by ultrasound.



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Acute appendicitis ultrasound

The patient is a 19-year-old female who presented to the emergency department with right

lower quadrant pain. The gray scale ultrasound of the appendix is projected in the

longitudinal (A) and transverse planes (B). A noncompressible appendix measures almost 20

mm in diameter, consistent with a diagnosis of acute appendicitis. The echogenic mucosal

and submucosal portions of the wall have become discontinuous (arrows) suggesting

disruption as a result of sloughing. Luminal air (arrowheads) results in posterior shadowing.



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Appendicolith on abdominal films

This plain film of the abdomen reveals a 1.2 cm calcific density, an

appendicolith. The patient presented with right lower quadrant pain and

was diagnosed with acute appendicitis.



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Magnetic resonance image of appendicitis in

pregnancy

T2 weighted magnetic resonance image of a woman with appendicitis

at 9 weeks of gestation. The appendix was fluid-filled and measured 7

mm (arrow). The gestational sac (gs) is seen lower in the pelvis.

Courtesy of Deborah Levine, MD.



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Tuboovarian abscess

Gross intraoperative photograph of a left tuboovarian abscess in a

patient with pelvic inflammatory disease.

Courtesy of Mitchel Hoffman, MD.



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Ruptured ovarian cyst

Computed tomography. Arrows indicate free blood within peritoneal

cavity surrounding liver and spleen.

Courtesy of William J Mann, Jr, MD.



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Adnexal mass

Image

Computed tomography. Arrow indicates poorly defined adnexal mass, which at

exploration was ruptured corpus luteum cyst and clot.

Courtesy of William J Mann, Jr, MD.



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Ovarian and tubal torsion demonstrating marked

vascular engorgement as well as increased size

and distension

Anatomy was restored and both structures were salvaged despite non-

viable appearance.

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6th

ed, Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott Williams & Wilkins,

Philadelphia 2012. Copyright © 2012 Lippincott Williams & Wilkins.

www.lww.com.


http://www.lww.com/


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Tubal torsion demonstrating severe distension of the

distal tube

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6th ed,

Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott Williams & Wilkins,

Philadelphia 2012. Copyright © 2012 Lippincott Williams & Wilkins.

www.lww.com.


http://www.lww.com/


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Enlarged left ovary found torsed upon laparotomy

demonstrating a dark, dusky appearance

secondary to venous lymphatic congestion in the

setting of continued arterial perfusion

Reproduced with permission from: Pediatric and Adolescent Gynecology, 6th

ed, Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott Williams & Wilkins,Philadelphia 2012. Copyright © 2012 Lippincott Williams & Wilkins.

www.lww.com.


http://www.lww.com/


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Peritoneal endometriosis

The peritoneum in this woman with endometriosis is studded with

reddish, irregularly shaped implants.

Reprinted with permission. Copyright 1990 Syntex Laboratories, Inc. All rights

reserved.



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Contributor Disclosures

Ronald F Martin, MD Nothing to disclose. Martin Weiser, MD Nothing to disclose. Wenliang Chen, MD,PhD Nothing to disclose.

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Acute Appendicitis in Adults_ Clinical Manifestations and Differential Diagnosis