Is the appendix on the right or left side?

DEAR DOCTOR K:

Every time my husband has abdominal pain, he worries that it’s appendicitis. Can you tell me the actual symptoms so I can assure him he’s fine?

DEAR READER:

Many different conditions can cause abdominal pain. The cause of most abdominal pain is a temporary and simple disorder, such as a pocket of gas trapped in the intestine, or stomach acid causing heartburn.

But serious conditions also cause abdominal pain, and appendicitis is one of the most common of those serious conditions. It affects one in every 500 people in the United States each year.

Appendicitis is an inflammation of the appendix. Your appendix is a small, fingerlike tube. We don’t know of anything good the appendix does for us — we just know it can cause trouble.

Many people, including many of my patients, worry about appendicitis whenever they get a pain in their belly. It’s worth worrying about: Appendicitis can have serious and life-threatening consequences. Left untreated, an inflamed appendix can burst. The infection can then spread throughout the abdominal cavity and into the bloodstream.

The appendix hangs from the lower right side of the large intestine. If your husband’s pain is predominantly on his left side, it’s probably not appendicitis. (See illustration.)

Location of appendix

Appendicitis causes the following symptoms:

Abdominal pain: This usually starts just above the belly button, then moves over several hours to the right lower side of the abdomen.

  • Nausea
  • Vomiting
  • Abdominal swelling
  • Pain when the right side of the abdomen is touched
  • Low-grade fever
  • Inability to pass gas
  • Change in normal bowel pattern

Appendicitis is an emergency and requires immediate attention to avoid the risk of a ruptured appendix. If your husband ever has symptoms of appendicitis, he should contact his doctor right away.

The doctor will ask about his symptoms, then check for pain in the lower right abdomen. Blood tests, ultrasound or a computed tomography (CT) scan can also provide evidence for or against the diagnosis.

When the symptoms, physical examination and tests all strongly suggest that a person has appendicitis, surgery to remove the appendix (an appendectomy) is required, as soon as possible. That’s because a ruptured appendix can be life-threatening, while an appendectomy is a relatively low-risk operation.

If doctors think the likelihood of appendicitis is high — even without blood tests or imaging studies — they’ll operate. If doctors think appendicitis is unlikely but still possible, they’ll continue to observe a person in the emergency room, and operate later if the person doesn’t get better.

Still, our diagnostic accuracy is not perfect: In about 10 percent to 25 percent of appendectomies, the appendix is normal. It’s usually removed anyway, since it’s easy to do once the abdomen has been opened, and because it could cause trouble in the future.

THERAPEUTIC APPROACHES

US Pharm. 2019:44(12):HS-2-HS-9.

Abstract: Acute appendicitis is the most common abdominal emergency, with a lifetime risk of 7% to 8%. Clinical features vary but typically include right lower-quadrant abdominal pain, anorexia, nausea, and vomiting. Although there are many theorized etiologies, appendicitis is thought to occur primarily as a result of luminal obstruction that has progressed to inflammation, ischemia, and possibly perforation. Treatment is usually by appendectomy after appropriate fluid resuscitation, analgesia, and antibiotics. Emerging evidence suggests an antibiotic-treatment approach may be an alternative to surgery.

Acute appendicitis is one of the most common causes of acute abdominal pain requiring emergent surgery. The overall estimated lifetime risk is 7% to 8% with a slight predominance in Caucasian males.1,2 While no age is exempt, acute appendicitis commonly affects those aged 10 to 20 years.3 It is characterized by a wide range of symptoms that overlap with other gastroenterological, gynecologic, or urologic conditions, such as peptic ulcer disease, Meckel’s diverticulum, Crohn’s disease, gastroenteritis, irritable bowel disease, ectopic pregnancy, endometriosis, testicular or ovarian torsion, pelvic inflammatory disease, urinary tract infection, and renal stones.3

Most patients suffering from acute appendicitis will experience a typical migratory periumbilical pain, which intensifies in the first 24 hours. This eventually localizes to right lower quadrant abdominal pain, anorexia, nausea, and vomiting.2,4 Other nonspecific symptoms include general malaise, indigestion, diarrhea, and flatulence. A mild leukocytosis (white blood cell count >10,000 cells/microL), a slight hyperbilirubinemia (total bilirubin >1.0 mg/dL), and a low-grade fever (101.0°F) are additional findings that may be observed during acute appendicitis.5 Signs and symptoms usually correlate with the timing of disease onset (TABLE 1). Since symptoms may vary, imaging studies with CT (preferred), US, and MRI may be performed to increase the specificity of the diagnosis and help rule out perforation.

Despite being so common, the exact etiology of appendicitis is unknown.2 There are several proposed etiologies, yet they are all poorly understood.6 Most evidence suggests that the primary etiology is likely due to an obstruction of the appendiceal lumen secondary to a fecalith, calculi, hypertrophied lymphatic tissue, an infectious process, or a neoplasm.2,7 When obstruction occurs, gut bacteria will build up in the appendix causing acute inflammation, thrombosis, and localized ischemia. If significant enough, the appendix may rupture, leading then to localized abscess formation and generalized peritonitis.8 While timing of perforation varies, one study reported 65% of patients who had a perforated appendix had symptoms for longer than 48 hours.9 There is a possible genetic link supported by evidence to suggest that patients with a positive family history experience appendicitis at a three-times higher rate.10 Lastly, environmental factors have also been established in the development of appendicitis, with a largely seasonal presentation during the summer months.11

Because of the variability in the clinical presentation, making a diagnosis and selecting a management approach for a patient with acute appendicitis can be challenging. A variety of validated scoring tools have been developed that incorporate findings from the patient’s presentation and laboratory markers.12-15 Although the Alvarado Score System is the most common and widely applied diagnostic validating system, the Appendicitis Inflammatory Response (AIR) score is a newer, more commonly used tool (TABLE 2). These aids stratify patients as low, moderate, or high risk, assisting clinicians in making a decision on appropriate management.

Surgical removal of the appendix, via open laparotomy or laparoscopy, is the standard of therapy for acute appendicitis.16 Initial antibiotic therapy may precede surgery for some. More recent evidence suggests antibiotics may be used as the sole therapy in those with uncomplicated appendicitis, thus avoiding surgery. Additionally, pain control is an important part of care in patients with acute appendicitis. This article briefly reviews the current evidence-based therapeutic management of acute appendicitis in the adult population.

Surgery

Traditionally, the gold-standard curative therapeutic approach for acute appendicitis is IV cystalloid fluids along with source control via an appendectomy, using either an open laparotomy or laparoscopy.16 A recent meta-analysis consisting of 33 studies and over 3,600 patients compared both surgical techniques.17 Those who underwent a laparoscopic appendectomy had a longer operation time but experienced a lower incidence of wound infection, fewer postoperative complications, shorter length of stay, and a faster return to activity.17 Thus, the laparoscopic surgical approach is recommended. For those who develop an appendiceal abscess, percutaneous drainage may be required.18

Antibiotics

The obstructed appendix leads to bacterial overgrowth. Aerobic organisms predominate in early appendicitis, and mixed aerobes and anaerobes are seen later in the course. Anaerobic organisms that may be found include Bacteroides fragilis, Clostridium species (spp), and Prevotella spp, while aerobic, gram-negative bacilli found may include Escherichia coli, Klebsiella spp, and Proteus mirabilis.8,19 Pseudomonas aeruginosa, streptococci, enterococci, and mixtures of aerobes and anaerobes should also be considered when empirically selecting an antimicrobial regimen.8,19 Several treatment guidelines exist that offer therapeutic recommendations. The most recent guidelines by the Surgical Infection Society and Infectious Diseases Society of America were published in 2010.19 Due to emerging evidence, a revised guideline on the management of intra-abdominal infections was published in 2017 by the Surgical Infection Society.20 Updated guidelines are expected to be published in the fall of 2020.

Patients may be classified as having uncomplicated or complicated appendicitis. Uncomplicated appendicitis is defined as an infection confined within the visceral organ. However, if the infection proceeds beyond the organ (e.g., ruptures), it is considered to be complicated appendicitis. Furthermore, patients may be categorized as having community-acquired or healthcare/hospital-associated infection as well as being at low or high risk for treatment failure or death (TABLE 3). Guidelines recommend that empiric antimicrobial selection and dosing be based upon the classification, the patient’s comorbidities, physiologic conditions, and the risk of adverse outcomes (TABLE 4).20 Standard antibiotic dosing should be used in lower-risk patients who are not obese and have normal renal or hepatic function, while higher doses of antimicrobials should be used in higher-risk patients.20 For patients needing antifungal therapy, fluconazole is recommended for susceptible strains of Candida albicans while voriconazole should be considered for nonsusceptible strains of Candida.20 In severely ill patients, an echinocandin should be used.20

For some with uncomplicated appendicitis, evidence suggests antibiotic therapy alone may be sufficient instead of proceeding to surgery.21-23 The single-cohort, prospective, observational NOTA Study (Non Operative Treatment for Acute Appendicitis) evaluated the outcomes of patients (n = 159) with suspected appendicitis (mean AIR score 4.9) treated nonoperatively with a 7-day course of amoxicillin/clavulanic acid.22 The follow-up period was 2 years. Results showed that for patients who successfully completed antibiotic therapy, the 2-year efficacy was 83% (118 patients recurrence-free and 14 patients with recurrence nonoperatively managed), and the recurrence rate was 13.8%.22

Most recently, the Appendicitis Acuta (APPAC) trial (Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis) randomized more than 500 patients with uncomplicated appendicitis to early appendectomy or antibiotic treatment alone.23 Patients in the antibiotic arm of the study received IV ertapenem (1 g daily) for 3 days followed by 7 days of oral levofloxacin (500 mg, once daily) and metronidazole (500 mg, 3 times daily).23 The primary outcome was resolution of appendicitis without the need for surgical intervention and no recurrence for one year. At study end, 99.6% of those in the appendectomy group had a successful appendectomy with an overall complication rate of 20.5%; 27.3% of those in the antibiotic group needed an appendectomy, with an overall complication rate of 7%.23 Thus, the study did not meet noninferiority criteria when compared with appendectomy. Limitations acknowledged by the authors included small sample size, thereby underpowering the study, and a short follow-up period. The investigators also completed a 5-year follow-up of patients included in the APPAC trial.24 At the 5-year mark, late recurrent appendicitis and complication rates were assessed. Appendicitis had recurred in 39% of patients in the antibiotic group, and the overall complication rate was 24% in the appendectomy group compared with 7% for those randomized to antibiotics.24 The authors concluded that for some a nonoperative treatment approach might be reasonable.24

The appropriate duration of antibiotic therapy has been debated, and it is dependent on the clinical scenerio. Results from the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial determined there was no difference between 3 to 5 days of antibiotic therapy compared with 5 to 10 days.25 Current guidelines suggest postoperative antibiotic therapy continue for 24 to 72 hours.20 In patients who do not undergo source control, 5 to 7 days of therapy are recommended.20 If the patient has no response after 5 to 7 days, the patient should be reassessed for another source-control procedure.20 For patients who have bacteremia, antibiotics may be stopped after 7 days if there is adequate source control and the bacteremia has resolved.20

Analgesics

Given the degree of pain most will experience with acute appendicitis, analgesic therapy should be included in the treatment plan. Historically, administration of analgesics had been discouraged because of concerns that the therapeutic effects might mask appendicitis symptoms. However, data do not support this claim. Several randomized, controlled studies have demonstrated that administering opioid analgesia is safe and does not lead to a diagnostic error.26-28 In those unable to receive opioids, acetaminophen and nonsteroidal anti-inflammatories should be considered for pain management in patients with suspected acute appendicitis.26-28

COMPLICATIONS

While appendicitis therapy is straightforward, complications may still arise. The most concerning complication is perforation of the appendix. This may occur if therapy is delayed. Perforations may lead to peritonitis, which increases morbidity and mortality. A study of more than 4,000 patients revealed that perforation increases postsurgical morbidity from 16.3% to 24.9% and mortality from 1.8% to 4.0%.29 Prompt treatment of appendicitis, whether operative or nonoperative, is crucial in reducing further complications.

CONCLUSION

Acute appendicitis is a common abdominal emergency requiring immediate attention. Pharmacists are in a position to quickly identify and refer patients who may be affected with this condition. Furthermore, pharmacists have the opportunity to be an integral part of the healthcare team and can assist in appropriate selection and dosing of antibiotic and analgesic regimens for these patients. While a laparoscopic appendectomy is considered the standard of treatment for appendicitis, emerging evidence suggests antibiotic regimens alone may also be effective.

1. Stewart B, Khanduri P, McCord C, et al. Global disease burden of conditions requiring emergency surgery. Br J Surg. 2014;101(1):e9-e22.
2. Humes DJ, Simpson J. Acute appendicitis. BMJ. 2006;333(7567):530-534.
3. Jacobs DO. Acute appendicitis and peritonitis. In: Jameson J, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018:2298-2302.
4. Laurell H, Hansson LE, Gunnarsson U. Manifestations of acute appendicitis: a prospective study on acute abdominal pain. Dig Surg. 2013;30:198-206.
5. Tehrani HY, Petros JG, Kumar RR, Chu Q. Markers of severe appendicitis. Am Surg. 1999;65:453-455.
6. Carr NJ. The pathology of acute appendicitis. Ann Diagn Pathol. 2000;4:46-58.
7. Bhangu A, Soreide K, Di Saverio S, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386:1278-1287.
8. Hamilton AL, Kamm MA, Ng SC, Morrison M. Proteus spp. as putative gastrointestinal pathogens. Clin Microbiol Rev. 2018;31(3):e00085-17.
9. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults: a prospective study. Ann Surg. 1995;221(3):278-281.
10. Ergul E. Heredity and familial tendency of acute appendicitis. Scand J Surg. 2007;96:290-292.
11. Wei PL, Chen CS, Keller JJ, Lin HC. Monthly variation in acute appendicitis incidence: a 10-year nationwide population-based study. J Surg Res. 2012;178:670-676.
12. Ebell MH, Shinholser J. What are the most clinically useful cutoffs for the Alvarado and Pediatric Appendicitis scores? A systematic review. Ann Emerg Med. 2014;64(4):365-372.e2.
13. Kollár D, McCartan DP, Bourke M, et al. Predicting acute appendicitis? A comparison of the Alvarado score, the Appendicitis Inflammatory Response score and clinical assessment . World J Surg. 2015;39(1):104-109.
14. Pogorelic Z, Rak S, Mrklic I, Juric I. Prospective validation of Alvarado score and Pediatric Appendicitis Score for the diagnosis of acute appendicitis in children. Pediatr Emerg Care. 2015;31(3):164-168.
15. Scott AJ, Mason SE, Arunakirinathan M, et al. Risk stratification by the Appendicitis Inflammatory Response score to guide decision-making in patients with suspected appendicitis. Br J Surg. 2015;102(5):563-572.
16. Jaschinski T, Mosch C, Eikermann M, et al. Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC Gastroenterol. 2015;15:48.
17. Dai L, Shuai J. Laparoscopic versus open appendectomy in adults and children: a meta-analysis of randomized controlled trials. United European Gastroenterol J. 2017;5(4):542-553.
18. Marin D, Ho LM, Barnhart H, et al. Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome. AJR Am J Roentgenol. 2010;194:422-429.
19. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133-164.
20. Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017;18(1):1-76.
21. Mason RJ, Moazzez A, Sohn H, Katkhouda N. Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis. Surg Infect (Larchmt). 2012;13(2):74-84.
22. Di Saverio S, Sibilio A, Giorgini E, et al. The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg. 2014;260(1):109-117.
23. Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348.
24. Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320(12):1259-1265.
25. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372:1996-2005.
26. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14):1764-1774.
27. Mousavi SM, Paydar S, Tahmasebi S, Ghahramani L. The effects of intravenous acetaminophen on pain and clinical findings of patients with acute appendicitis; a randomized clinical trial. Bull Emerg Trauma. 2014;2(1):22-26.
28. Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2011;(1):CD005660.
29. Margenthaler JA, Longo WE, Virgo KS, et al. Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults. Ann Surg. 2003;238(1):59-66.
30. Solomkin J, Evans D, Slepavicius A, et al. Assessing the efficacy and safety of eravacycline vs ertapenem in complicated intra-abdominal infections in the Investigating Gram-Negative Infections Treated with Eravacycline (IGNITE 1) trial: a randomized clinical trial. JAMA Surg. 2017;152(3):224-232.
31. FDA. FDA approves new treatment for complicated urinary tract and complicated intra-abdominal infections . July 17, 2019. www.fda.gov/news-events/press-announcements/fda-approves- new-treatment-complicated-urinary-tract-and-complicated intra-abdominal infections. Accessed August 31, 2019.

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McBurney’s point and diagnosing appendicitis in children

Three Part Question

In how at

Clinical Scenario

You are examining a 4 year old child with abdominal pain – with appendicitis at the top of your differential diagnosis. If the child is tender at McBurney’s point is that enough to confirm your suspicion of appendicitis and prompt surgical referral?

Search Strategy

MEDLINE 1950 – Nov week 1 2007 using the OVID interface AND EMBASE 1980 to 2007 week 23
LIMIT to human AND English

Search Outcome

MEDLINE:24 papers were found of which 18 were irrelevant or of insufficient quality.
EMBASE: 27 papers were found of which 26 were irrelevant or of insufficient quality (excluding duplicates)
The remaining 7 papers are shown in the table.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Alvardo, A
1985
USA
305 patients (4-80) admitted with abdominal pain suggestive of acute appendicitis. 227 confirmed acute appendicitis at appendicectomy. Retrospective review Tenderness in right lower quadrant in acute appendicitis Sens 100% No subset analysis for children No power calculation
Spec 12%
Predicitive value 100%
Nauta RJ and Magnant C
1986
USA
97 patients (2.5-91) admitted with pre-operative diagnosis of appendicitis. Histological diagnosis of appendicitis confirmed in 81%. Cohort Rebound tenderness in appendicitis 67% No subset analysis for children. No power calculation ‘Rebound tenderness’ not specified at McBurney’s point. Study type unclear – retrospective or prospective No data on sensiticity or specificity
Rebound tenderness in non-appendicitis 39%
Significant (95% CI 0.19 and 0.59)
Golledge J et al
1996
UK
100 patients (4-81) presented with right iliac fossa pain, with a provisional diagnosis of appendicitis. Prospective cohort Right iliac fossa tenderness sens 100% spec 7% ppv 46% No subset analysis for children. Small number in study – no power calculation
Percussion tenderness over McBurney’s pt sens 57% spec 86% ppv 76%
Lane, R and Grabham, J
1997
UK
83 patients (7-80) admitted to surgical ward with tenderness in the right iliac fossa. Gold standard: histological diagnosis of appendicitis made in 59% Prospective diagnostic test study Modified sign – 1 min pressure on McBurney’s point to illicit peritoneal irriation sens 94% No subset analysis for children Small study – no power calculation One difference of opinion between clinicians
spec 71 %
Kharbanda AB et al
2005
USA
601 patients (3-18) presenting to paediatric Emergency Department with symptoms and signs of appendicitis. Post-surgery diagnosis of appendicitis 35% Prospective cohort study Maximal tenderness in right lower quadrant sens 79.9% spec 40.7% No power calculation Was part of creation of clinical decision rule to predict those children at low risk of appendicitis
npv 77.9%
Bundy DG et al
2007
USA
Children with suspected appendicitis-which signs and symptoms increased likely diagnosis Review of literature-42 studies met inclusion criteria, of which 25 were assigned quality level of 3 or above Presence of fever increases likelihood of appendicits (LR 3.4, CI 2.4-4.8) Review article-meta-analysis not performed States that signs and symptoms are most useful in combination.
Rebound tenderness LR 3, CI 2.3-3.9
Mid-abdominal pain migrating to RIF LR range 1.9-3.1
WCC Decreases likelihood (LR 0.22, CI 0.17-0.30)

Comment(s)

Across the papers there was consistently high sensitivity – 79.9 – 100%. This implies that when there is no tenderness at McBurney’s point appendicitis can be ruled out. The papers did not agree on specificity (7-100%) hence it must be concluded that positive tenderness does not rule in a diagnosis of appendicitis – simply peritonism which has many causes. A number of different methods used to elicit tenderness at McBurneys point (palpation, 1 minutes pressure, percussion) are proven to be comparable.

Clinical Bottom Line

Eliciting tenderness at McBurney’s point is a valuable part of the abdominal examination – if negative appendicitis is a less likely diagnosis. However symptoms and signs are needed in combination.

  1. Alvardo, A. A Practical Score for the Early Diagnosis of Acute Appendicitis Annals of Emergency Medicine 1986;15(5):557-64
  2. Nauta RJ. Magnant C. Observation Versus Operation for Abdominal Pain in the Right Lower Quadrant. Roles of the Clinical Examination and the Leukocyte Count American Journal of Surgery 1986;151(6):746-8
  3. Golledge J et al Assessment of peritonism in appendicitis Annals of the Royal Colledge of Surgeons of England 1996;78(1):11-4
  4. Lane, R and Grabham, J A useful sign for the diagnosis of peritoneal irritation in the right iliac fossa Annals of the Royal College of Surgeons of England 1997;79(2):128-9
  5. Kharbanda, AB et al. A clinical decision rule to identify children at low risk for appendicitis Pediatrics 2005;116(3):709-716
  6. Bundy DG. Byerley JS. Liles EA. Perrin EM. Katznelson J. Rice HE. Does this child have appendicitis? JAMA 298(4):438-51, 2007 Jul 25

Cardiology & Current Research

Clinical presentation

Acute appendicitis diagnosis depends on a detailed history and the organized physical examination. Acute appendicitis can mimic the presentation of many surgical, medical, gynecological and urological emergency cases (Table 1) .

Alvarado score

Variable Value

Symptoms

Migration

Anorexia-acetone

Nausea-vomiting

Signs

Tenderness in right lower quadrant

Rebound pain

Elevation of temperature C 37.3_

Laboratory

Leukocytosis > 10.0 × 109/L

Shift to the left > 75%

Total*

Table 1: Alvarado scoring scale for diagnosis of acute appendicitis .

History: The history of acute appendicitis can go through many sequence (stages); first central colicky peri-umbilical abdominal pain (99%), followed by vomiting and pain migration (50%) to the right iliac fossa (RIF) . The pain progression results from the nonspecific initial visceral pain to more localized parietal peritoneum pain . Associated symptoms include anorexia (24-99%), nausea (62-90%), infrequent vomiting (32-75%) to profuse vomiting (diffuse peritonitis), low grade fever (67-69%) and constipation . The clinical presentations of appendicitis depend mainly on the anatomical positions (retrocaecal /retrocolic, subcaecal/pelvic and pre/postileal) of their appendix location and anatomical surrounding structures (Table 2) .

MANTRELS score

Variable Value

M = Migration of pain to the RIF

A = Anorexia

N = Nausea and vomiting

T = Tenderness in RIF

R = Rebound pain

E = Elevated temperature

L = Leukocytosis

S = Shift of WBCs to the left

Total*

Source: Alvarado.

Table 2: MANTRELS score for diagnosis of acute appendicitis .

*Total score of 1- 4: Appendicitis unlikely; 5 – 6: Appendicitis possible; 7 – 8: Appendicitis probable; 9 – 10: Appendicitis very probable.

Examination: A physician should examine suspected cases of acute appendicitis thoroughly starting the general appearance, and do vital signs, inspection, palpation, percussion, and auscultation of abdominal sounds (Table 3) . There are two important abdominal tests to diagnose a case of acute appendicitis are ; first coughing and second hopping test; by asking the patient either to cough or hop upward which exacerbates abdominal pain . The physician should also, notice any muscle guarding and rigidity in 21% of the cases, and if there is maximum tenderness over McBurneys’ in 26% of the cases (Figure 1) which either verify by abdominal palpation or percussion (Figure 2) . Physician should avoid rebound tenderness to avoid disturbing the patient. The physician should elicit the four most important signs to diagnosis a case of acute appendicitis (coughing, hopping test, percussion tenderness, and guarding / rigidity) with high positive likehood ratio (LR + 4.0) .

A physician should always perform a rectal or vaginal examination in acute abdomen; which is positive in pelvic appendicitis with Odds Ratio of 1.3 . The physician should notice if there is pain in RIF when palpate LIF (Positive Rovsing’s Sign) (Figure 3) . Ask patient to lie in supine position with flex right hip, then ask patient to lift the right thigh whereas physician applying pressure just above the knee (Figure 4) or the physician apply a passive extension of right leg at the right hip, while the patient posture has left lateral decubitus position (Positive Psoas Sign) (Figure 5 & 7) . The physician can elicit a positive Obturator Sign by applying passive flex right knee with internal rotation the right hip (Figure 6 & 7) .

Figure 1: McBurneys’ point which is approximately at two thirds of a line drawn from the umbilicus to the anterior superior iliac spine .Figure 2: McBurneys’ point tenderness in RIF site .Figure 3: Positive Roving’s Sign by palpate LIF exacerbate pain in RIF .Figure 4: Positive Psoas Sign with flex hip against resistant.Figure 5: Positive Psoas Sign with backward leg extension .Figure 6: Positive Obturator Sign by flex right knee with internal rotation of the right hip .Figure 7: Positive Psoas and Obturator Signs .

Laboratory investigations

The presence or absence of inflammatory markers is either support or refute diagnosis of acute appendicitis such as, increase level of leucocyte/neutrophil/granulocyte and C-reactive protein (CRP) . Urine analysis and microscopy can either support or refute urinary tract infection, but it is confusing in pelvic acute appendicitis . Other important biochemical tests are serum/urine beta HCG, amylase, lipase, liver function tests, and electrolyte levels. Serum bilirubin is potential biomarkers for the diagnosis of acute perforated appendicitis . Other inflammatory markers of less importance are Interleukin-6; plasma D-lactate levels lactoferrin and calprotectin; have not been shown to aid the diagnosis of acute appendicitis or reduce unnecessary appendectomy .

Scoring systems

Sometimes, there are many difficult cases of acute appendicitis are missed in primary and secondary care. Moreover; there are many negative, unnecessary appendectomies (range 14 – 75%) . Using clinical scoring systems (computer-aided diagnosis algorithm) to improve diagnosis of acute appendicitis based on symptoms, signs and laboratory findings. In suspected adult, use Alvarado Scores (AS) , whereas, in suspected children use Pediatric Appendicitis Scores (PAS) or Samuel Scores (SS) . It will increase the diagnostic accuracy up to 97.2%; also it is shown decrease in the number of appendicular perforations .

General Examination

Flushed, a fetor or is, in pain, lie still, low grade fever and tachycardia

Abdominal Examination Signs of localized/ generalized peritoneal irritation

Dunphy’s sign

Increased pain in the right lower quadrant with coughing

Hip flexion sign

Patient maintains hip flexion with knees drawn up for comfort

Other peritoneal signs

Rebound tenderness, hyperesthesia of the skin in the right lower quadrant

Positive Hopping Test

Increased pain in the right lower quadrant with hopping

Positive Rebound Tenderness in McBurney’s Point

Positive localized rebound tenderness on right lower quadrant and muscular guarding and Muscular Rigidity.

Positive Percussion Tenderness

Localized tenderness over percussion site at McBurney’s point

Normal Rectal or Vaginal examination

RIF pain on rectal/ vaginal examination may indicate a pelvic appendix

Positive Rovsing’s Sign

RIF Pain on palpation left iliac fossa

Positive Psoas’s Sign

Pain on hyperextension of right thigh in lateral decubitus position (retroperitoneal retrocecal appendix)

Pain thigh lifting against resistant in supine position (retroperitoneal retrocecal appendix)

Positive Obturator’s Sign

Pain on internal rotation of right thigh (pelvic appendix)

Table 3: Complete examination of suspected cases of acute appendicitis.

Alvarado score

Variable Value

Symptoms

Migration

Anorexia-acetone

Nausea-vomiting

Signs

Tenderness in right lower quadrant

Rebound pain

Elevation of temperature C 37.3_

Laboratory

Leukocytosis > 10.0 × 109/L

Shift to the left > 75%

Total*

Table 4: Alvarado scoring scale for diagnosis of acute appendicitis .

MANTRELS score

Variable Value

M = Migration of pain to the RIF

A = Anorexia

N = Nausea and vomiting

T = Tenderness in RIF

R = Rebound pain

E = Elevated temperature

L = Leukocytosis

S = Shift of WBCs to the left

Total*

Source: Alvarado.

Table 5: MANTRELS score for diagnosis of acute appendicitis .

*— Total score of 1- 4: Appendicitis unlikely; 5 – 6: Appendicitis possible; 7 – 8: Appendicitis probable; 9 – 10: Appendicitis very probable.

Other Scoring Systems: The use of Tzanakis Scoring System combined with ultrasound scanning along with clinical and laboratory findings (Ultrasound positive for acute appendicitis, tenderness in the right lower quadrant, rebound tenderness and a leukocyte count ≥12,000/L); aid physician for early diagnosis of appendicitis . The use of eight independent predictive variables in Appendicitis Inflammatory Response Score (AIRS) (right lower quadrant pain, rebound tenderness, muscular defense, WBC count, proportion of neutrophils, CRP, body temperature and vomiting) with high Sensitivity (0.97 vs. 0.92), and Specificity (0.93 vs. 0.88) to diagnose appendicitis cases . The use of seven independent predictive variables in Ohmann score (right lower quadrant pain, rebound tenderness, no micturition difficulties, steady pain, leukocyte count ≥ 10.0, age ≤ 50 years, and positive abdominal rigidity) . The predictive symptoms and signs to diagnosis appendicitis in children by using Lintula score (gender, intensity of pain, relocation of pain, vomiting, pain in the right lower quadrant, fever, guarding, bowel sounds and rebound tenderness); which subsequently been validated in adults . The Fenyo-Lindberg scoring system uses nine clinical and one laboratory variable to form a score to predict cases of appendicitis .

Pediatric Appendicitis Score (PAS) (Samuel score): The use of eight independent predictive variables in The Pediatric Appendicitis Score (PAS) (Cough/percussion/hoping tenderness in the RIF, anorexia, pyrexia, nausea and emesis, tenderness over the right iliac fossa, leukocytosis, polymorph nuclear neutrophil and migration of pain), the score are of sensitivity of 1, specificity of 0.92, positive predicted value (PPV) of 0.96 and negative predictive value (NPV) of 0.99 . It is useful in stratifying the clinical risk of children with acute appendicitis by categorizing them as low (< 2), while in medium (3-6) need for further radiological examination (ultrasound or computed tomography) or need for a period of further evaluation, however high risk (≥7) of acute appendicitis , while those with an Alvarado score between 3 and 6 should undergo a CT scan of the abdomen (sensitivity of 90.4% and specificity of 95%) . None of the scoring systems definitive diagnose acute appendicitis or predict the need for further investigation. Therefore, clinical examination combined with clinical decision and using scoring scales will guide physicians for further investigation in unclear acute appendicitis.

Difficult diagnostic cases

Extreme of age: Listless infant and confused elderly may present with atypical signs and symptoms of acute appendicitis. So, the physician needs a high index of suspicion in examination of suspected appendicitis in this category .

Appendicitis in children: While acute appendicitis is very common childhood abdominal operation , but diagnosis of appendicitis in ambulatory care was reaching only 2.3% because it remained a challenge for many clinicians . Early diagnosis of appendicitis will ultimately decrease appendicular perforation , abscess, gangrene, peritonitis and a shortening period of post-operative hospitalization . Usually, there was a delay in diagnosis of acute appendicitis in children due to misdiagnosis . Misdiagnosis rate was ranging from 7.5% to 37% for children and the reason of misdiagnosis was either acute gastritis or gastroenteritis . The common age incidence of childhood appendicitis is mostly at 9-12 years , and the red flag of acute appendicitis in childhood are vomiting , leukocytosis, high C-reactive protein level right lower quadrant tenderness . A high level of clinical suspicion; may need further investigation by either, abdominal ultra-sonographers (sensitivities range from 85% -90% and specificities range from 95% -100%) and CT scan which increase diagnostic accuracy and decrease negative laparotomy .

Appendicitis wit urological symptoms: While one third of acute appendicitis may have urological manifested (e.g. right flank pain and dysuria, pyurea > 10 cells per high-power field) due to abnormal pelvic and retrocecal appendix positions .

Appendicitis in Pregnancy: Usually, a typical appearance of appendicitis is present mostly during late pregnancy; because of appendix displacement from gravid uterus. The common complaints are nausea and vomiting with unspecified tenderness located on the right side of the abdomen (Right lower quadrant pain or mid or even upper right side of the abdomen) is the most common symptom. Acute appendicitis is common during pregnancy with an incidence of 0.15–2.1 per 1,000 pregnancies. Early use of either magnetic resonance imaging (MRI) or abdominal ultrasound (US) will increase diagnostic accuracy of acute appendicitis in pregnancy and prevent both maternal (1–4%) and fetal (1.5–35%) mortality associated with perforation, which may occur more mostly in the third trimester . Missed appendicitis in pregnancy is common in primary care because of unusual presentation (e.g. heartburn, bowel irregularity, flatulence, malaise, or diarrhea, urinary frequency, dysuria or tenesmus and diarrhea) .

Appendicitis in women of child bearing age: Moreover, Pelvic pain of women is challenging scenario because of the long list of differential diagnoses ranged from lifesaving condition (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) to fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be con­sidered . To increase accuracy of early diagnosis of appendicitis and decrease the rate of negative histopathology of appendectomy, we need to identify clinical scoring systems, laboratory and diagnostic imaging .

Appendicular abscess/ Appendicular mass: The physician should palpate abdomen for a tender mass at RIF in patient with swinging pyrexia with leukocytosis. The diagnosis was confirmed by either abdominal US or CT scans .

PMC

Discussion

The pregnant patient with appendicitis presents unique challenges to both the surgeon and gynaecologist. First, the diagnosis of pregnancy needs confirmation at the time of presentation. Secondly, the anaemia and physiological changes that normally occur during pregnancy alter the physical findings and laboratory values that are often used for diagnosis of appendicitis. Thirdly, cases of appendicitis that occur during pregnancy can produce significant morbidity and mortality if not promptly identified and treated. Fourthly, the treating surgeon has limitations in the use of certain diagnostic procedures because of possible teratogenicity like intravenous pyelography and X-ray abdomen. Finally the surgeon is treating two patients simultaneously, the mother and the fetus and must be aware of the potential effects of treatment on both patients at all times .

Recent studies have shown a preponderance in the second trimester, with approximately 30% of cases occurring during the first trimester, 45% during the second trimester and 25% during the third trimester, labor, or puerperium . But in our study 60% of cases were seen during the first trimester and rest during the second trimester. The incidence of appendicitis during pregnancy is equal to non pregnant women of the same age . Appendicitis occurs more frequently during the first two trimesters than the third, as was seen in this study.

During the first six months of pregnancy, symptoms of appendicitis are same as in non pregnant woman. But still, these can be confused with morning sickness and ectopic pregnancy during first trimester and twisted ovarian cyst in early second trimester . During third trimester, patient complains of pain, higher and more lateral in the abdomen or right flank as enlarged uterus leads to displacement and lateral rotation of caecum and appendix. Positional changes of appendix as the pregnancy progresses are shown in Fig 1. The appendix remains in the right iliac fossa during the first trimester, moves to the pelvic brim during second trimester and reaches the lower right upper quadrant in the third trimester. Incidence of perforated diffuse peritonitis is high as infection cannot be localized due to uterine contractions and inability of the omentum to reach inflamed appendix. Guarding and rigidity are difficult to elicit in third trimester due to stretched abdominal muscles Laboratory examination of blood and urine may be of little diagnostic aid (Table 4). Premature labour is seen in about half of women but was seen only in one of the patients in the present study. Fetal mortality is high due to septicaemia and prematurity. Obstetric and nonobstetric conditions mimicking acute appendicitis are enumerated in Table 5. These conditions should be ruled out while evaluating a patient of acute appendicitis.

Positional changes of appendix during pregnancy

Table 4

Laboratory findings in pregnant patients with preoperative diagnosis of appendicitis

Laboratory values Trimester Total %
1 2 3
Leukocyte count
< 10,000/mm3 2 0 0 1 33
10,000-15,000/mm3 1 2 0 3 50
> 15,000/mm3 0 2 0 2 33
Polymorphs > 80% 3 1 0 4 67
Urinalysis
 Pyuria 1 2 0 3 50
 Bacteriuria 1 2 0 3 50

Table 5

Conditions mimicking appendicitis

Nonobstetric Obstetric
Pyelonephritis Ectopic pregnancy
Cholecystitis Threatened abortion
Pancreatitis Abruptio placentae
Gastroenteritis Preterm labour
Renal calculus Round ligament pain
Intestinal obstruction Degenerating uterine fibroid
Salpingitis Chorioamnionitis
Mesenteric adenitis Adnexal torsion

Appendectomy should be performed on suspicion of the presence of appendicitis just as if pregnancy was not present . If surgery is performed before the appendix ruptures, surgery does not disturb the pregnancy as was seen in this study. Once acute appendicitis is suspected in a pregnant patient, we recommend a close working relationship between surgeon, obstetrician and anaesthesiologist to minimize maternal and fetal morbidity and mortality . Hence, early operation for acute appendicitis should be performed whenever diagnosis is considered. Due to difficulty in the diagnosis of acute appendicitis in a pregnant patient, a higher negative laparotomy rate in these patients (20–35%) is acceptable as compared to non pregnant patients (15%). Hence, an aggressive surgical approach is justified. Incidence of perforation increases to 66% if there is delay in removing the appendix after diagnosis has been made, leading to grave consequences. The mortality of appendicitis in pregnancy is due to delayed diagnosis and operation . There is often a tendency amongst obstetricians to relate cases of pain abdomen during pregnancy with the genital organs leading to late referrals and diagnosis. Maternal mortality from appendicitis is now almost zero, and is nearly always associated with unconfirmed perforation and peritonitis. Overall fetal mortality reported is 2–8.5% but increases to 35% in perforation and peritonitis . Preterm labour is a problem, but preterm delivery is rare .

To conclude, appendicitis in pregnancy has always been a difficult problem compared to nonpregnant patients. Early appendectomy is the secret of success and is the treatment of choice recommended at all stages of pregnancy . Factors affecting the type and location of incision in a patient with acute appendicitis are shown in Table 6. Appendectomy is usually performed by a muscle splitting incision over the point of maximum tenderness in the right lower quadrant. Location of the incision is modified with the more advanced gestational age towards right upper quadrant at the point of maximum tenderness. However, if appendix ruptures or abscess forms, emergency exploration by a midline or right paramedian abdominal incision is recommended in the presence of diffuse peritonitis. There is a definite role of diagnostic laparoscopy in patients with right lower quadrant abdominal pain with positive pregnancy test, equivocal evidence of uterine enlargement and in patients with past history of menstrual irregularity or pelvic inflammatory disease . Laparoscopy can be diagnostic and will reduce rate of negative laparotomy and rules out ectopic pregnancy or salpingitis. Computed tomography of the appendix should not be considered during pregnancy because of radiation exposure to the fetus . When the diagnosis of appendicitis is made, laparoscopic appendectomy may be done in early pregnancy and is associated with negligible maternal and fetal complications. The use of helical computed tomography in pregnancy has been brought out recently . However, this was not possible due to lack of facilities in our set up.

Table 6

Factors selecting the type and location of incision

Uterine size

Gestational age

Type of abdominal pain

Location of abdominal pain

Presence of peritonitis

Tocolytic agents have been used successfully if premature contractions set in as was done in 4 patients in this study. Isoxuprine drip was continued for three days as a precautionary measure to stall preterm labour with close monitoring of pulse and blood pressure. Isoxuprine causes peripheral vasodilation causing pooling of blood resulting in tachycardia and hypotension. Due care was given to monitor the drip to avoid these complications. Inj HCG was used empirically in one patient during first trimester pregnancy keeping in mind its utility in cases of threatened abortion during first trimester. It was used with the idea of offering the best to the patient although the basis of its use remains empirical.

Stomach Pain: How to Know If It’s Caused by One of the 15 Body Parts That Could Disappear In the Future

The next time that you drop something on your big toe, feel a twinge of stomach pain or suffer from a toothache, think about this: Some of the body parts that give us the most trouble may one day become extinct. Yep, scientists believe there are at least 15 unnecessary body parts that we can happily live without, including the appendix. Good thing too, because appendicitis is the number one cause of abdominal pain requiring surgery and it can land you in the ER with life-threatening complications if left untreated.

So for those of us who still have an appendix, here’s how to tell if it’s giving you problems or if it could be something else.

Stomach pain: where does it hurt?

Each year, over 10 million Americans go to an emergency room for abdominal pain — more than for any other complaint. When you think about all of the organs that are in there, it’s easy to understand why stomach pain often needs a professional diagnosis. Like chest pain, which is another warning sign that should never be self-diagnosed, stomach pain could indicate a number of different illnesses or conditions.

When to go to the ER with stomach pain.

It’s a good idea to get medical help for stomach pain that is:

  • Severe or prolonged (lasting 24 or more hours)
  • Accompanied by
    • Blood in the urine or stool
    • High fever
    • Nausea or repeated vomiting
    • Dehydration
    • Other serious or unusual symptoms, such as difficulty breathing or change in behavior
  • Localized to one particular area
    • Right upper could indicate cholecystitis or a gallbladder infection
    • Right lower front could indicate appendicitis
    • Right lower back could indicate kidney stones
    • Left upper could indicate a ruptured spleen
    • Left lower front could indicate diverticulitis or a colon infection
    • Left lower back could indicate kidney stones

Passing a kidney stone: beyond a 10.

We won’t belabor this issue because David Cameron, DO, an emergency medicine physician at Medical City McKinney, says passing a kidney stone will be the worst back pain and/or stomach pain of your life. You won’t have to guess if you should see a doctor immediately.

How to prevent kidney stones.

According to the National Kidney Foundation, each year more than half a million people are treated in emergency rooms for problems related to kidney stones. Men are nearly twice as likely to get them as women but they are on the rise across all demographics. High blood pressure, diabetes and obesity may increase risk for kidney stones.

Saravanan Balamuthusamy, MD, a nephrologist at Medical City Fort Worth, says that inflammatory bowel disease and a strong family history of kidney stones can also increase risk. In addition to pain, nausea and vomiting, symptoms can include blood in the urine, pain while urinating, unexplained fevers and urinary tract infections.

Diagnosing kidney stones goes beyond confirming that you have them. Because there are four main types of stones with different causes, in order to help prevent future stones doctors must figure out what kind of stones you have.

However, Dr. Balamuthusamy says there are six things everyone can do to help prevent the formation of kidney stones:

  • Drink at least 60 ounces of water a day to flush stone-causing minerals out of your kidneys €” especially when doing a lot of sweating
  • To help prevent calcium oxalate stones, limit foods containing oxalates and balance them with calcium-rich foods when you do eat them
  • Decrease your salt intake less than 3 grams daily and decrease your intake of sugar and sugary drinks
  • Eat or drink foods high in citrate €” including lemons, limes, oranges and grapefruit €” but be sure to make sugar-free choices
  • Avoid red meat, organ meats, shellfish, alcohol and crash diets/weight loss pills to help prevent uric acid stones
  • Follow the advice of your doctor by sticking to prescribed dietary adjustments and medications – having even one kidney stone greatly increases your chances of having another and for developing chronic kidney disease

As for the other useless body parts that scientists say may one day disappear, those joining the appendix include:

  • Body hair (no more shaving or waxing!)
  • Toes (turns out, we no longer rely on them for balance when walking)
  • Paranasal sinuses (buh-bye sinus infections!)
  • Wisdom teeth (these bad boys are already becoming history, with a large percentage of the population missing one, two, three or even all four)

Until they go the way of the dodo bird, we know how important it is to take care of all of your body parts. When an accident or illness happens, one of our many Medical City Healthcare emergency locations has you covered. With average wait times posted online, if you do have an emergency, you can spend less time waiting and more time on the moments that matter most.

Find a fast Medical City Healthcare ER near you or call our free 24/7 Ask-A-Nurse hotline.

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Symptoms of Appendicitis: Nausea, Fever, Abdominal Pain, and More

How Appendicitis Is Diagnosed — and Sometimes Misdiagnosed

To diagnose appendicitis, your doctor will begin with your medical history and ask more detailed questions about your abdominal pain, other symptoms you’ve experienced, medical conditions you may have, and your alcohol and drug (both legal and illegal) use.

Your doctor will then perform a physical exam and look for signs (2) of an inflamed appendix, including:

  • Rebound tenderness
  • Rovsing’s sign, in which you experience pain in the lower right side of your abdomen when pressure is applied and released on the lower left side of your abdomen
  • Psoas sign, in which flexing your psoas muscles near your appendix causes abdominal pain
  • Obturator sign, in which pain is felt during flexion and internal rotation of the hip
  • Guarding, in which you subconsciously tense your abdominal muscles before your doctor touches your belly

It may also be necessary to examine your rectum, which may be tender from appendicitis.

But these signs don’t necessarily mean you have appendicitis; they can occur with other conditions, too. Your doctor will likely order a number of laboratory tests that will point toward a diagnosis of appendicitis. These can include a blood test to look for signs of infection, a urine test to rule out urinary tract infections and kidney stones, and a pregnancy test if you’re a woman.

Additionally, your doctor may conduct imaging tests, including abdominal ultrasounds and magnetic resonance imaging (MRI) scans. These tests can reveal inflammation and rupturing of the appendix, appendix obstructions that can cause appendicitis, and other sources of abdominal pain. Computerized tomography (CT) scans are also typically used to diagnose appendicitis, but the radiation from CT scans can be harmful to a developing fetus, so CT is usually avoided in pregnant women. (2)

Because the symptoms of appendicitis are similar to so many other conditions, it is sometimes misdiagnosed. A study published in 2011 in the American Journal of Surgery found that almost 12 percent of all appendectomies performed in the United States between 1998 and 2007 occurred in people who did not in fact have appendicitis, but had some other condition. (7)

Additional reporting by Deborah Shapiro.

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