Appendicitis occurs when luminal obstruction or mucosal ulceration begins an inflammatory process. In 1886 Reginald Fitz first accurately described appendicitis. His advocacy of appendectomy was considered heretical. Because many diseases mimic appendicitis, it is frequently misdiagnosed (20%), resulting in delays that are strongly correlated with increased risk of perforation and its sequelae. Between 5% and 10% of the population (about 1 per 1,000) have appendicitis at some time, generally in the second and third decades of life.

Appendicoliths are most frequently the pathologic obstructive agents. Fecaliths, worms, tumors, viral infections, and anatomic lesions may cause obstruction. In the absence of obstruction, infection by Yersinia organisms or lymphoid hyperplasia causes ulcerative processes. Next, normal mucosal secretions become impacted, eventually exceeding the appendix's 0.1- to 0.3-ml capacity. Luminal pressure rises, causing vascular constriction and susceptibility to local bowel flora invasion. Without appendectomy, luminal bacteria multiply until they perforate the appendiceal wall, and gangrene may occur.

• Familial
• Perforation—children under 2 years of age: 70% to 80% increased risk; patients over 70 years of age: 30% increased risk

• Initially, mild periumbilical or epigastric regional pain for four to six hours; increases in severity as inflammation progresses
• McBurney's point (4 to 6 cm from iliac crest along line between iliac crest and umbilicus)—point of maximal localized tenderness
• Rebound tenderness and rigidity—indicates peritonitis
• Unsuccessful urges to defecate or pass gas
• Anorexia (70%)
• Nausea, nonprotracted vomiting
• Temperature—slightly elevated; ³ 101 degrees Fahrenheit with perforation
• Diarrhea—with juxtaposition to sigmoid
• Urinary frequency, dysuria—with juxtaposition to bladder
• Children under 2 years of age—abdominal distention, fever more common
• Patients over 70 years of age—bloating, distention; more atypical presentations
• Psoas sign—pain with passive extension or active flexion of right hip
• Obdurator sign—pain with passive rotation of right hip
• Rovsing's sign—pain referred to the right lower quadrant upon palpation of the left lower quadrant

• Mesenteric lymphadenitis
• Pelvic inflammatory disease
• Ovarian cyst
• Endometriosis
• Gastroenteritis
• Cholecystitis
• Perforated ulcer
• Diverticulitis
• Pancreatitis
• Urinary tract infection
• Testicular torsion

Sequence and duration of symptoms is significant to diagnosis. Consequently, careful history is of great importance. Common physical findings are abdominal tenderness and guarding of the right lower quadrant. Tenderness correlates to location of the appendix; for example, examination will likely reveal rectal pain in the case of retrocecal appendicitis. Rebound tenderness may indicate perforation or abscess. See section entitled Signs and Symptoms for additional information. Vital signs are typically normal; increased heart rate and temperature indicate perforation.

Tests can support but not establish diagnosis.

• Leukocytosis—10,000 to 18,000 cells/microliter (75%), but can be normal; > 20,000 cells/microliter is suggestive of perforation
• Urinalysis—eliminates genitourinary conditions
• Erythrocyte sedimentation rate and C-reactive protein tests—inconclusive

• Luminal obstruction or mucosal ulceration
• Luminal pressure may be as high as 60 cm H₂O
• Appendix becomes hypoxic, mucosa ulcerate, bacteria invade, and further swelling ensues
• Venous engorgement, arterial compromise of appendiceal wall
• Perforation into peritoneal cavity (80% at 48 hours), resulting in peritonitis
• Localized abscess—terminal ileum, cecum, or the omentum may wall off appendiceal area

• Radiography—rarely valuable; may reveal opaque fecalith
• Ultrasound—excludes ovarian cysts, ectopic pregnancy, tubo-ovarian abscess; 87% to 96% accuracy diagnosing appendicitis
• Computed tomography (CT)—98% accuracy and reduction in hospital costs; rectally administered contrast material and CT, following ultrasound, correctly changed management for 73.1% of children studied
• Barium enema—questionable value; appendicitis unlikely with luminal filling
• Leukocyte scanning with indium-111 or technetium-99m—labels leukocytes and scans lower abdomen; high indeterminate rate

• Laparoscopy—high rate of negative findings (20%; 45% in women 21 to 40 years)
• Scoring systems combining aspects of history, physical exam and routine lab tests are thought to be accurate, but are cumbersome and not easily remembered.

Diagnostic tests should not delay treatment of apparent appendicitis. With moderate clinical probability, prompt exploratory surgery and/or appendectomy are necessary to reduce complications. Such patients should refrain from taking anything by mouth; be given intravenous hydration or parenteral anti-emetics if needed; and begin prophylactic antibiotic therapy.

• Broad-spectrum antibiotics—can mask perforation when given before diagnosis. If an operation is undertaken in the presence of a palpable mass and if a phlegmon is discovered and complications arise from dissecting the phlegmon, then the patient should be treated with broad-spectrum antibiotics, parenteral fluids, and rest. Resolution of the mass and complications can be expected within one week following treatment.
• Parenteral fluids—for abscess, dehydration. Also, see statement under broad-spectrum antibiotics.

• Appendectomy—curative
• Laparoscopic appendectomy—curative, faster recovery
• Interval appendectomy—with abscess first treated with antibiotics, intravenous fluids, possibly surgical drainage; elective appendectomy six weeks to three months later.

As discussed, acute appendicitis is a medical emergency and should be treated as such. According to the studies that follow, certain nutritional practices may help to prevent appendicitis or possibly enhance immunity. Also, non-Western medical approaches (particularly Traditional Chinese Medicine (TCM) with the use of herbal remedies and/or acupuncture) document some interesting historical practices for treating appendicitis.

On the other hand, certain folk remedies may exacerbate or mimic appendicitis, or directly precipitate an acute appendicitis. For instance, traditional Mexican American remedies used to treat stomach upset include elemental mercury or lead salts which may confuse the presenting picture by producing abdominal pain, nausea, vomiting, and malaise (McKinney 1999).

An epidemiological study in England and Wales investigated the hypothesis that acute appendicitis may be caused by insufficient intake of dietary fiber and excessive consumption of sugar and meat. To determine possible correlation with rates of acute appendicitis, the study evaluated the household food purchases of 49,690 patients discharged from the hospital following acute appendicitis. Significant negative correlations were found between acute appendicitis and consumption of fresh and frozen green vegetables and fresh and processed tomatoes, i.e., the more fresh and frozen green vegetables and fresh and processed tomatoes consumed, the less likely the appendicitis. (Ninety-five percent of the green vegetables consumed were cabbages, cauliflowers, peas, beans, Brussels sprouts, and leafy salad vegetables. All but leafy salad vegetables were negatively correlated with appendicitis.) The researchers concluded that consumption of green vegetables and possibly tomatoes may have a protective effect against appendicitis (Barker et al. 1986).

Other foods were less conclusive, showed no effect, or showed an effect that was not independent of the consumption of green vegetables. Fruit consumption, specifically of bananas and pitted fruit, showed mixed results. Sugar consumption was only weakly associated with appendicitis. No significant association was found with breads, meat, and fish, root vegetables, and total dietary fiber (Barker et al. 1986).

The authors hypothesize that the ultimate pathogenesis of appendicitis is the invasion of the distal appendicular wall by organisms common to appendicular flora. Incompletely digested green vegetables may positively influence the substrate of the bacterial flora (Barker et al. 1986)

The link between altered gut flora and immune modulation is further explored in a case-incidence, population-based, case-control study evaluating the relationship between breast-feeding and acute appendicitis. Interviews were conducted with two groups, the mothers of 222 children admitted to the hospital with acute appendicitis (treatment group) and the mothers of 222 randomly selected children living in the area (control group). A significant finding was that children with acute appendicitis were less likely to have been breast-fed over a prolonged period of time in comparison with the control group. The authors hypothesize that the immune components of human milk enhance immunity and decrease the severity of infection along with associated inflammatory reactions. A lowered inflammatory response could also be due to a more tolerant lymphoid tissue at the base of the appendix (Pisacane et al. 1995).

Traditional Chinese herbal therapies may be efficacious in the treatment of appendicitis; although sufficient research has not yet been carried out on either the use of Chinese or Western herbs to draw conclusions, it is interesting to consider some of the case reports from a TCM perspective. In a report of 425 cases of acute appendicitis treated with Chinese herbal preparations, with or without antibiotics, most did well and did not require surgery. Of the 425 cases, 397 (93.4%) were cured with TCM alone, 16 (3.8%) with TCM and antibiotics together, and 12 (2.8%) with surgical intervention following the failure of medication. Thirty cases (7%) had acute relapse shortly after recovery. The herbal mixture specific for appendicitis was given orally once or twice daily depending on disease stage. This formula was supplemented with additional herbs in cases of high fever and thirst, chronic recurrent appendicitis, peritonitis, appendiceal abscess, or paralytic intestinal obstruction. In cases with appendiceal abscess or mass, the original herbal mixture was further supplemented and applied externally with local iontophoresis (Chin Med J Engl 1977) Iontophoresis, or ion therapy, is the therapeutic transfer of topical solutions into bodily tissues by means of electrical currents (Hull 1997).

One hundred of the 397 nonsurgical cases cured with TCM with or without antibiotics were followed for three to twelve months. Of these, 85 completely recovered, 8 had occasional vague pain in the hypogastrium, and 7 relapsed. Pathological exams were made of 67 appendices from patients who had been clinically cured with the herbal anti-appendicitis preparation but received elective appendectomies (interval appendectomy— see section entitled Surgery above) shortly after treatment. Histopathological evaluation revealed resolution of inflammation in 64.2% of the appendices, amelioration in 16.4%, and a tendency toward amelioration in 4.5% (Chin Med J Engl 1977).

Some examples of herbal therapies used in TCM include: detoxifying and antipyretic herbs (Flos lonicerae, Fructus forsythiae, Herba taraxaci, Patrinia scabioseafolia, Gypsum fibrosum); herbs to stimulate circulation (Semen persicae, Radix paeoniae rubra, Squama manitis, Spina gleditsiae); and laxatives (Rhizoma rhei, Mirabilitum depuratum) (Chin Med J Engl 1977).

In a separate report of 1200 patients with acute appendicitis, a combination of Western and Chinese herbal treatments was used. Ninety-four percent of the patients recovered without surgery. The researchers recommend nonoperative treatment for cases of simple appendicitis, mild suppurative appendicitis, and acute appendicitis with abscess (Wu 1979).

Not everyone would agree with these recommendations, however. At the time of the reports mentioned, a UCLA physician points out that standards of practice differ in China and the U.S. Clinical standards in the U.S. favor surgery for suspected perforation or even mild suppurative appendicitis. In addition, the author questions whether the original diagnosis of acute appendicitis was accurate for the 1200 cases reported by the Institute for Acute Abdominal Diseases in 1979. A number of U.S. hospitals have found that the final diagnosis of acute appendicitis is typically 15% to 20% inaccurate in cases where the signs and symptoms are serious enough to warrant surgery (Longmire 1979). In addition, the data reported in the TCM studies are from the 1970s. Given the lack of more up-to-date research, it is unclear whether present-day Chinese practices more closely resemble current Western practices.

The efficacy of this modality has not been subjected to scientific scrutiny in the treatment of appendicitis. Belladonna and Bryonia are classic homeopathic remedies used for an inflamed appendix, and administration of the appropriate remedy may alleviate symptoms and hasten resolution of appendicitis even in the acute setting when used as an adjunct to conventional Western medicine.

The therapeutic mechanism of acupuncture in the treatment of acute abdominal conditions is complex but appears to involve analgesia, regulation of peristalsis, and increased intra-abdominal circulation. Clinical cases suggest that acupuncture may be applied in cases of acute simple appendicitis and mild cases of suppurative appendicitis. Point prescription includes zusanli (V 36), lanwei (Extra 33), ah shi points (local tenderness), and points corresponding to symptoms, such as shangwan (RM 13) and neiguan (PC 6) for nausea and vomiting, quchi (IC 11) and hegu (IC 4) for fever, and tianshu (V 25) for distention. Auricular needling at appendix, sympathetic nerve, and shenmen points is suggested. Electroacupuncture may also be employed. In Chinese medical terms, acute abdominal syndromes are related to manifestations of excessiveness and heat; appendicitis specifically is thought to be caused by obstruction of circulation of vitality and blood. (This is not too dissimilar to the Western definition—see section entitled Etiology above (Fan and Zhang 1983; Zheng et al. 1985). Close observation of the patient with appendicitis should always be exercised in order to proceed with surgical intervention if necessary (Zheng et al. 1985).

Some reports suggest that acupuncture has been used clinically to treat appendicitis without the need for herbs or Western medications. A case report of 633 inpatients with acute appendicitis revealed an overall effectiveness rate of 93.7% with 395 cases (62.4%) cured, 198 (31.3%) improved, and 40 (6.3%) unavailable. Total effective rate for simple appendicitis was 95.1%, and for suppurative, 93.6%. Acupuncture was not effective for cases of perforation with peritonitis. Long-term effects on 461 of these cases showed 179 patients (38.8%) did not need surgery; 272 (59.0%) required appendectomy of which 39 (8.5%) were due to acupuncture treatment failure; 227 (49.2%) required appendectomy due to recurrence; and 6 (1.3%) underwent appendectomy incidental to other unrelated abdominal operations. The 10 remaining patients (2.2%) died of unrelated conditions. During a 19- to 21-year follow-up, 145 (81%) of the 179 intact cases remained well without relapse and 34 (19%) suffered recurrences (Fan and Zhang 1983).

Contraindicated in appendicitis.

• Serial abdominal examinations over 6 to 12 hours—improves diagnostic accuracy, decreases negative laparotomies
• Postoperative visits recommended in weeks 2 and 6, particularly to monitor wound healing

See section entitled Nutrition for some considerations

• Recurrent appendicitis—often with complete resolution between episodes
• Perforation—localized or disseminated peritonitis and intra-abdominal or pelvic abscess; sepsis; obstruction of fallopian tube, infertility; increases hospital stay and mortality rate
• Wound infection—35% with perforation
• Pneumoperitoneum, small bowel obstruction, pylephlebitis (rare)

• Mortality rate: without perforation—0.1%; with perforation—3% to 6%; 0.24% for children; as high as 15% for elderly

• Appendicitis occurs in approximately 1 in 1,000 pregnancies
• First to second trimester—mild discomfort, nausea mimic pregnancy symptoms
• Third trimester—enlarging uterus causes displacement of cecum and appendix laterally and to right upper quadrant

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