What are the symptoms and treatment of appendicitis?

Appendicitis Symptoms and Treatment

Acute appendicitis classically presents with periumbilical pain that migrates to the right lower quadrant, accompanied by anorexia, nausea, vomiting, and low-grade fever, though this complete triad occurs in only a minority of patients, particularly in elderly and very young populations. 1

Classic Clinical Presentation

Key Symptoms:

• Periumbilical pain migrating to the right lower quadrant (RLQ) - the most characteristic symptom pattern 1, 2
• Anorexia - nearly universal when present 1, 2
• Nausea and vomiting - common but nonspecific 1, 2
• Low-grade fever - present in 30-80% of cases, though frequently absent in elderly patients 1
• RLQ tenderness - most reliable physical finding 1, 3

Physical Examination Findings:

• Abdominal rigidity and guarding - highly predictive, especially in adults 3
• Rebound tenderness - indicates peritoneal irritation 1
• Positive Rovsing sign (pain in RLQ with palpation of left lower quadrant) - reliable in children 3
• Positive psoas sign (pain with hip extension) - suggests retrocecal appendix 3
• Positive obturator sign (pain with internal hip rotation) - indicates pelvic appendix 3
• Decreased or absent bowel sounds - particularly reliable in children 3

Age-Specific Variations

Pediatric Patients (<5 years):

• More frequently present with atypical symptoms 1
• Higher rate of perforated appendicitis due to delayed diagnosis 1
• Diagnosis is more challenging and less reliable based on clinical findings alone 1

Elderly Patients (>65 years):

• The classic triad is infrequently observed - only a minority present with all typical symptoms together 1
• More signs of advanced disease at presentation including abdominal distension, generalized tenderness, palpable mass 1
• Symptoms may mimic ileus or bowel obstruction 1
• Delayed presentation is common, with longer time from symptom onset to admission 1
• Lower rate of correct preoperative diagnosis compared to younger patients 1
• Fever may be absent despite significant disease 1

Diagnostic Approach

Clinical Scoring Systems:

• Alvarado Score and Pediatric Appendicitis Score help stratify patients into low, intermediate, and high-risk categories 1, 3
• These scores are most useful for excluding appendicitis in low-risk patients and identifying high-risk patients who may proceed directly to surgery 1
• Do not rely on scoring systems alone for diagnosis in elderly patients 1
• Imaging is essential for intermediate-risk patients where clinical assessment is equivocal 1

Laboratory Findings:

• Elevated white blood cell count - common but not diagnostic 1
• Elevated C-reactive protein (CRP) - particularly high values (>101.9 mg/L) suggest perforation in elderly 1
• Normal inflammatory markers have high negative predictive value (100% in some studies) for excluding appendicitis 1
• Do not base diagnosis on laboratory tests alone - insufficient diagnostic accuracy, especially in elderly 1

Imaging:

• Ultrasound is recommended as first-line imaging, particularly in children and pregnant women 3
• CT scan is highly accurate for diagnosis and identifying complications 2, 3
• Imaging facilitates management and decreases negative appendectomy rates in children 1

Treatment

Standard Surgical Management:

• Laparoscopic appendectomy within 24 hours of diagnosis is the gold standard treatment 4
• Laparoscopic approach is superior to open surgery with less pain, lower surgical site infection rates, shorter hospital stays, and earlier return to work 4
• Conventional three-port laparoscopic technique is preferred over single-incision approaches 4
• Single preoperative dose of broad-spectrum antibiotics is mandatory for all patients undergoing appendectomy 4
• For uncomplicated appendicitis, postoperative antibiotics are not recommended 4
• For complicated appendicitis with adequate source control, limit antibiotics to 3-5 days postoperatively 4

Antibiotic-First Approach (Selected Patients):

• Antibiotics alone successfully treat uncomplicated appendicitis in approximately 70% of patients 2
• Broad-spectrum regimens include piperacillin-tazobactam monotherapy or cephalosporins/fluoroquinolones with metronidazole 2
• High-risk CT findings predict antibiotic failure: appendicolith, mass effect, appendiceal diameter >13mm (≈40% failure rate) 2
• Patients without high-risk CT findings may consider either appendectomy or antibiotics as first-line 2
• After one year, only 63-73% of antibiotic-treated patients remain asymptomatic without recurrence 5, 2

Complicated Appendicitis with Abscess/Phlegmon:

• Early laparoscopic appendectomy is preferable to non-operative management when laparoscopic expertise is available 1
• Conservative management (antibiotics ± percutaneous drainage) may be considered for large abscesses, though 25.7% fail and require surgery 1
• Percutaneous drainage followed by antibiotics is an option for hemodynamically stable patients with large abscesses 6

Intraoperative Decisions:

• Remove the appendix even if it appears normal during surgery when no other pathology is found in symptomatic patients 1, 4
• Surgeon's macroscopic judgment is inaccurate - 19-40% of normal-appearing appendices show pathological changes on histology 1
• Do not routinely place abdominal drains following appendectomy for complicated appendicitis 4

Special Populations

Pregnant Patients:

• Should undergo timely surgical intervention to decrease risk of complications 6
• Appendicitis is the most common nonobstetric surgical emergency during pregnancy 3

Immunosuppressed/Transplant Patients:

• Should undergo appendectomy as soon as possible, usually within 24 hours 4, 6
• May lack typical leukocytosis but typically have elevated CRP 4

Patients ≥40 Years with Complicated Appendicitis:

• Both colonoscopy and interval contrast-enhanced CT scan are recommended for follow-up due to higher incidence of appendicular neoplasms 4
• Routine histopathological examination of all appendectomy specimens is mandatory to avoid missing unexpected malignancy 4

Critical Pitfalls to Avoid

• Do not delay appendectomy beyond 24 hours from admission - increases risk of adverse outcomes 4
• Do not rely solely on clinical signs and symptoms for diagnosis, especially in elderly patients 1
• Do not base diagnosis on scoring systems alone in elderly patients 1
• Do not base diagnosis on elevated WBC and CRP alone - insufficient diagnostic accuracy 1
• Do not leave a normal-appearing appendix in place during surgery for suspected appendicitis when no other pathology is found 1, 4
• Do not skip histopathological examination - may miss unexpected findings including malignancy 4