Table of contents · 10 sections
In a nutshell. Acute appendicitis is the most common acute surgical condition (7% lifetime risk). Clinical presentation: visceral epigastric pain shifting to the right lower quadrant (Kocher's sign), nausea, anorexia, low-grade fever. Key signs: Blumberg's, Rovsing's, Sitkovskiy's, Bartomier-Michelson's, Psoas (Obraztsov's), Cope's (obturator) signs. Scoring systems: Alvarado (< 4 low, 4–6 intermediate, ≥ 7 high risk) and AIR. Ultrasound is preferred in children and pregnant women; CT is the standard in adults. Treatment — laparoscopic appendectomy; non-operative antibiotic therapy is an option for uncomplicated appendicitis in adults (APPAC trial).
1. Anatomy and pathogenesis
- The appendix arises from the cecum; length 5–15 cm.
- Positions: pelvic, retrocecal, retroperitoneal, subhepatic, medial — determine the clinical picture.
- Blood supply: appendicular artery (branch of the ileocolic artery).
- Pathogenesis: luminal obstruction (fecalith, lymphoid hyperplasia, tumor, parasites) → ↑ pressure → ischemia → bacterial invasion → catarrhal → phlegmonous → gangrenous → perforated appendicitis.
- From onset to perforation — 24–72 hours on average.
2. Clinical presentation
- Kocher-Volkovitch sign — migration of pain from the epigastrium to the right lower quadrant.
- Anorexia, nausea, vomiting 1–2 times.
- Low-grade fever (> 38 °C — in destructive forms).
- Tachycardia.
- Localized tenderness at McBurney's point (junction of the middle and outer thirds of the line from the umbilicus to the ASIS).
- Constipation or diarrhea (in pelvic position).
- Dysuria (with bladder-pelvic contact).
3. Symptoms
| Sign | Description |
|---|---|
| Blumberg's sign | Increased pain upon sudden release of pressure from the abdomen — sign of peritoneal irritation |
| Rovsing's sign | Pain in the right lower quadrant elicited by ballotment in the left lower quadrant |
| Sitkovskiy's sign | Increased pain in the right lower quadrant when turning to the left side |
| Bartomier-Michelson's sign | Increased pain upon palpation while lying on the left side |
| Obraztsov's sign (psoas sign) | Pain upon lifting and resisting the straightened right leg — retrocecal |
| Cope's sign (obturator sign) | Pain upon internal rotation of the flexed right leg — pelvic appendicitis |
| Voskresensky's sign ("shirt sign") | Pain upon sliding a hand over a taut shirt from the epigastrium to the right lower quadrant |
| Razdolsky's sign | Painful percussion in the right lower quadrant |
| Dumbadze's sign | Tenderness upon palpation through the umbilicus (peritonitis) |
4. Alvarado score
| Sign | Score |
|---|---|
| Migration of pain | 1 |
| Anorexia | 1 |
| Nausea/vomiting | 1 |
| Right lower quadrant tenderness | 2 |
| Blumberg's sign | 1 |
| Temperature > 37.3 °C | 1 |
| Leukocytosis > 10 × 10⁹ | 2 |
| Shift to the left | 1 |
- 0–4: low risk, observe.
- 5–6: intermediate, CT/US.
- 7–10: high, surgery.
AIR score (Appendicitis Inflammatory Response)
- Includes CRP; more sensitive in adults, especially women.
5. Diagnostics
- Clinical examination + scoring systems.
- CBC: leukocytosis, left shift, CRP.
- Urinalysis: rule out renal pathology; leukocyturia may occur with pelvic appendicitis.
- Ultrasound: first-line for children, pregnant women, and slim adults; sensitivity 85%, specificity 90%. Criteria: diameter > 7 mm, non-compressibility, "target sign", free fluid, increased echogenicity of surrounding fat.
- Abdominal CT with IV contrast: gold standard in adults, sensitivity/specificity > 95%.
- MRI: pregnant women with inconclusive ultrasound.
- β-hCG — in women of reproductive age (to rule out ectopic pregnancy).
6. Differential Diagnosis
- Gynecological: ovarian torsion, follicular cyst rupture, ectopic pregnancy, PID.
- Urological: renal colic, pyelonephritis.
- Gastrointestinal: mesenteric lymphadenitis, ileitis in yersiniosis/Crohn's disease, diverticulitis (incl. Meckel's), intussusception in children.
- Extra-abdominal: right-sided pneumonia with pleural reaction, diabetic ketoacidosis.
- Other: acute cholecystitis, perforated peptic ulcer.
7. Complications of Appendicitis
- Perforation → generalized peritonitis.
- Appendiceal infiltrate — a dense, painful mass in the right iliac fossa; management: conservative (antibiotics) for 4–6 weeks → interval appendectomy (sometimes unnecessary).
- Appendiceal abscess — percutaneous drainage under US/CT guidance, antibiotic therapy, interval surgery in 6–8 weeks.
- Pylephlebitis (ascending thrombosis of the portal vein) — rare, formidable.
- Sepsis.
8. Treatment
Surgical (Standard)
- Laparoscopic appendectomy — preferred (less pain, wound infection, faster recovery).
- Open — for complicated cases, lack of equipment, pregnancy (individually).
- Perioperative antibiotic therapy: cefoxitin or ceftriaxone + metronidazole.
- For complicated cases (peritonitis): carbapenems or ceftriaxone + metronidazole, 4–7 days.
Conservative
- Uncomplicated appendicitis in adults — antibiotic treatment is an option (APPAC, CODA trials).
- Recurrence — 30–40% within 5 years.
- Indications: patient refusal of surgery, high surgical risk, complex logistics.
Special Populations
- Pregnant women: higher risk of perforation (physiological immunosuppression, displacement). Ultrasound/MRI. Laparoscopy is safe in the 2nd trimester.
- Children: more difficult diagnosis (atypical presentation, rapid perforation), ultrasound is the primary method.
- Elderly: often atypical presentation, delayed diagnosis; mortality up to 10% in case of perforation.
9. Perioperative Management
- Preoperative antibiotic prophylaxis 30–60 minutes before incision.
- Early mobilization and feeding (ERAS).
- Analgesia: multimodal (paracetamol, NSAIDs, opioids if necessary).
- Wound care, monitoring for infectious complications.
- If the appendix appears normal during surgery — exploration: Meckel's diverticulum, ileitis, uterine adnexa.
10. FAQ
When is conservative therapy acceptable?
Uncomplicated appendicitis in adults without an appendicolith: antibiotics + observation. One-third require subsequent surgery within a year. The patient must be informed of this option as an alternative.
Why is "abdominal flushing" dangerous in suspected appendicitis?
An obsolete practice. Active heat procedures and enemas accelerate perforation. NPO only, IV fluids, antibiotics, surgical evaluation.
Why is appendicitis dangerous in pregnant women?
Atypical localization (displaced superiorly and laterally), masked by pregnancy-related nausea, difficult diagnosis. Perforation → peritonitis → ↑ fetal loss up to 30%.
How to differentiate appendicitis from an ectopic pregnancy?
Positive β-hCG, lower abdominal pain radiating to the shoulder upon rupture, hemodynamic instability, ultrasound showing pelvic fluid without an intrauterine pregnancy.
What is an appendiceal infiltrate?
A dense, painful, localized mass — a local peritoneal response. Management: conservative (antibiotic therapy + cold, rest) for 4–6 weeks. Surgery in the "cold" interval if symptoms persist. Abscess — percutaneous drainage.
See also: Peritonitis · Intestinal obstruction · PID · Cholecystitis · Surgery Catalog