Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

154 Appendicitis

Signs & Symptoms

■Pain most common presenting symptom

■Early pain visceral; often periumbilical or diffuse, may not be recalled

by pt

■Later pain may be more localized, typically to RLQ

■Late pain may be atypical if appendiceal location unusual: eg, if

retrocecal, in low pelvis, in LLQ, or other locations

■Anorexia very common

■Nausea common but almost never precedes pain

■Vomiting variably present & not usually severe

■Duration of symptoms important: perforation unusual w/ symptoms

<24 h; high fever & toxicity unusual w/ short history of symptoms

■Localized tenderness in RLQ most reliable sign

■Fever variably present: less common w/ shorter duration of symp-

toms, more likely w/ perforation

■CVA tenderness suggests retrocecal appendicitis (or other diagnosis)

■If right adnexal tenderness or anterior rectal tenderness present,

consider pelvic appendicitis

■Distal small bowel obstruction in young pt w/o prior abdominal

surgery likely to be appendicitis w/ abscess

➣Difficult hosts to diagnose appendicitis:

Pregnancy

Diabetes

Infants & young children

tests

Laboratory

■WBC more likely? or left shifted w/ greater duration of appendicitis:

may be normal in 1/3 or more of pts

Imaging

■Plain abdominal x-ray: highly suggestive of appendicitis if fecalith

present; distal small bowel obstruction in young pt w/o prior surgery

likely to be appendiceal abscess

■Appendiceal US >90% sensitive in thin pts by experienced

ultrasonographer; normal appendixes not usually identified

■Abdominal CT+/−contrast probably >90% sensitive & specific for

appendicitis

differential diagnosis

■Mesenteric lymphadenitis

■Diverticulitis