Appendicitis - Revision history

Danbot: Embed Alvarado Calculator on clinical page

2026-03-22T09:55:50Z

Embed Alvarado Calculator on clinical page

← Older revision		Revision as of 09:55, 22 March 2026
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	*If appendicitis suspected but imaging equivocal: observation with serial exams or repeat imaging in 6-12 hours		*If appendicitis suspected but imaging equivocal: observation with serial exams or repeat imaging in 6-12 hours
	*Discharge with close follow-up only if alternative diagnosis confirmed and appendicitis reliably excluded		*Discharge with close follow-up only if alternative diagnosis confirmed and appendicitis reliably excluded

			== Calculators ==
			{{Alvarado Calculator}}

	==See Also==		==See Also==

Danbot: Strip excess bold

2026-03-22T09:29:25Z

Strip excess bold

← Older revision		Revision as of 09:29, 22 March 2026
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	==Background==		==Background==
	*'''Most common surgical emergency''' worldwide		*'''Most common surgical emergency''' worldwide
	*Lifetime risk: ~~'''~~~7-8%~~'''~~ (peak incidence ages 10-30)		*Lifetime risk: ~7-8% (peak incidence ages 10-30)
	*Pathophysiology: ~~'''~~luminal obstruction~~'''~~ (fecalith, lymphoid hyperplasia, rarely tumor) → bacterial overgrowth → wall inflammation → ischemia → perforation		*Pathophysiology: luminal obstruction (fecalith, lymphoid hyperplasia, rarely tumor) → bacterial overgrowth → wall inflammation → ischemia → perforation
	*~~'''~~Perforation risk increases with time~~'''~~: ~2% at 24 hours, increasing to ~50% by 72 hours		*Perforation risk increases with time: ~2% at 24 hours, increasing to ~50% by 72 hours
	*Atypical presentations common in: children, elderly, pregnant women, immunocompromised		*Atypical presentations common in: children, elderly, pregnant women, immunocompromised

	==Clinical Features==		==Clinical Features==
	===Classic Presentation===		===Classic Presentation===
	*~~'''~~Periumbilical pain migrating to RLQ~~'''~~ over 12-24 hours (migration is most specific historical feature)		*Periumbilical pain migrating to RLQ over 12-24 hours (migration is most specific historical feature)
	*~~'''~~Anorexia~~'''~~ (nearly universal; absence should raise doubt)		*Anorexia (nearly universal; absence should raise doubt)
	*Nausea, vomiting (usually after onset of pain)		*Nausea, vomiting (usually after onset of pain)
	*Low-grade [[fever]] (high fever suggests perforation/abscess)		*Low-grade [[fever]] (high fever suggests perforation/abscess)

	===Physical Exam===		===Physical Exam===
	*~~'''~~McBurney point tenderness~~'''~~ (1/3 distance from ASIS to umbilicus)		*McBurney point tenderness (1/3 distance from ASIS to umbilicus)
	*~~'''~~Rovsing sign~~'''~~: RLQ pain with LLQ palpation		*Rovsing sign: RLQ pain with LLQ palpation
	*~~'''~~Psoas sign~~'''~~: RLQ pain with right hip extension (retrocecal appendix)		*Psoas sign: RLQ pain with right hip extension (retrocecal appendix)
	*~~'''~~Obturator sign~~'''~~: RLQ pain with internal rotation of flexed right hip (pelvic appendix)		*Obturator sign: RLQ pain with internal rotation of flexed right hip (pelvic appendix)
	*~~'''~~Rebound tenderness~~'''~~ and ~~'''~~guarding~~'''~~ (peritoneal irritation)		*Rebound tenderness and guarding (peritoneal irritation)
	*~~'''~~Dunphy sign~~'''~~: increased pain with coughing		*Dunphy sign: increased pain with coughing

	===Atypical Presentations===		===Atypical Presentations===
	*~~'''~~Retrocecal appendix~~'''~~ (~30%): flank or back pain, positive psoas sign, less peritoneal irritation		*Retrocecal appendix (~30%): flank or back pain, positive psoas sign, less peritoneal irritation
	*~~'''~~Pelvic appendix~~'''~~: suprapubic pain, urinary symptoms, diarrhea		*Pelvic appendix: suprapubic pain, urinary symptoms, diarrhea
	*~~'''~~Pregnant women~~'''~~: RUQ pain (displaced appendix); less peritoneal signs; higher perforation rate<ref>Mourad J, et al. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. ''Am J Obstet Gynecol''. 2000;182(5):1027-1029. PMID 10819817</ref>		*Pregnant women: RUQ pain (displaced appendix); less peritoneal signs; higher perforation rate<ref>Mourad J, et al. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. ''Am J Obstet Gynecol''. 2000;182(5):1027-1029. PMID 10819817</ref>
	*~~'''~~Elderly~~'''~~: delayed presentation, less fever, higher perforation rate (~50%)		*Elderly: delayed presentation, less fever, higher perforation rate (~50%)
	*~~'''~~Children <5~~'''~~: nonspecific symptoms; perforation common by presentation		*Children <5: nonspecific symptoms; perforation common by presentation

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
	===Labs===		===Labs===
	*~~'''~~WBC~~'''~~: elevated in ~80% (but ~~'''~~normal WBC does NOT exclude appendicitis~~'''~~)		*WBC: elevated in ~80% (but normal WBC does NOT exclude appendicitis)
	*~~'''~~CRP~~'''~~: elevated; ~~'''~~combined normal WBC + normal CRP has high NPV~~'''~~		*CRP: elevated; combined normal WBC + normal CRP has high NPV
	*~~'''~~Urinalysis~~'''~~: mild pyuria/hematuria may occur (inflammation adjacent to ureter) — does not exclude appendicitis		*Urinalysis: mild pyuria/hematuria may occur (inflammation adjacent to ureter) — does not exclude appendicitis
	*~~'''~~Pregnancy test~~'''~~ in all reproductive-age women		*Pregnancy test in all reproductive-age women
	*~~'''~~Lipase~~'''~~ if epigastric component		*Lipase if epigastric component

	===Clinical Decision Rules===		===Clinical Decision Rules===
	*~~'''~~Alvarado Score (MANTRELS)~~'''~~: Migration, Anorexia, Nausea, Tenderness RLQ, Rebound, Elevation of temp, Leukocytosis, Shift to left		*Alvarado Score (MANTRELS): Migration, Anorexia, Nausea, Tenderness RLQ, Rebound, Elevation of temp, Leukocytosis, Shift to left
	**Score ≤3: low risk; 4-6: moderate; ≥7: high probability		**Score ≤3: low risk; 4-6: moderate; ≥7: high probability
	*~~'''~~AIR Score~~'''~~ (Appendicitis Inflammatory Response): incorporates CRP		*AIR Score (Appendicitis Inflammatory Response): incorporates CRP
	*'''These scores help risk-stratify but do NOT replace clinical judgment'''		*'''These scores help risk-stratify but do NOT replace clinical judgment'''

	===Imaging===		===Imaging===
	====CT Abdomen/Pelvis with IV Contrast (Test of Choice in Adults)====		====CT Abdomen/Pelvis with IV Contrast (Test of Choice in Adults)====
	*~~'''~~Sensitivity 94-98%, specificity 95%~~'''~~		*Sensitivity 94-98%, specificity 95%
	*Findings: enlarged appendix ~~'''~~> 6 mm~~'''~~ diameter, periappendiceal fat stranding, appendicolith, wall enhancement		*Findings: enlarged appendix > 6 mm diameter, periappendiceal fat stranding, appendicolith, wall enhancement
	*Signs of perforation: abscess, extraluminal air, phlegmon		*Signs of perforation: abscess, extraluminal air, phlegmon
	*~~'''~~Oral contrast generally NOT needed~~'''~~		*Oral contrast generally NOT needed

	====Ultrasound (First-line in Pediatrics and Pregnancy)====		====Ultrasound (First-line in Pediatrics and Pregnancy)====
	*~~'''~~Sensitivity 86%, specificity 81%~~'''~~ (operator dependent)		*Sensitivity 86%, specificity 81% (operator dependent)
	*Findings: non-compressible appendix ~~'''~~> 6 mm~~'''~~, target sign, periappendiceal fluid		*Findings: non-compressible appendix > 6 mm, target sign, periappendiceal fluid
	*~~'''~~If US equivocal in pediatrics~~'''~~: MRI preferred over CT to avoid radiation		*If US equivocal in pediatrics: MRI preferred over CT to avoid radiation

	====MRI (Alternative in Pregnancy)====		====MRI (Alternative in Pregnancy)====
	*~~'''~~Sensitivity 94%, specificity 97%~~'''~~		*Sensitivity 94%, specificity 97%
	*Preferred over CT in pregnancy (no radiation)		*Preferred over CT in pregnancy (no radiation)

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	===Uncomplicated Appendicitis===		===Uncomplicated Appendicitis===
	*'''NPO, IV fluids, pain control''' (analgesics do NOT mask peritoneal signs)		*'''NPO, IV fluids, pain control''' (analgesics do NOT mask peritoneal signs)
	*~~'''~~Pre-operative antibiotics~~'''~~: cefoxitin 2g IV or ceftriaxone + metronidazole		*Pre-operative antibiotics: cefoxitin 2g IV or ceftriaxone + metronidazole
	*~~'''~~Laparoscopic appendectomy~~'''~~ (standard of care)		*Laparoscopic appendectomy (standard of care)
	*~~'''~~Antibiotics-first approach~~'''~~: emerging evidence supports nonoperative management with antibiotics alone for selected uncomplicated appendicitis (CODA trial)<ref>CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. ''N Engl J Med''. 2020;383(20):1907-1919. PMID 33017106</ref>		*Antibiotics-first approach: emerging evidence supports nonoperative management with antibiotics alone for selected uncomplicated appendicitis (CODA trial)<ref>CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. ''N Engl J Med''. 2020;383(20):1907-1919. PMID 33017106</ref>
	**~30% failure/recurrence rate at 1 year		**~30% failure/recurrence rate at 1 year
	**Shared decision-making with patient and surgeon		**Shared decision-making with patient and surgeon

	===Complicated Appendicitis (Perforated/Abscess)===		===Complicated Appendicitis (Perforated/Abscess)===
	*~~'''~~Broad-spectrum antibiotics~~'''~~: piperacillin-tazobactam 3.375-4.5g IV OR ceftriaxone + metronidazole		*Broad-spectrum antibiotics: piperacillin-tazobactam 3.375-4.5g IV OR ceftriaxone + metronidazole
	*Small ~~'''~~phlegmon/abscess (<3 cm)~~'''~~: antibiotics + interval appendectomy in 6-8 weeks		*Small phlegmon/abscess (<3 cm): antibiotics + interval appendectomy in 6-8 weeks
	*~~'''~~Large abscess (>3 cm)~~'''~~: CT-guided percutaneous drainage + antibiotics + interval appendectomy		*Large abscess (>3 cm): CT-guided percutaneous drainage + antibiotics + interval appendectomy
	*~~'''~~Peritonitis/sepsis~~'''~~: emergent appendectomy		*Peritonitis/sepsis: emergent appendectomy

	==Disposition==		==Disposition==
	*~~'''~~Surgical consultation~~'''~~ for all confirmed or highly suspected appendicitis		*Surgical consultation for all confirmed or highly suspected appendicitis
	*~~'''~~Admit~~'''~~ for surgical management		*Admit for surgical management
	*If appendicitis suspected but imaging equivocal: ~~'''~~observation with serial exams~~'''~~ or repeat imaging in 6-12 hours		*If appendicitis suspected but imaging equivocal: observation with serial exams or repeat imaging in 6-12 hours
	*~~'''~~Discharge with close follow-up~~'''~~ only if alternative diagnosis confirmed and appendicitis reliably excluded		*Discharge with close follow-up only if alternative diagnosis confirmed and appendicitis reliably excluded

	==See Also==		==See Also==

Danbot: Major update: Alvarado/AIR scores, CODA trial antibiotics-first approach, atypical presentations (pregnancy/elderly/retrocecal), MRI in pregnancy, interval appendectomy, references with PMIDs

2026-03-21T19:53:46Z

Major update: Alvarado/AIR scores, CODA trial antibiotics-first approach, atypical presentations (pregnancy/elderly/retrocecal), MRI in pregnancy, interval appendectomy, references with PMIDs

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Danbot: Move calculators to own section with header (visible in TOC), expanded, before External Links

2026-03-21T15:07:18Z

Move calculators to own section with header (visible in TOC), expanded, before External Links

← Older revision		Revision as of 15:07, 21 March 2026
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			== Calculators ==
			{{Alvarado_Calculator}}

	==External Links== <!--T:145-->		==External Links== <!--T:145-->
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	<references/>		<references/>

	~~<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">~~
	~~<div style="font-weight:bold;">📊 Alvarado Score Calculator [show]</div>~~
	~~<div class="mw-collapsible-content">~~
	~~{{Alvarado_Calculator}}~~
	~~</div>~~
	~~</div>~~
	[[Category:GI]]		[[Category:GI]]
	[[Category:Surgery]]		[[Category:Surgery]]
	[[Category:ID]]		[[Category:ID]]
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Danbot: Add Alvarado Score calculator (collapsible)

2026-03-21T13:43:27Z

Add Alvarado Score calculator (collapsible)

← Older revision		Revision as of 13:43, 21 March 2026
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			<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">
			<div style="font-weight:bold;">📊 Alvarado Score Calculator [show]</div>
			<div class="mw-collapsible-content">
			{{Alvarado_Calculator}}
			</div>
			</div>
	[[Category:GI]]		[[Category:GI]]
	[[Category:Surgery]]		[[Category:Surgery]]
	[[Category:ID]]		[[Category:ID]]
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2026-01-15T15:26:26Z

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2026-01-15T15:25:06Z

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← Older revision		Revision as of 15:25, 15 January 2026
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			<languages/>
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	{{AdultPage\|appendicitis (peds)}}		{{AdultPage\|appendicitis (peds)}}
			<translate>

	==Background==		==Background==

	[[File:Appendix locations.png\|thumb\|Drawing of colon with variability of appendix locations as seen from anterior view.]]		[[File:Appendix locations.png\|thumb\|Drawing of colon with variability of appendix locations as seen from anterior view.]]
	*Acute inflammation of the vermiform appendix		*Acute inflammation of the vermiform appendix
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	*Most commonly caused by luminal obstruction by a fecalith		*Most commonly caused by luminal obstruction by a fecalith
	*There are no historical or physical exam findings that can definitively rule out appendicitis		*There are no historical or physical exam findings that can definitively rule out appendicitis



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	[[File:McBurney's point.jpg\|thumb\|Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).]]		[[File:McBurney's point.jpg\|thumb\|Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).]]



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	**Retrocecal appendix can cause [[Special:MyLanguage/flank pain\|flank]] or [[Special:MyLanguage/pelvic pain\|pelvic pain]]		**Retrocecal appendix can cause [[Special:MyLanguage/flank pain\|flank]] or [[Special:MyLanguage/pelvic pain\|pelvic pain]]
	**Gravid uterus sometimes displaces appendix superiorly → [[Special:MyLanguage/RUQ pain\|RUQ pain]]		**Gravid uterus sometimes displaces appendix superiorly → [[Special:MyLanguage/RUQ pain\|RUQ pain]]



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	**Rebound		**Rebound
	**Rigidity		**Rigidity



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	\| 1.12		\| 1.12
	\|}		\|}



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	==Differential Diagnosis==		==Differential Diagnosis==

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	{{Abd DDX RLQ}}		{{Abd DDX RLQ}}
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	[[File:X-ray showing fecalith which has caused appendicitis.jpg\|thumb\|Fecalith (arrow) and stranding in the setting of acute appendicitis.]]		[[File:X-ray showing fecalith which has caused appendicitis.jpg\|thumb\|Fecalith (arrow) and stranding in the setting of acute appendicitis.]]
	[[File:CAT scan demonstrating acute appendicitis.jpg\|thumb\|Dialated appendix and stranding in the setting of acute appendicitis.]]		[[File:CAT scan demonstrating acute appendicitis.jpg\|thumb\|Dialated appendix and stranding in the setting of acute appendicitis.]]



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	===Appendicitis Risk Scores===		===Appendicitis Risk Scores===

			</translate>
	{{Alvarado scoring system}}		{{Alvarado scoring system}}
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	*Consider CRP		*Consider CRP
	**Normal CRP AND WBC makes appendicitis unlikely		**Normal CRP AND WBC makes appendicitis unlikely



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	**MRI		**MRI
	***When unable to identify appendix in children or pregnant women		***When unable to identify appendix in children or pregnant women



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	#[[Special:MyLanguage/Fluid resuscitation\|Fluid resuscitation]]		#[[Special:MyLanguage/Fluid resuscitation\|Fluid resuscitation]]
	#[[Special:MyLanguage/Analgesia\|Analgesia]]/[[Special:MyLanguage/antiemetics\|antiemetics]]		#[[Special:MyLanguage/Analgesia\|Analgesia]]/[[Special:MyLanguage/antiemetics\|antiemetics]]



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	===[[Special:MyLanguage/Antibiotics\|Antibiotics]]===		===[[Special:MyLanguage/Antibiotics\|Antibiotics]]===

			</translate>
	{{Appendicitis Antibiotics}}		{{Appendicitis Antibiotics}}
			<translate>



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	**Patients who present <72 hours after the onset of symptoms usually undergo immediate appendectomy		**Patients who present <72 hours after the onset of symptoms usually undergo immediate appendectomy
	**Patients who present >72hrs and have perforated appendix may be treated initially with antibiotics, intravenous fluids, and bowel rest		**Patients who present >72hrs and have perforated appendix may be treated initially with antibiotics, intravenous fluids, and bowel rest



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	*Admission		*Admission



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	*Either a simple wound infection or an intraabdominal abscess		*Either a simple wound infection or an intraabdominal abscess
	**Typically in patients with perforated appendicitis		**Typically in patients with perforated appendicitis



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	*Treatment similar to that of primary appendicitis and likely requires surgical revision of the appendiceal stump or removal of retained tissue		*Treatment similar to that of primary appendicitis and likely requires surgical revision of the appendiceal stump or removal of retained tissue
	*Delay in diagnosis and treatment can result in perforation and sepsis		*Delay in diagnosis and treatment can result in perforation and sepsis



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	*[[Special:MyLanguage/Appendicitis (Peds)\|Appendicitis (Peds)]]		*[[Special:MyLanguage/Appendicitis (Peds)\|Appendicitis (Peds)]]



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	*[https://www.acep.org/patient-care/clinical-policies/appendicitis/ ACEP Clinical Policy Statement]		*[https://www.acep.org/patient-care/clinical-policies/appendicitis/ ACEP Clinical Policy Statement]
	*[http://www.emdocs.net/appendicitis-why-do-we-miss-it-and-how-do-we-improve/ emDocs - Appendicitis: Why Do We Miss It, and How Do We Improve?]		*[http://www.emdocs.net/appendicitis-why-do-we-miss-it-and-how-do-we-improve/ emDocs - Appendicitis: Why Do We Miss It, and How Do We Improve?]



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	[[Category:Surgery]]		[[Category:Surgery]]
	[[Category:ID]]		[[Category:ID]]
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Ostermayer: Removed page from translation

2026-01-15T15:19:59Z

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Ostermayer at 15:09, 15 January 2026

2026-01-15T15:09:47Z

← Older revision		Revision as of 15:09, 15 January 2026
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	<languages/>		<languages/>
	~~<translate>~~
	~~</translate>~~
	{{AdultPage\|appendicitis (peds)}}		{{AdultPage\|appendicitis (peds)}}
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Ostermayer: Marked this version for translation

2026-01-15T13:37:01Z

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