Appendicitis: Signs, Types and Treatment


Appendicitis symptoms

The partial irritation of the peritoneum, in the iliac fossa, is from time to time installation with the aid of disorder in Appendix cancer. The appendix having been perforated by ulcerations, occasioned by means of the lodgement of the fecal concretions in its cavity, extravasation takes place, and inflame-motion of an extra severe and serious kind is originated. Nature every now and then succeeds in limiting the irritation too part right aspecthowever, it’s far at different instance subtle over the whole abdomen, and fast proves fatal. The critical appendicitis signs are discussed in the essential article.



  • It is not unusual in young males.
  • It is not unusual in white races.
  • Fiber wealthy food plan prevents appendicitis. Less fiber weight loss programs will increase the chance of appendicitis.
  • It is acquainted in May, and August-seasonal variation-regularly referred to as epidemic appendicitis.
  • Active contamination can also reason mucosal edema, infection, and that afters get contaminated by way of bacteria inflicting appendicitis.
  • The family records can be relevant in 30% of appendicitis in children with appendicitis happening in first diploma relatives.
  • Obstruction of the lumen of appendix resulting in obstructive appendicitis.
  • Blockage takes place due to—faecoliths, stricture, overseas body, roundworm, or threadworm.
  • Adhesions and kinking—carcinoma caecum near the base, ileocaecal Crohn’s ailment.
  • Distal colonic obstruction.
  • Abuse of purgatives.
  • Faecolith is the most not unusual cause.



Coli (85%), enterococci, (30%), streptococci, Anaerobic streptococci, Cl. Welchii, Bacteroides.
Pseudoappendicitis is appendicitis because of acute ileitis following Yersinia contamination. It is often due to Crohn’s disorder.

Symptoms of appendicitis

The common appendicitis signs are enlisted below:

  1. Sudden pain that starts off evolved on the right facet of the decrease stomach ache
  2. The sudden ache that impels around your navel and time and again shifts to your decrease right abdomen.
  3. Pain that aggravates if you cough, walk or make any jarring movements.
  4. Nausea and vomiting
  5. Low-grade fever
  6. Loss of appetite (anorexia)
  7. Constipation or diarrhea

The site of your ache or pain may alter, depending on your age and the position of your appendix. When you’re pregnant, the pain may additionally appear to begin from your top stomach because your appendix is advanced to the everyday position during pregnancy.

Clinical signs in appendicitis



  • Rovsing’s sign
  • Blumberg’s sign (Release sign)
  • Cope’s psoas check
  • Obturator check
  • Baldwin’s test
  • Bastede sign
  • Dumphy’s cough tenderness sign (Refer to fascinating signs and symptoms for detail)
  • Bapat mattress shaking test
  • Heel Drop test



Acute appendicitis in infancy: Even although it’s miles uncommon whilst it happens, it has got 80% chances of perforation with excessive mortality (50%).

Acute appendicitis in kids:

  • Here localization isn’t present, and so peritonitis takes place early.
  • It requires early surgery. Dehydration, septicemia are commonplace.

In the elderly:

Gangrene and perforation are not unusual. Because of the lax belly wall, localization is poor, and so peritonitis sets in early.

In pregnancy:

  • Incidence is 1 in 2,000 pregnancies. It is extra, not unusual in 1st and 2d trimesters.
  • Appendix shifts to the upper abdomen. So the ache is better and more lateral.
  • Rebound tenderness and guarding may not be evident.
  • TC might be very excessive with neutrophilia.
  • The hazard of premature labor is 15%.
  • Fetal demise in early appendicitis is 5% however will become 29% once appendix perforates in pregnancy.
  • After six months, maternal mortality increases by means of ten instances than regular and also end in untimely labor.
  • Appendicitis is the most commonplace non-gynaecologic surgical emergency in the course of pregnancy.
  • The incidence of perforation is highest in the third trimester.
  • Surgery is the treatment.




  • Acute irritation of the mucous membrane with the secondary ailment without obstruction causes acute nonobstructive appendicitis. It may lead to resolution, fibrosis, recurrent appendicitis, or eventual obstructive appendicitis.
  • Luminal obstruction by way of faecolith, lymphoid hyperplasia, pinworm (Oxyuris Vermicularis), different worms, overseas body, carcinoma/Crohn’s disorder-mucus, and inflammatory fluid collects within the lumen–increases intraluminal pressure—results in blockage of lymphatic and venous drainage–ensuing in elevated edema of mucosa and wall-reasons mucosal ulceration and ischemia —bacterial translocation —bacterial unfold through the submucosa and muscular Propria –acute obstructive appendicitis—thrombosis of the appendicular artery–ischaemic necrosis of complete thickness of the wall of the appendix–gangrene of the appendix—perforation on the tip or at the base–peritonitis.
  • After perforation– localization by using more omentum and dilated ileum occurs—with suppuration and pus interior forming an appendicular abscess.
  • In severe acute appendicitis, —localization can occur by omentum and dilated ileum without pus interior—forming an appendicular mass.
  • Acute appendicitis with obstruction at the outlet of the lumen—irritation hardly ever subsides—mucus collects within the lumen of the appendix ensuing in its enlargement—Mucocele of the appendix.




Acute nonobstructive appendicitis (catarrhal) (mucosal appendicitis):
Inflammation of mucous membrane happens with redness, edema, and hemorrhages which may work for following courses:

  1. Resolution
  2. Ulceration
  3. Fibrosis
  4. Suppuration
  5. Recurrent appendicitis
  6. Gangrene-uncommon initially in nonobstructive type but later can occur
  7. Peritonitis. 
  8. Acute obstructive appendicitis: Here, pus collects inside the blocked lumen of the appendix, that blackish, gangrenous, oedematous, and rapidly progresses, main to perforation either at the tip or at the base of the appendix. This results in peritonitis, the formation of an appendicular abscess or pelvic abscess. Most frequently, there may be thrombosis of the appendicular artery.
  9. Recurrent appendicitis: Repeated assaults of nonobstructive appendicitis ends in fibrosis, adhesions causing recurrent appendicitis.
  10. Subacute appendicitis is a milder form of acute appendicitis.
  11. Stump appendicitis is retained long stump of the appendix after usually laparoscopic appendicectomy.
  12. It is uncommon earlier than the age ofcommonplace in kids and different age groups.
  13. Pain: It is the earliest symptom. Visceral ache begins around the umbilicus because of distension of appendix, and later after some hours, somatic ache happens in right iliac fossa due to inflammation of parietal peritoneum because of an inflamed appendix. The ache eventually becomes extreme and diffuse, which signifies the unfold of contamination into the general peritoneal cavity.
  14. Vomiting: Due to reflex pylorospasm.


Murphy’s triad


  • • Pain—first • Vomiting—next • Temperature—last
  • Constipation is the same old hallmark, but diarrhea can occur if the appendix is in submit ileal or pelvic positions.
  • Fever, tachycardia, foetor oris are different functions.
  • Urinary reiterations: Inflamed appendix may are available in contact with bladder and can cause the bladder infection.
  • Tenderness and rebound tenderness at McBurney’s is the factor in proper iliac fossa (release sign-Blumberg ‘s sign) are typical.
  • Rovsing’s sign: On palpating left iliac fossa, pain occurs inside the right iliac fossa, which is due to the shifting of bowel loops, which irritates the parietal peritoneum.
  • Hyperextension (in case of retrocausal appendix-Cope’s psoas test) or internal rotation (in case of the pelvic appendix-obturator take a look at) of the right hip reasons pain in proper iliac fossa because of infection of the psoas muscle and obturator internus muscle respectively.
  • Baldwin’s test is positive in Retrocaecal appendix-whilst legs are lifted away from bed with the knee extended, the affected person complains of pain whilst pressing over the flanks.
  • P/R examination shows tenderness on the proper side of the rectum
  • Hyperaesthesia in ‘Sherren’s triangle.’ This triangle is assembled by using the anterosuperior iliac spine, umbilicus, pubic symphysis.




Differential Diagnosis for Acute Appendicitis


  • Many conditions mimic acute appendicitis. It differs in youngsters, adults, aged, and females.
  • They have a perforated duodenal ulcer. In duodenal ulcer perforation, fluid creeps to the lowest along the proper paracolic gutter and mimics appendicitis. Upper abdominal ache, obliterated liver dullness, gas below the diaphragm in X-ray, and CT test differentiate it from acute appendicitis.
  • Acute cholecystitis: Pain within the proper upper stomach, fever, jaundice, upper belly guarding are the features of acute cholecystitis. US; HIDA test, LFT will differentiate it from acute appendicitis.
  • Acute pancreatitis: Pain in epigastrium, radiating to back, raised serum amylase and lipase, CT stomach with a history of alcohol intake often are diagnostic.
  • Right ureteric colic: Pain is colicky in nature, which frequently refers to genitalia. Haematuria, urinary signs and symptoms are not unusual. It mimics Retrocaecal/pelvic acute appendicitis. Often in ureteric stone, the stomach is gentle and non-tender. CT is an important way to distinguish.
  • Acute typhlitis: Inflammation of caecum is known as as typhlitis. Often it’s far tough to differentiate it from acute appendicitis. Intravenous/oral metronidazole absolutely controls the sickness.
  • Acute bacterial enterocolitis: It affords with ache abdomen, diarrhea, toxemia, dehydration. Often it’s far difficult to distinguish from acute appendicitis.
  • Right-sided acute pyelonephritis: Here, there might be pain and tenderness in loin. Urine analysis, US are diagnostic. Often DTPA scan can be needed.
  • Crohn ‘s ailment providing with acute signs and symptoms will have similar functions of acute appendicitis.
  • Pelvic inflammatory disorder, like salpingo-oophoritis, mimics acute appendicitis. 
  • Twisted/hemorrhagic/ruptured ovarian cyst/ruptured ectopic gestation/endometriosis/Tubo-ovarian abscess mimics acute appendicitis. US laparoscopy helps to distinguish it from others. Mittelschmerz is lower abdominal pain due to the rupture of the follicular cyst at some stage in mid-cycle. It subsides on its own. There aren’t any systemic capabilities.
  • Meckel’s diverticulitis presents clinically like acute appendicitis. It isn’t possible to distinguish between two clinically.
  • Intussusception mimics acute appendicitis in kids. ISS is common earlier than the age of 2 years. Acute appendicitis is rare earlier than the age of two years. Palpable mass, features of intestinal obstruction, barium enema X-ray, US are useful methods to distinguish.
  • Worm infestation (roundworm bolus/ball): It frequently affords as pain inside the right iliac fossa. 
  • Properties of intestinal obstruction are common here.
  • Right-sided lobar pneumonia and pleurisy are often now not easy to distinguish from acute appendicitis. Pleural rub, trade-in breath sounds, chest X-ray can pick out pneumonia.
  • Testicular torsion/acute intense orchitis regularly seem like acute appendicitis. Referred pain in the iliac fossa, and if scrotum isn’t palpated clinically these conditions are fallacious for acute appendicitis. These problems are much greater obvious if the testis is undescended
  • Sigmoid diverticulitis in aged with loop lying towards right facet can also present as ache inside the proper iliac fossa.
  • Carcinoma caecum may additionally present with capabilities of acute appendicitis without any earlier typical functions.
  • Ruptured aortic aneurysm, acute intestinal obstruction, mesenteric ischemia may also present as acute appendicitis.
  • Rare situations like preherpetic ache of the proper tenth and 11th dorsal nerves may additionally mimic acute appendicitis. Guarding and stress will not be present. There can be full-size hyperaesthesia.
  • Tabetic disaster, tuberculosis of the spine, secondaries inside the spine, multiple myeloma, osteoporotic pain regularly can mimic acute appendicitis.
  • Acute crisis of porphyria and diabetes mellitus mimic acute appendicitis with extreme abdominal ache.



Differential diagnosis

=> Perforated peptic ulcer
=> Ruptured or twisted ovarian cyst
=> Acute cholecystitis
=> Right ureteric colic
=> Enterocolitis
=> Right acute pyelonephritis
=> Mesenteric lymphadenitis
=> Lobar pneumonia
=> Crohn’s sickness
=> Acute pancreatitis
=> Meckel’s diverticulitis
=> Acute disaster of porphyria
=> Salpingitis
=> Diabetic stomach
=> Ectopic gestation—ruptured
=> Typhlitis

Differential diagnosis in teenager (children) 

=> Meckel’s diverticulitis
=> Acute colitis
=> Acute iliac lymphadenitis
=> Intussusception
=> Roundworm colic
=> Lobar pneumonia

Differential diagnosis in females

=> Ruptured ectopic gestation
=> Mittelschmerz rupture of the ovarian follicle during the mid-menstrual period
=> Ovarian cyst torsion
=> Salpingo-oophoritis

Differential diagnosis in the elderly

=> Acute diverticulitis
=> Carcinoma caecum—acute functions
=> Mesenteric ischemia
=> Intestinal obstruction
=> Aortic aneurysm leak
=> Crohn’s disorder

Sequelae of acute appendicitis

=> Resorption
=> Relapse and recurrent appendicitis
=> Appendicular mass
=> Appendicular abscess
=> Perforation—has were given 20% mortality
=> Peritonitis, septicemia
=> Portal pyemia
=> Intestinal obstruction because of obstructive ileus, inflammatory adhesion, the formation of the band between appendix and omentum or between the appendix and small bowel 



  • The overall leucocyte count is increased.
  • Ultrasound is done to rule out other situations like ureteric stone, pancreatitis, ovarian cyst, ectopic pregnancy, and also to affirm appendicular mass or abscess.
  • Laparoscopy is the most beneficial method.




Sonographic standards for appendicitis (85% Specificity)


  • Noncompressible appendix of size > 6 mm AP diameter, hyperechoic thickened appendix wall > 2 mm—goal sign.
  • Appendicolith.
  • Interruption of submucosal continuity.
  • Periappendicular fluid.
  • Kalam changed Alvarado scoring (1994), where the shift to the left is removed.
  • Tzamakis scoring system 2005-lower stomach tenderness-4; rebound tenderness-3; total count number> 12,000/cm-2; USG functions-6.
  • RIPASA scoring gadget (2010)-with parameters.
  • Anderson scoring deviceeight parameters.



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