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Acute Appendicitis – 10 Clinical Pearls For Residents


The pain of acute appendicitis usually migrates to right illiac fossa.

Acute appendicitis is one of the leading surgical emergencies worldwide. The incidence of appendectomy for appendicitis in United States have been increasing since 1990s. The classic pain of acute appendicitis usually starts in the periumbilical region and radiates to right illiac fossa. However, anatomical positions of appendix may vary in some people which may give rise to pain at a different location. Below are 10 golden points to enhance clinical expertise in diagnosis and management of acute appendicitis.

  1. Acute appendicitis can mimic partial intestinal obstruction and vice versa.
  2. If there is no history of nausea and anorexia in a case of suspected acute appendicitis, consider revising the diagnosis.
  3. Perforated or Complicated appendicitis is common in children (less than 5 years) and very old (more than 65 years). The most frequent mechanism in perforation is tension gangrene due to accumulating secretions.
  4. The percentage of misdiagnosis of acute appendicitis is significantly higher among women (22%) than men (9.3%).
  5. Acute mesenteric adenitis is the disease most often confused with acute appendicitis in pediatric patient. It may be impossible to distinguish diverticulitis or perforating carcinoma of cecum from appendicitis in elderly patient.
  6. The most common initiating factor in appendicitis is luminal obstruction and the earliest symptom is pain.
  7. Diffuse peritonitis following appendicitis is usually seen when appendicular perforation occurs within 24 hours.
  8. The diagnosis of acute appendicitis is usually clinical supported by systemic inflammatory response with leukocytosis and neutrophilia. CT is used as investigation of choice only in cases of inconclusive USG, gaseous distension of bowel, obese patients and probable advanced appendicitis.
  9. Laparascopic appendectomy has slight benefit over open appendectomy. Single incision appendectomy has no obvious advantage over standard laparascopic appendectomy.
  10. Early antibiotics have no role in prevention of rupture in acute appendicitis. Immediate appendix surgery (appendectomy) is the recommended treatment.

Acute appendicitis is a surgical emergency widely encountered in emergency care settings all over the world. Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000 people per year.

  • Schwartz’s Principles Of Surgery-10th Edition
  • Sabiston Textbook of Surgery-19th Edition
  • Farguharson’s Textbook of Operative Surgery
  • Bailey & Love’s Short Practice of Surgery -26th Edition




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