T.Kravchenko

1. O.O.Bogomolets National Medical University
Department of Faculty Surgery #1
“Approved”
at the Methodist Faculty Surgery
Department # 1 Council
“__”_____2008, protocol #_____
Head of
Faculty Surgery Department # 1
Professor _______ M.P.Zakharash
Study Guide for Practical Work for Teachers and Students
Topic: “ The differential diagnosis for appendicitis”.
Course 4
Foreign Students’ Medical Faculty
Duration of the lesson – 45 min.
Worked out by
Assistant T.Kravchenko
Kyiv
2008

2. I. The theme actuality
The differential diagnosis of appendicitis can include almost all causes of abdominal
pain, as described in the classic treatise “Cope's Early Diagnosis of the Acute
Abdomen.” A useful rule is never to place appendicitis lower than second in the
differential diagnosis of acute abdominal pain in a previously healthy person.
II. Student must know:
- the differential diagnosis of appendicitis
- appendicitis in young children
- appendicitis in elderly
- appendicitis during pregnancy
- appendicitis in HIV infection
III. Student must be able to:
- to interpret correctly the present manifestations of disease and investigation
results
- to differentiate appendicitis
- to diagnose and make the chart of treatment
- to apply the instrumental methods of examination
- to conduct examination of patient
- to interpret data of examinations
IV. Education aims of the study
- forming the deontology presentations, skills of conduct with the patients
- to develop deontology presentations, be able to carry out deontology approach
to the patient
- to develop the presentations of influence of ecological and socio-economic
factors on the state of health

3. - to develop sence of responsibility for a timeliness and loyalty of professional
actions
- to lay hands on ability to set psychological contact with a patient and his family
V. The contents of a theme
Differential Diagnoses
The diagnosis of appendicitis is particularly difficult in the very young and in the
elderly. It is in these groups that diagnosis is most often delayed and perforation
occurs most frequently. Imaging studies are strongly considered here. Because of
increasing concerns about radiation-induced cancers among children, ultrasonography
is the preferred initial imaging modality in this group. Ultrasonography was shown to
change the disposition of 59% of children with abdominal pain that had already been
evaluated by the surgical team. For older patients, CT has the advantages of detection
of the broader array of conditions, such as diverticulitis and malignancy, found in the
differential diagnosis.
In infants, nonfocal findings such as lethargy, irritability, and anorexia may be present
in the early stages, with vomiting, fever, and pain apparent as the disease progresses.
Ultrasound is useful in the evaluation of appendicitis and other acute abdominal
emergencies, such as pyloric stenosis, in infants.
In preschool-aged children, the differential diagnosis includes intussusception,
Meckel's diverticulitis, and acute gastroenteritis. Intussusception may be distinguished
by the colicky nature of the pain, with intervening pain-free periods, and the absence
of peritonitis. Meckel's diverticulitis is relatively uncommon, but its presentation is
similar to that of appendicitis with the exception that the pain and tenderness typically
localize in the periumbilical region. Gastroenteritis can be difficult to distinguish from

4. acute appendicitis in any age group. Typically, diarrhea and vomiting occur early and
persistently in gastroenteritis, and focal abdominal tenderness and peritoneal signs are
uncommon. However, it is advisable to discuss with parents of a child suspected of
having gastroenteritis the importance of re-evaluation within 12 to 24 hours if the
child develops worsening abdominal pain, or other signs of clinical deterioration,
because misdiagnosed appendicitis remains high on the list of considerations.
In school-aged children, gastroenteritis often presents with abdominal pain and
diarrhea without fever or leukocytosis. The most common mimicker of appendicitis in
this population is mesenteric lymphadenitis, which may be caused by a wide variety
of enteric infections. Ultrasonography may be helpful in identifying enlarged lymph
nodes in the region of the ileal mesentery in conjunction with thickening of the ileal
wall and a normal appendix, in which case appendectomy may be avoided. It is
important to bear in mind that enlarged mesenteric lymph nodes may also be the result
of acute appendicitis. Inflammatory bowel disease is also considered in children,
particularly if there is a history of recurrent episodes of abdominal pain. Constipation
and functional pain are common in this age group. Although constipation may be
associated with relatively severe pain, there are no peritoneal signs, fever, or
leukocytosis, and the diagnosis is supported by a recent history of hard stools.
Functional pain is usually somewhat milder, recurrent, and self-limited.
In adults, it is important to consider other regional inflammatory conditions, such as
pyelonephritis, colitis, and diverticulitis. The pain and tenderness of pyelonephritis are
typically located in the flank and are accompanied by high fever and white blood cell
count as well as pyuria. Colitis is often accompanied by diarrhea, and the location of
the pain typically outlines the trajectory of the colon. In Crohn's colitis, diarrhea is
uncommon, but there is often a pattern of recurrent symptoms. The onset of right-
sided diverticulitis is typically insidious, worsening over a period of days, and

5. involves a larger area of the right lower abdomen than does appendicitis. CT scan is
helpful in identifying the inflamed diverticula and enhancement of cecal wall
thickening that accompanies this diagnosis.
The differential diagnosis for appendicitis among women in their childbearing years is
broad and accounts for the higher incidence of false-positive diagnoses in this group.
Pelvic pathology that may mimic acute appendicitis includes pelvic inflammatory
disease (PID), tubo-ovarian abscess, ruptured ovarian cyst or ovarian torsion, and
ectopic pregnancy, among others. These conditions are typically distinguished from
acute appendicitis by the absence of gastrointestinal symptoms. Pelvic ultrasound is
especially helpful in these patients because of its high sensitivity and specificity for
the diagnosis of pelvic pathology. If a normal appendix is also seen, appendicitis is
unlikely.
Appendicitis is the most common nonobstetric surgical disease of the abdomen during
pregnancy. Diagnosis may be difficult because symptoms of nausea, vomiting, and
anorexia, as well as elevated white blood cell count, are common during pregnancy.
Moreover, the location of tenderness varies with gestation. After the 5th month of
gestation, the appendix is shifted superiorly above the iliac crest, and the appendiceal
tip is rotated medially into the right upper quadrant by the gravid uterus. Ultrasound is
helpful both in establishing the diagnosis and the location of the inflamed appendix. In
cases in which ultrasound has been equivocal, magnetic resonance imaging (MRI) has
been used successfully, thereby avoiding ionizing radiation exposure to the
developing fetus. The main challenge is to recognize the possibility of appendicitis in
pregnant patients and intervene promptly because peritonitis significantly increases
the rate of fetal loss (2.6%-10.9% in one meta-analysis). Laparoscopic appendectomy
has been performed through the second trimester of pregnancy, although data are
lacking comparing the safety of this approach to the open procedure.

6. Appendicitis in the elderly can be difficult to diagnose because many patients delay in
seeking care and present atypically. Fever is uncommon, the white blood cell count
may be normal, and many older patients with appendicitis do not experience right
lower quadrant pain. About one half of older patients are incorrectly diagnosed at the
time of admission, and these patients have a much higher rate of perforation at the
time of surgery because of delays in operative intervention. More than 50% of older
patients have perforated appendicitis, compared with less than 20% for younger
patients. Diverticulitis and bowel obstruction are common misdiagnoses in this patient
population, and the differential diagnosis also includes malignancies of the
gastrointestinal tract and reproductive system, perforated ulcers, and cholecystitis,
among others. CT has become an invaluable tool in the evaluation of abdominal pain
among older patients, and its use has shortened preoperative hospital delays.
Diagnostic Algorithm
Patients in whom the diagnosis of appendicitis is being considered should have a
surgical evaluation. Early involvement of the surgical team in the diagnostic
evaluation of these patients may improve diagnostic accuracy and help to avoid
expensive and unnecessary diagnostic studies. Experienced clinicians accurately
diagnose appendicitis based on a combination of history, physical exam, and
laboratory studies about 80% of the time. We stratify patients based on their clinical
findings starting with the extremes, which are easier to identify. Patients with a high
probability of uncomplicated appendicitis undergo surgery. Patients suspected of
having an appendiceal abscess undergo further imaging, typically ultrasonography for
children or CT for adults. The next step in the evaluation of patients in whom the
likelihood of appendicitis is believed to be low is determined by the probability and

7. severity of alternate diagnoses under consideration. Many of these patients will be
discharged with a planned follow-up visit or phone call the next day. Most older
patients with abdominal pain undergo CT before discharge because of the high
prevalence of surgical pathology in this patient population. The remaining patients are
believed to have an intermediate probability of having appendicitis. Children and
pregnant women in this category typically undergo abdominal ultrasonography.
Women in their childbearing years may undergo pelvic ultrasonography or CT scan
depending on the index of suspicion of pelvic pathology. Among patients that would
otherwise be admitted to the hospital for observation, CT may reduce hospital costs by
reducing length of stay. Following the completion of imaging studies, the patient is re-
examined to determine whether pain and tenderness have localized to the right lower
quadrant. If the diagnosis remains uncertain at this point, patients either undergo
diagnostic laparoscopy, especially in fertile women, are admitted for observation and
re-examination, or are discharged with follow-up the next day.
VI. Lesson topic control questions.
Key points:
- Acute appendicitis in young children: diagnosis is more difficult and more rapid
progression to peritonitis and rupture
- Acute appendicitis in elderly: more rapid progression to perforation, comorbid
diseases, high index of suspicion should be maintained
- Acute appendicitis during pregnancy: more frequent during first two trimesters,
rebound and guardian signs are less frequent, when diagnosis is in doubt,
ultrasound may be beneficial
- Acute appendicitis in HIV infection: increased risk of appendeceal rupture (delay
in clinical presentation), possible cause of RLQ pain may be the opportunistis
infections (CMV, Kaposhi sarcoma, TB, lymphoma, mucosal ischemia)

8. - Appendectomy remains the only curative treatment for appendicitis
Cases
A 42-year-old white male presents to the ER at 10:00 p.m. with complaints of
abdominal pain, nausea, vomiting. He states the pain is 8/10 in intensity and began
early in the morning. The pain is located in the left upper quadrant (LUQ) without
radiation and is described as being achy and dull. There are no exacerbating or
alleviating factors. He also complains of a low-grade fever and having no bowel
movements in the last two days. There is no other significant medical history. Lab
works reveals WBC 16,000 with left shift, UA is negative. Physical examination
reveals tenderness in the lower border of LUQ, with some guarding, but no rebound or
rigidity. A CT of abdomen revealed malrotation with appendicitis. What is the most
appropriate surgical option?
1. A Rocky-Davis incision with appendectomy
2. A midline mini-laparotomy incision with appendectomy
3. Laparoscopic appendectomy
4. Mini-laparotomy incision with appendectomy and excision of Ladd’s bands
Answer is 4
This is a rare presentation of appendicitis within this age group. Malrotation is most
commonly found within the pediatric population secondary to obstruction. The small
bowel lacks appropriate fixation to the posterior wall and therefore the cecum fails to
migrate to the RLQ as well as the colon not attaching to the lateral abdominal wall.
The may lead to right upper quadrant (RUQ) position of the cecum which may extend
bands (Ladd’s bands) across the duodenum which may lead to obstruction. The
surgical correction is to perform an appendectomy as well as a Ladd’s procedure. This
is extremely difficult throught a Rocky-Davis incision and therefore best performed
through a midline incision.

9. VII. Supporting materials required for teaching
1. Participation in clinical duties on admission
2. Working in library
VIII. Literature
1. Townsend CM, Harris JW. Sabiston’s Textbook of Surgery, 16th ed. Philadelphia,
PA: W.B. Saunders Co, 2001, vol.44
2. Schwartz SI, Schires GT, Spencer FC, Daly JM, Fischer JE, Galloway AC.
Principles of Surgery, 7th ed. New York: McGraw-Hill, 1999, vol.27
3. Bruce E. Jarrell, R.Antthony Carabasi. Surgery, 3rd ed. Williams & Wilkins, 1998