Cirujano

Review article General

January-March 2019
Vol. 41, no. 1 / p. 33-38

Acute appendicitis: literature review

Apendicitis aguda: revisión de la literatura

Jorge Hernández‑Cortez,* Jorge Luis De León‑Rendón,** Martha Silvia Martínez‑Luna,*

Jesús David Guzmán‑Ortiz,* Antonio Palomeque‑López,*
Néstor Cruz‑López,* Hernán José‑Ramírez*

Keywords:
Acute appendicitis, ABSTRACT RESUMEN
epidemiology, clinical
manifestations, Acute appendicitis is the most common abdominal La apendicitis aguda es la patología quirúrgica abdominal
appendectomy. pathology in the world and it represents the main cause más común en el mundo y representa la causa principal de
of emergency abdominal surgery; it is the most frequent cirugía abdominal de urgencia; se informa que su mayor
Palabras clave: cause of surgery in patients between 20 and 30 years of frecuencia se observa en la población de entre 20 y 30 años
Apendicitis aguda, age, and it does not have a sex predominance. Its clinical y no tiene predominio de género. Su presentación clínica es
epidemiología, picture is variable, and this fact should be considered in variable en algunas ocasiones, por lo que se deben utilizar
manifestaciones diagnostic studies for accurate diagnosis. The approach of estudios imagenológicos para su diagnóstico certero. El
clínicas, acute appendicitis can be laparoscopic or open surgery. The tratamiento de la apendicitis aguda es mediante cirugía
apendicectomía. purpose of our review is to present updated information con abordaje laparoscópico o abierto. El propósito de
on this common topic. nuestra revisión es exponer la información actualizada
sobre este tema tan común.

INTRODUCTION true diverticulum, since its wall is made up of

mucosa, submucosa, longitudinal and circular
ppendicitis is defined as inflammation of muscle and serosa. Its anatomical relationships
A the vermiform appendix and represents
the most common cause of acute abdomen
are the iliopsoas muscle and the lumbar plexus
posteriorly, and the abdominal wall anteriorly.
and emergency surgical indication in the world. The irrigation of the cecal appendix comes from
The study of the cecal appendix dates back the appendicular artery, a terminal branch of
to the anatomical drawings made by Leonardo the ileocolic artery, which crosses the length
da Vinci in 1492. It was later detailed by of the mesoappendix to end at the tip of the
* Division of Surgery,
Berengario da Carpi in 1521 and illustrated organ. The mesoappendix is a structure of
“Dr. Aurelio Valdivieso” in the work of Andreas Vesalius De Humani variable size in relation to the appendix, which
General Hospital.
Oaxaca, Mexico.
Corporis Fabrica, published in 1543.1 entails variability in its positions.2-4 Therefore,
** Division of the tip of the appendix can migrate to different
Coloproctology, General ANATOMY locations: retrocecal, subcecal, preileal,
Hospital d “Dr. Eduardo
Liceaga”, Mexico City. postileal, and pelvic.3,5
The vermiform appendix is a tubular structure
Received: 02/01/2018
Accepted: 20/12/2018
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EPIDEMIOLOGY
located on the posteromedial wall of the
cecum, 1.7 cm from the ileocecal valve, where
the taenias of the colon converge on the cecum. Acute appendicitis represents the most
Its average length is 91.2 and 80.3 mm in men common indication of emergency nontraumatic
and women, respectively. The appendix is a abdominal surgery in the world. This pathological

How to cite: Hernández-Cortez J, De León-Rendón JL, Martínez-Luna MS, Guzmán-Ortiz JD, Palomeque-López A, Cruz-
López N, José-Ramírez H. Acute appendicitis: literature review. Cir Gen. 2019; 41(1): 33-38.

Cirujano General 2019; 41 (1): 33-38 www.medigraphic.com/cirujanogeneral

34 Hernández-Cortez J et al. Acute appendicitis

process occurs more frequently between the a higher risk than those with no family history
second and third decades of life. The risk of of suffering from it.10
presenting it is 16.33% in men and 16.34%
in women. Its annual incidence is 139.54 per CLINICAL MANIFESTATIONS
100,000 habitants; in 18.5% it is associated
with overweight and in 81.5% with obesity.6-8 Abdominal pain is the most frequent symptom
that occurs in patients, although other symptoms
ETHIOPATHOGENESIS such as anorexia, nausea, constipation/diarrhea
and fever are also described.9,14 Pain is typically
The central pathogenic event of acute periumbilical and epigastric, and later migrates
appendicitis is obstruction of the appendicular to the lower right quadrant; however, despite
lumen, which may be secondary to fecaliths, being considered a classic symptom, migratory
lymphoid hyperplasia, foreign bodies, parasites, pain occurs only in 50 to 60% of patients with
primary tumors (carcinoid, adenocarcinoma, acute appendicitis.9 The appearance of nausea
Kaposi’s sarcoma, lymphoma, etc.) or metastatic and vomiting occurs after the installation
tumors (colon and breast). Inflammation of the of pain, and fever usually manifests around
appendicular wall is the initial phenomenon, six hours after the general clinical picture.
vascular congestion, ischemia, perforation This varies considerably from person to
and, occasionally, development of localized person, which in some cases is attributable
(contained) abscesses or generalized peritonitis to the location of the tip of the appendix.
ensue later. During these phenomena, bacterial For example, an anteriorly located appendix
proliferation occurs, in the early course of the produces marked and localized pain in the
disease, aerobic microorganisms appear and right lower quadrant, whereas a retro-cecal
later, mixed forms (aerobic and anaerobic) one can cause dull abdominal pain or pain
appear. 9,10 Normally, the cecal appendix in the lower lumbar region. Likewise, due to
functions as a reservoir for the E. coli microbiota the irritation produced by the appendix, other
and Bacteroides sp., which are the most symptoms such as urinary urgency, dysuria or
common; however, patients with predominantly rectal symptoms such as tenesmus or diarrhea
different microbiota, such as Fusobacterium, may appear.14
have been found. This latter correlates with The physical examination of these patients
cases of complicated (perforated) appendicitis.11 should initiate with the measurement of vital
Such bacteria invade the appendicular wall signs. A body temperature greater than 38 oC,
and then produce a neutrophilic exudate; the tachycardia and, in some cases, tachypnea
flow of neutrophils causes a fibrinopurulent can be found. The early clinical signs of
reaction on the serous surface, as well as appendicitis are often non-specific.14 However,
irritation of the adjacent parietal peritoneum.12 as inflammation progresses, involvement of
Once inflammation and necrosis occur, the the parietal peritoneum causes tenderness in
appendix is at risk of perforation, leading to the right lower quadrant that can be elicited
the formation of localized abscesses or diffuse on physical examination; also, pain can be
peritonitis. The time to appendicular perforation exacerbated by movement or cough.15
is variable. In general, perforation correlates The maximum localization of pain in the
to the evolution of the appendicular clinical abdomen almost always corresponds to the
picture: no appendicular perforation if less than McBurney point, which is located two thirds
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24 hours of evolution and perforation when
more than 48 hours.13
of the distance from the navel on a line drawn
from it to the right anterior superior iliac spine.
However, the etiology of acute appendicitis The patient will be sensitive and will show
is currently uncertain and poorly understood. signs of peritoneal irritation with localized
Recent theories focus on genetic factors, muscular defense (it occurs only if there is
environmental influence and infections. As a peritonitis).15 Rectal and/or vaginal examination
sample it is reported that people with a family can cause pain in patients with pelvic localized
history of acute appendicitis have three times appendicitis, therefore their presence or

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Hernández-Cortez J et al. Acute appendicitis 35

absence does not rule out appendicular 87%, specificity 74%), and of the appendicular
pathology, and its routine use in the exploration wall (sensitivity 75%, specificity 85%).25-27
of these patients is controversial.15-17
Different clinical signs have been described ABDOMINAL ULTRASOUND
in the physical examination to facilitate
diagnosis. It is worth mentioning that they It is an operator-dependent method; however,
are reported in only 40% of patients with inexpensive and ideal for diagnosis. The
appendicitis, so their absence does not rule out findings reported by ultrasound are an
the diagnosis. These include Blumberg (pain appendicular diameter greater than 6 mm,
from sudden decompression in the right iliac with a sensitivity of 88%, specificity of 92%,
fossa), Rovsing (palpation in the left iliac fossa and positive predictive values of 94% and
elicits referred pain in the right fossa), psoas sign negative predictive values of 86%.28,29
(pain in the right iliac fossa [RIF] from extension
of the right hip), obturator sign (pain in the RIF X-RAY IMAGES
after flexion and internal rotation of the right
hip), etc.18,19 They are of little use in establishing the
diagnosis of appendicitis; however, the
LABORATORY following radiographic findings have been
associated with acute appendicitis:
Leukocyte count greater than 10,000 cells/mm3
and left deviation, C-reactive protein greater 1. Appendicolith in the lower right quadrant.
than 1.5 mg/l are likely diagnostic indicators 2. Ileus located to the right iliac fossa.
for acute appendicitis. Leukocytosis greater 3. “Erasure” of the psoas muscle image.
than 20,000/μl is associated with appendicular 4. Free air (occasionally).
perforation; however, appendicular perforation 5. Increased density in the right lower
is reported in up to 10% of patients with normal quadrant.
white blood cell and C-reactive protein values,
so the absence of these altered values does Despite the above, some recommend that
not rule out perforation.20,21 The sensitivity the evaluation of patients with clinical suspicion
and specificity of these laboratory tests for the of acute appendicitis should be submitted to
diagnosis of acute appendicitis are reported from other studies, due to their high number of false
57 to 87% for C-reactive protein and from 62 negatives.30,31
to 75% for leukocytosis. Therefore, other studies
have been attempted for the timely diagnosis; MAGNETIC RESONANCE
such is the case of pro-calcitonin and bilirubin.
Both have been shown useful for diagnosing It is considered the radiographic study of choice
complicated cases of appendicitis.22,23 in pregnant women with clinical suspicion of
acute appendicitis. The magnetic resonance
CT SCAN parameter is the appendicular diameter,
when greater than 7 mm (filled with fluid)
It represents one of the imaging studies that it is considered as a diagnostic, and those
allows us to make a more precise diagnosis between 6-7 mm are considered inconclusive
and, also, to differentiate between perforated findings.32-34
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and non-perforated acute appendicitis.24 The
DIAGNOSIS
radiological signs described for the diagnosis
of acute appendicitis are the following: an
increase in appendicular diameter greater The diagnosis of this pathology is made
than 6 mm (sensitivity 93%, specificity 92%), according to findings on clinical interrogation,
appendicular wall thickness greater than two physical examination and laboratory and/
millimeters (sensitivity 66%, specificity 96%), or imaging. Different diagnostic modalities
thickened peri-appendicular fat (sensitivity have been studied and compared, the use

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36 Hernández-Cortez J et al. Acute appendicitis

of laboratory values alone is ineffective for inflammatory response (AIR), pediatric

diagnosis. However, when used together, appendicitis score (PAS), adult score for
the diagnostic possibility increases. 35 The appendicitis (ASA). Comparing the scales, the
diagnostic efficacy by physical examination AIR system (as opposed to Alvarado) reduces
as the only study method ranges from 75% to the number of unnecessary hospital admissions,
90%. Its efficacy depends on the experience optimizes the usefulness of radiographic studies
of the examiner. 36 Therefore, different and prevents negative abdominal examinations,
diagnostic systems have been designed, which is corroborated by the best discrimination
in order to combine the clinic with the observed in the ROC curve (receiver operative
laboratory findings to determine therapeutic characteristic), 0.97 versus 0.92, respectively.42
behavior in this type of patient.
TREATMENT
DIAGNOSTIC SCORING SYSTEMS
The current treatment for acute appendicitis
There are different systems for the diagnosis ranges from surgical modalities to conservative
of acute appendicitis; Alvarado’s scale is management. Therefore, and for its understanding,
the most widely used for diagnosis and has it is necessary to know a classification of acute
been modified since its introduction. There appendicitis such as the described by the Mexican
are reviews in which this scale is compared Association of General Surgery; namely:43
with clinical judgment, and it has been found
that the scale has a lower sensitivity (72% • Acute appendicitis: leukocyte infiltration
vs 93%), since some cases ruled out by the to the basement membrane in the cecal
Alvarado score do occur.37 Likewise, when appendix.
comparing this scale with radiographic studies, • Uncomplicated appendicitis: acute
it is comparatively less sensitive and specific in appendicitis without perforation data.
relation to computed tomography images.38 • Complicated appendicitis: perforated acute
The modified Alvarado scale scores appendicitis with and without localized
according to the following criteria: 39-41 abscess and/or purulent peritonitis.
migratory pain towards the right iliac fossa (1
point), anorexia (1 point), nausea and vomiting P r e v i o u s l y, t h e m a n a g e m e n t o f
(1 point), pain on palpation in the right iliac uncomplicated appendicitis by conservative
fossa (2 points), positive rebound in the right treatment with antibiotics was considered an
iliac fossa (1 point), temperature greater than alternative; however, the latest meta-analysis
37.5 °C (1 point) and leukocytosis (2 points). results comparing conservative versus surgical
management have found surgical management
The handling will be according to the sum as the treatment modality of choice in this type
of points:39-41 of patients.44-46 It is important to recognize that
if a patient wants conservative treatment and
• Score 0-3: low risk for appendicitis and could accepts the recurrence risk of 38%, this type of
be discharged with the counseling to return approach can be offered.42
if there is no symptomatic improvement. Management is surgical, by laparoscopic
• Score 4-6: hospitalization; If the score approach ideally; however, the open modality
remains the same after 12 hours, surgical will always be a choice when the conditions
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intervention is recommended.
• Male with a score of 7-9: appendectomy.
and means are not available for laparoscopic
approaches.47,48
• Nonpregnant female with a score of 7-9:
diagnostic laparoscopy and appendectomy
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