What are the key symptoms of appendicitis. How is appendicitis diagnosed. What are the potential complications of untreated appendicitis. Who is most at risk for developing appendicitis. How is appendicitis treated.

Understanding Appendicitis: Causes and Risk Factors

Appendicitis is a common acute surgical condition affecting the abdomen, with approximately 7% of the population experiencing it in their lifetime. The peak incidence occurs between the ages of 10 and 30 years. But what exactly causes this potentially dangerous condition?

The primary trigger for appendicitis is obstruction of the narrow appendiceal lumen. This obstruction can result from various factors:

• Lymphoid hyperplasia (often related to viral illnesses)
• Fecaliths (hardened fecal matter)
• Parasites
• Foreign bodies
• Crohn’s disease
• Primary or metastatic cancer
• Carcinoid syndrome

Lymphoid hyperplasia is particularly common in children and young adults, which explains the higher incidence of appendicitis in these age groups. The appendix’s location can also influence the presentation of symptoms. In up to 30% of cases, the appendix may be “hidden” in a pelvic, retroileal, or retrocolic position, potentially altering the typical clinical manifestations.

Recognizing Appendicitis Symptoms: More Than Just Abdominal Pain

While abdominal pain is the hallmark symptom of appendicitis, it’s crucial to be aware of other associated signs and symptoms. What should you look out for?

• Abdominal pain, typically starting around the navel and migrating to the lower right quadrant
• Anorexia (loss of appetite)
• Nausea and vomiting
• Low-grade fever
• Constipation or diarrhea
• Abdominal bloating

It’s important to note that symptoms can vary, especially in children, elderly patients, and pregnant women. Any persistent abdominal pain, particularly if accompanied by fever or vomiting, warrants medical attention.

The Diagnostic Process: From Physical Examination to Imaging

Diagnosing appendicitis remains primarily based on the patient’s history and physical examination. However, additional tests and imaging can provide valuable information. What does the diagnostic process typically involve?

Physical Examination

During the physical exam, doctors look for specific signs of an inflamed appendix:

• Rebound tenderness
• Rovsing’s sign (pain in the lower right side when pressure is applied and released on the lower left side)
• Psoas sign (pain when flexing the psoas muscles near the appendix)
• Obturator sign (pain during flexion and internal rotation of the hip)
• Guarding (involuntary tensing of abdominal muscles)

Laboratory Tests

Several laboratory tests may be ordered to support the diagnosis:

• Complete blood count (to check for signs of infection)
• Urinalysis (to rule out urinary tract infections and kidney stones)
• Pregnancy test (for women of childbearing age)

Imaging Studies

In equivocal cases, imaging studies can be particularly helpful:

• Abdominal ultrasound
• Magnetic Resonance Imaging (MRI)
• Computerized Tomography (CT) scans (except in pregnant women due to radiation risks)

These imaging techniques can reveal inflammation, rupture, or obstruction of the appendix, as well as other potential sources of abdominal pain.

The Challenges of Diagnosis: When Appendicitis Mimics Other Conditions

Despite advances in medical technology, diagnosing appendicitis can be challenging due to its similarities with other conditions. How often is appendicitis misdiagnosed?

A study published in the American Journal of Surgery in 2011 found that nearly 12% of all appendectomies performed in the United States between 1998 and 2007 were on patients who did not actually have appendicitis. This highlights the importance of thorough diagnostic procedures and the potential for misdiagnosis.

Conditions that may mimic appendicitis include:

• Gastroenteritis
• Urinary tract infections
• Ovarian cysts or torsion
• Ectopic pregnancy
• Diverticulitis
• Crohn’s disease

Given these potential mimics, it’s crucial for healthcare providers to consider a wide range of possibilities when evaluating abdominal pain.

The Race Against Time: Why Prompt Diagnosis Matters

Timely diagnosis of appendicitis is critical. But why is speed so important in managing this condition?

Delay in diagnosing appendicitis significantly increases the risk of perforation and subsequent complications. The mortality rate for non-perforated appendicitis is less than 1%. However, this rate can climb to 5% or higher in young children and elderly patients, where diagnosis is often delayed, making perforation more likely.

Potential complications of delayed diagnosis include:

• Peritonitis (inflammation of the abdominal lining)
• Abscess formation
• Sepsis
• Bowel obstruction
• Fertility issues (particularly in women)

These complications not only increase the risk of mortality but can also lead to prolonged hospital stays, additional surgical interventions, and long-term health issues.

Treatment Approaches: From Conservative Management to Surgery

Once diagnosed, how is appendicitis typically treated? The standard treatment for acute appendicitis has long been surgical removal of the appendix, known as an appendectomy. However, recent research has explored alternative approaches in certain cases.

Appendectomy

Appendectomy remains the gold standard treatment for most cases of acute appendicitis. This procedure can be performed in two ways:

1. Open appendectomy: A single incision is made in the lower right abdomen to remove the appendix.
2. Laparoscopic appendectomy: Several small incisions are made, and the appendix is removed using special surgical tools and a camera.

Laparoscopic surgery generally results in shorter hospital stays, less postoperative pain, and quicker return to normal activities. However, the choice between open and laparoscopic surgery depends on various factors, including the patient’s overall health, body type, and the severity of the appendicitis.

Conservative Management

In recent years, there has been growing interest in non-operative management of uncomplicated appendicitis in select patients. This approach typically involves:

• Intravenous antibiotics
• Close monitoring
• Follow-up imaging

While this approach may be suitable for some patients, it’s important to note that there’s a risk of recurrence, and long-term outcomes are still being studied. The decision to pursue conservative management should be made on a case-by-case basis in consultation with healthcare providers.

Special Populations: Appendicitis in Children and the Elderly

While appendicitis can affect anyone, certain age groups present unique challenges in diagnosis and treatment. How does appendicitis differ in children and the elderly?

Appendicitis in Children

Diagnosing appendicitis in children can be particularly challenging for several reasons:

• Difficulty in communicating symptoms clearly
• Atypical presentation of symptoms
• Overlap with other common childhood illnesses

Children may experience more diffuse abdominal pain, and the classic migration of pain to the right lower quadrant may not occur. Additionally, children are more prone to rapid progression to perforation, making timely diagnosis crucial.

Appendicitis in the Elderly

In older adults, appendicitis can be equally challenging to diagnose due to:

• Atypical or muted symptoms
• Multiple comorbidities that may mask appendicitis
• Delayed presentation to medical care

The elderly are also at higher risk for perforation and complications, partly due to delayed diagnosis and partly due to age-related changes in the appendix and immune system.

In both these age groups, healthcare providers must maintain a high index of suspicion for appendicitis when evaluating abdominal pain, and may rely more heavily on imaging studies for diagnosis.

Prevention and Future Directions: Can Appendicitis Be Avoided?

While appendicitis is generally considered an unavoidable condition, ongoing research is exploring potential preventive measures and improved diagnostic techniques. What does the future hold for appendicitis management?

Potential Preventive Measures

While there’s no surefire way to prevent appendicitis, some studies suggest that certain lifestyle factors may influence risk:

• High-fiber diet: Some research indicates that a diet rich in fiber may reduce the risk of appendicitis.
• Probiotics: Maintaining a healthy gut microbiome through probiotics or fermented foods might play a role in prevention.
• Hygiene: Good hygiene practices may help prevent infections that could lead to appendicitis.

However, it’s important to note that these measures are not guaranteed to prevent appendicitis, and more research is needed to establish their effectiveness.

Advances in Diagnosis

Researchers are continually working on improving diagnostic accuracy for appendicitis. Some promising areas include:

• Biomarkers: Identifying specific blood markers that could indicate appendicitis more accurately.
• Artificial Intelligence: Developing AI algorithms to assist in interpreting imaging studies and predicting appendicitis risk.
• Point-of-care ultrasound: Improving bedside ultrasound techniques for quicker, more accessible diagnosis.

Treatment Innovations

Future directions in appendicitis treatment may include:

• Refined antibiotic therapies for non-operative management
• Minimally invasive surgical techniques
• Personalized treatment plans based on genetic factors and individual risk profiles

As research progresses, we may see a shift towards more tailored approaches to appendicitis management, potentially reducing the need for surgery in some cases while improving outcomes for those who do require operative intervention.

In conclusion, while appendicitis remains a common and potentially serious condition, our understanding and management of it continue to evolve. Awareness of symptoms, prompt medical attention, and ongoing advancements in diagnosis and treatment all contribute to improving outcomes for patients with this acute abdominal condition.

Appendicitis Symptoms and Warning Signs

To diagnose appendicitis, your doctor will begin with your medical history and ask more detailed questions about your abdominal pain, other symptoms you’ve experienced, medical conditions you may have, and your alcohol and drug (both legal and illegal) use.

Your doctor will then perform a physical exam and look for signs (2) of an inflamed appendix, including:

• Rebound tenderness
• Rovsing’s sign, in which you experience pain in the lower right side of your abdomen when pressure is applied and released on the lower left side of your abdomen
• Psoas sign, in which flexing your psoas muscles near your appendix causes abdominal pain
• Obturator sign, in which pain is felt during flexion and internal rotation of the hip
• Guarding, in which you subconsciously tense your abdominal muscles before your doctor touches your belly

It may also be necessary to examine your rectum, which may be tender from appendicitis.

But these signs don’t necessarily mean you have appendicitis; they can occur with other conditions, too. Your doctor will likely order a number of laboratory tests that will point toward a diagnosis of appendicitis. These can include a blood test to look for signs of infection, a urine test to rule out urinary tract infections and kidney stones, and a pregnancy test if you’re a woman.

Additionally, your doctor may conduct imaging tests, including abdominal ultrasounds and magnetic resonance imaging (MRI) scans. These tests can reveal inflammation and rupturing of the appendix, appendix obstructions that can cause appendicitis, and other sources of abdominal pain. Computerized tomography (CT) scans are also typically used to diagnose appendicitis, but the radiation from CT scans can be harmful to a developing fetus, so CT is usually avoided in pregnant women. (2)

Because the symptoms of appendicitis are similar to so many other conditions, it is sometimes misdiagnosed. A study published in 2011 in the American Journal of Surgery found that almost 12 percent of all appendectomies performed in the United States between 1998 and 2007 occurred in people who did not in fact have appendicitis, but had some other condition. (7)

Additional reporting by Deborah Shapiro.

Acute Appendicitis: Review and Update

D. MIKE HARDIN, JR., M.D., Texas A&M University Health Science Center, Temple, Texas

Am Fam Physician. 1999 Nov 1;60(7):2027-2034.

Appendicitis is common, with a lifetime occurrence of 7 percent. Abdominal pain and anorexia are the predominant symptoms. The most important physical examination finding is right lower quadrant tenderness to palpation. A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and supporting the presence or absence of appendicitis, while appendiceal computed tomographic scans and ultrasonography can be helpful in equivocal cases. Delay in diagnosing appendicitis increases the risk of perforation and complications. Complication and mortality rates are much higher in children and the elderly.

Appendicitis is the most common acute surgical condition of the abdomen.1 Approximately 7 percent of the population will have appendicitis in their lifetime,2 with the peak incidence occurring between the ages of 10 and 30 years.3

Despite technologic advances, the diagnosis of appendicitis is still based primarily on the patient’s history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications.4 The mortality rate in nonperforated appendicitis is less than 1 percent, but it may be as high as 5 percent or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.1

Pathogenesis

The appendix is a long diverticulum that extends from the inferior tip of the cecum.5 Its lining is interspersed with lymphoid follicles. 3 Most of the time, the appendix has an intraperitoneal location (either anterior or retrocecal) and, thus, may come in contact with the anterior parietal peritoneum when it is inflamed. Up to 30 percent of the time, the appendix may be “hidden” from the anterior peritoneum by being in a pelvic, retroileal or retrocolic (retroperitoneal retrocecal) position.6 The “hidden” position of the appendix notably changes the clinical manifestations of appendicitis.

Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis. Obstruction has multiple causes, including lymphoid hyperplasia (related to viral illnesses, including upper respiratory infection, mononucleosis, gastroenteritis), fecaliths, parasites, foreign bodies, Crohn’s disease, primary or metastatic cancer and carcinoid syndrome. Lymphoid hyperplasia is more common in children and young adults, accounting for the increased incidence of appendicitis in these age groups.1,5

History and Physical Examination

Abdominal pain is the most common symptom of appendicitis. 3 In multiple studies,3–5  specific characteristics of the abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis (Table 1). A thorough review of the history of the abdominal pain and of the patient’s recent genitourinary, gynecologic and pulmonary history should be obtained.

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TABLE 1

Common Symptoms of Appendicitis

Common symptoms*	Frequency (%)
Abdominal pain	~100
Anorexia	~100
Nausea	90
Vomiting	75
Pain migration	50
Classic symptom sequence (vague periumbilical pain to anorexia/nausea/unsustained vomiting to migration of pain to right lower quadrant to low-grade fever)	50

TABLE 1

Common Symptoms of Appendicitis

Common symptoms*	Frequency (%)
Abdominal pain	~100
Anorexia	~100
Nausea	90
Vomiting	75
Pain migration	50
Classic symptom sequence (vague periumbilical pain to anorexia/nausea/unsustained vomiting to migration of pain to right lower quadrant to low-grade fever)	50

Anorexia, nausea and vomiting are symptoms that are commonly associated with acute appendicitis. The classic history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50 percent of patients.1 Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis.1

In a recent meta-analysis,7  likelihood ratios were calculated for many of these symptoms (Table 2). A likelihood ratio is the amount by which the odds of a disease change with new information (e.g., physical examination findings, laboratory results).8  This change can be positive or negative. Symptoms such as anorexia, nausea and vomiting commonly occur in acute appendicitis; however, the presence of these symptoms does not necessarily increase the likelihood of appendicitis nor does their absence decrease the likelihood of the diagnosis. Moreover, other symptoms have more notable positive and negative likelihood ratios (Table 2).

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TABLE 2

Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis

Symptom/sign	Positive likelihood ratio (LR+)
Right lower quadrant (RLQ) pain	8. 0
Pain migration	3.2
Pain before vomiting	2.8
Anorexia, nausea and vomiting*	Much lower LR+ than RLQ pain, pain migration and pain before vomiting
Psoas sign	2.38
Rebound tenderness	1.1 to 6.3†
Fever	1. 9‡
Guarding and rectal tenderness*	Much lower LR+ than rigidity, psoas sign and rebound tenderness
Symptom/sign	Negative likelihood ratio (LR−)
RLQ pain§	0 to 0.28†
No similar pain previously∥	0.3
Pain migration	0.5
Guarding	0 to 0. 54†
Rebound tenderness	0 to 0.86†
Fever, rigidity and psoas sign¶
note: LR is the amount by which the odds of a disease change with new information, as follows:

Likelihood ratio	Degree of change in probability
> 10 or < 0.1	Large (often conclusive)
5 to 10 or 0. 1 to 0.2	Moderate
2 to 5 or 0.2 to 0.5	Small (but sometimes important)
1 to 2 or 0.5 to 1	Small (rarely important)

TABLE 2

Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis

Symptom/sign	Positive likelihood ratio (LR+)
Right lower quadrant (RLQ) pain	8.0
Pain migration	3. 2
Pain before vomiting	2.8
Anorexia, nausea and vomiting*	Much lower LR+ than RLQ pain, pain migration and pain before vomiting
Psoas sign	2.38
Rebound tenderness	1.1 to 6.3†
Fever	1.9‡
Guarding and rectal tenderness*	Much lower LR+ than rigidity, psoas sign and rebound tenderness
Symptom/sign	Negative likelihood ratio (LR−)
RLQ pain§	0 to 0. 28†
No similar pain previously∥	0.3
Pain migration	0.5
Guarding	0 to 0.54†
Rebound tenderness	0 to 0.86†
Fever, rigidity and psoas sign¶
note: LR is the amount by which the odds of a disease change with new information, as follows:

Likelihood ratio	Degree of change in probability
> 10 or < 0. 1	Large (often conclusive)
5 to 10 or 0.1 to 0.2	Moderate
2 to 5 or 0.2 to 0.5	Small (but sometimes important)
1 to 2 or 0.5 to 1	Small (rarely important)

A careful, systematic examination of the abdomen is essential. While right lower quadrant tenderness to palpation is the most important physical examination finding, other signs may help confirm the diagnosis (Table 3). The abdominal examination should begin with inspection followed by auscultation, gentle palpation (beginning at a site distant from the pain) and, finally, abdominal percussion. The rebound tenderness that is associated with peritoneal irritation has been shown to be more accurately identified by percussion of the abdomen than by palpation with quick release.1

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TABLE 3

Common Signs of Appendicitis

Right lower quadrant pain on palpation (the single most important sign)
Low-grade fever (38°C [or 100.4°F])—absence of fever or high fever can occur
Peritoneal signs
	Localized tenderness to percussion
	Guarding
Other confirmatory peritoneal signs (absence of these signs does not exclude appendicitis)
	Psoas sign—pain on extension of right thigh (retroperitoneal retrocecal appendix)
	Obturator sign—pain on internal rotation of right thigh (pelvic appendix)
	Rovsing’s sign—pain in right lower quadrant with palpation of left lower quadrant
	Dunphy’s sign—increased pain with coughing
	Flank tenderness in right lower quadrant (retroperitoneal retrocecal appendix)
	Patient maintains hip flexion with knees drawn up for comfort

TABLE 3

Common Signs of Appendicitis

Right lower quadrant pain on palpation (the single most important sign)
Low-grade fever (38°C [or 100. 4°F])—absence of fever or high fever can occur
Peritoneal signs
	Localized tenderness to percussion
	Guarding
Other confirmatory peritoneal signs (absence of these signs does not exclude appendicitis)
	Psoas sign—pain on extension of right thigh (retroperitoneal retrocecal appendix)
	Obturator sign—pain on internal rotation of right thigh (pelvic appendix)
	Rovsing’s sign—pain in right lower quadrant with palpation of left lower quadrant
	Dunphy’s sign—increased pain with coughing
	Flank tenderness in right lower quadrant (retroperitoneal retrocecal appendix)
	Patient maintains hip flexion with knees drawn up for comfort

As previously noted, the location of the appendix varies. When the appendix is hidden from the anterior peritoneum, the usual symptoms and signs of acute appendicitis may not be present. Pain and tenderness can occur in a location other than the right lower quadrant.6 A retrocecal appendix in a retroperitoneal location may cause flank pain. In this case, stretching the iliopsoas muscle can elicit pain. The psoas sign is elicited in this manner: the patient lies on the left side while the examiner extends the patient’s right thigh (Figures 1a and 1b). In contrast, a patient with a pelvic appendix may show no abdominal signs, but the rectal examination may elicit tenderness in the cul-de-sac. In addition, an obturator sign (pain on passive internal rotation of the flexed right thigh) may be present in a patient with a pelvic appendix3 (Figures 2a and 2b).

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FIGURE 1A.

The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient’s right thigh while applying counter resistance to the right hip (asterisk).

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FIGURE 1A.

The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient’s right thigh while applying counter resistance to the right hip (asterisk).

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FIGURE 1B.

Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.

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FIGURE 1B.

Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.

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FIGURE 2A.

The obturator sign. Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.

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FIGURE 2A.

The obturator sign. Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.

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FIGURE 2B.

Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.

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FIGURE 2B.

Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.

The differential diagnosis of appendicitis is broad, but the patient’s history and the remainder of the physical examination may clarify the diagnosis (Table 4). Because many gynecologic conditions can mimic appendicitis, a pelvic examination should be performed on all women with abdominal pain. Given the breadth of the differential diagnosis, the pulmonary, genitourinary and rectal examinations are equally important. Studies have shown, however, that the rectal examination provides useful information only when the diagnosis is unclear and, thus, can be reserved for use in such cases.5

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TABLE 4

Differential Diagnosis of Acute Appendicitis

Gastrointestinal

Abdominal pain, cause unknown

Cholecystitis

Crohn’s disease

Diverticulitis

Duodenal ulcer

Gastroenteritis

Intestinal obstruction

Intussusception

Meckel’s diverticulitis

Mesenteric lymphadenitis

Necrotizing enterocolitis

Neoplasm (carcinoid, carcinoma, lymphoma)

Omental torsion

Pancreatitis

Perforated viscus

Volvulus

Gynecologic

Ectopic pregnancy

Endometriosis

Ovarian torsion

Pelvic inflammatory disease

Ruptured ovarian cyst (follicular, corpus luteum)

Tubo-ovarian abscess

Systemic

Diabetic ketoacidosis

Porphyria

Sickle cell disease

Henoch-Schönlein purpura

Pulmonary

Pleuritis

Pneumonia (basilar)

Pulmonary infarction

Genitourinary

Kidney stone

Prostatitis

Pyelonephritis

Testicular torsion

Urinary tract infection

Wilms’ tumor

Other

Parasitic infection

Psoas abscess

Rectus sheath hematoma

TABLE 4

Differential Diagnosis of Acute Appendicitis

Gastrointestinal

Abdominal pain, cause unknown

Cholecystitis

Crohn’s disease

Diverticulitis

Duodenal ulcer

Gastroenteritis

Intestinal obstruction

Intussusception

Meckel’s diverticulitis

Mesenteric lymphadenitis

Necrotizing enterocolitis

Neoplasm (carcinoid, carcinoma, lymphoma)

Omental torsion

Pancreatitis

Perforated viscus

Volvulus

Gynecologic

Ectopic pregnancy

Endometriosis

Ovarian torsion

Pelvic inflammatory disease

Ruptured ovarian cyst (follicular, corpus luteum)

Tubo-ovarian abscess

Systemic

Diabetic ketoacidosis

Porphyria

Sickle cell disease

Henoch-Schönlein purpura

Pulmonary

Pleuritis

Pneumonia (basilar)

Pulmonary infarction

Genitourinary

Kidney stone

Prostatitis

Pyelonephritis

Testicular torsion

Urinary tract infection

Wilms’ tumor

Other

Parasitic infection

Psoas abscess

Rectus sheath hematoma

Laboratory and Radiologic Evaluation

If the patient’s history and the physical examination do not clarify the diagnosis, laboratory and radiologic evaluations may be helpful. A clear diagnosis of appendicitis obviates the need for further testing and should prompt immediate surgical referral.

LABORATORY TESTS

The white blood cell (WBC) count is elevated (greater than 10,000 per mm³ [100 × 10⁹ per L]) in 80 percent of all cases of acute appendicitis.9 Unfortunately, the WBC is elevated in up to 70 percent of patients with other causes of right lower quadrant pain.10 Thus, an elevated WBC has a low predictive value. Serial WBC measurements (over 4 to 8 hours) in suspected cases may increase the specificity, as the WBC count often increases in acute appendicitis (except in cases of perforation, in which it may initially fall).5

In addition, 95 percent of patients have neutrophilia1 and, in the elderly, an elevated band count greater than 6 percent has been shown to have a high predictive value for appendicitis.9 In general, however, the WBC count and differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low specificities.

A more recently suggested laboratory evaluation is determination of the C-reactive protein level. An elevated C-reactive protein level (greater than 0.8 mg per dL) is common in appendicitis, but studies disagree on its sensitivity and specificity.4,5 An elevated C-reactive protein level in combination with an elevated WBC count and neutrophilia are highly sensitive (97 to 100 percent). Therefore, if all three of these findings are absent, the chance of appendicitis is low.5

In patients with appendicitis, a urinalysis may demonstrate changes such as mild pyuria, proteinuria and hematuria,1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose appendicitis.

RADIOLOGIC EVALUATION

The options for radiologic evaluation of patients with suspected appendicitis have expanded in recent years, enhancing and sometimes replacing previously used radiologic studies.

Plain radiographs, while often revealing abnormalities in acute appendicitis, lack specificity and are more helpful in diagnosing other causes of abdominal pain. Likewise, barium enema is now used infrequently because of the advances in abdominal imaging.5

Ultrasonography and computed tomographic (CT) scans are helpful in evaluating patients with suspected appendicitis.11 Ultrasonography is appropriate in patients in which the diagnosis is equivocal by history and physical examination. It is especially well suited in evaluating right lower quadrant or pelvic pain in pediatric and female patients. A normal appendix (6 mm or less in diameter) must be identified to rule out appendicitis. An inflamed appendix usually measures greater than 6 mm in diameter (Figure 3), is noncompressible and tender with focal compression. Other right lower quadrant conditions such as inflammatory bowel disease, cecal diverticulitis, Meckel’s diverticulum, endometriosis and pelvic inflammatory disease can cause false-positive ultrasonography results.12

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FIGURE 3.

Ultrasonogram showing longitudinal section (arrows) of inflamed appendix.

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FIGURE 3.

Ultrasonogram showing longitudinal section (arrows) of inflamed appendix.

CT, specifically the technique of appendiceal CT, is more accurate than ultrasonography (Table 5). Appendiceal CT consists of a focused, helical, appendiceal CT after a Gastrografin-saline enema (with or without oral contrast) and can be performed and interpreted within one hour. Intravenous contrast is unnecessary.12 The accuracy of CT is due in part to its ability to identify a normal appendix better than ultrasonography.13 An inflamed appendix is greater than 6 mm in diameter, but the CT also demonstrates periappendiceal inflammatory changes14 (Figures 4 and 5). If appendiceal CT is not available, standard abdominal/pelvic CT with contrast remains highly useful and may be more accurate than ultrasonography.12

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TABLE 5

Comparison of Ultrasound and Appendiceal CT Evaluation of Suspected Appendicitis

	Comparison graded ultrasound	Appendiceal computed tomographic scan
Sensitivity	85%	90 to 100%
Specificity	92%	95 to 97%
Use	Evaluate patients with equivocal diagnosis of appendicitis	Evaluate patients with equivocal diagnosis of appendicitis
Advantages	Safe	More accurate
	Relatively inexpensive	Better identifies phlegmon and abscess
	Can rule out pelvic disease in females	Better identifies normal appendix
	Better for children
Disadvantages	Operator dependent	Cost
	Technically inadequate studies due to gas	Ionizing radiation
	Pain	Contrast

TABLE 5

Comparison of Ultrasound and Appendiceal CT Evaluation of Suspected Appendicitis

	Comparison graded ultrasound	Appendiceal computed tomographic scan
Sensitivity	85%	90 to 100%
Specificity	92%	95 to 97%
Use	Evaluate patients with equivocal diagnosis of appendicitis	Evaluate patients with equivocal diagnosis of appendicitis
Advantages	Safe	More accurate
	Relatively inexpensive	Better identifies phlegmon and abscess
	Can rule out pelvic disease in females	Better identifies normal appendix
	Better for children
Disadvantages	Operator dependent	Cost
	Technically inadequate studies due to gas	Ionizing radiation
	Pain	Contrast

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FIGURE 4.

Computed tomographic scan showing cross-section of inflamed appendix (A) with appendicolith (a).

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FIGURE 4.

Computed tomographic scan showing cross-section of inflamed appendix (A) with appendicolith (a).

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FIGURE 5.

Computed tomographic scan showing enlarged and inflamed appendix (A) extending from the cecum (C).

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FIGURE 5.

Computed tomographic scan showing enlarged and inflamed appendix (A) extending from the cecum (C).

Treatment

The standard for management of nonperforated appendicitis remains appendectomy. Because prompt treatment of appendicitis is important in preventing further morbidity and mortality, a margin of error in over-diagnosis is acceptable. Currently, the national rate of negative appendectomies is approximately 20 percent.15 Some studies have investigated nonoperative management with parenteral antibiotic treatment, but 40 percent of these patients eventually required appendectomy.3

Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or laparoscopy. Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age, while therapeutic laparoscopy may be preferred in certain subsets of patients (e.g., women, obese patients, athletes).16

While laparoscopic intervention has the advantages of decreased postoperative pain, earlier return to normal activity and better cosmetic results, its disadvantages include greater cost and longer operative time.4 Open appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted.

Complications

Appendiceal rupture accounts for a majority of the complications of appendicitis. Factors that increase the rate of perforation are delayed presentation to medical care,17 age extremes (young and old)18 and hidden location of appendix.6 A brief period of in-hospital observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve diagnostic accuracy.18

Diagnosis of a perforated appendix is usually easier (although immediately after rupture, the patient’s symptoms may temporarily subside). The physical examination findings are more obvious if peritonitis generalizes, with a more generalized right lower quadrant tenderness progressing to complete abdominal tenderness. An ill-defined mass may be felt in the right lower quadrant. Fever is more common with rupture, and the WBC count may elevate to 20,000 to 30,000 per mm³ (200 to 300 × 10⁹ per L) with a prominent left shift.3

A periappendiceal abscess may be treated immediately by surgery or by nonoperative management.4 Nonoperative management consists of parenteral antibiotics with observation or CT-guided drainage, followed by interval appendectomy six weeks to three months later.1

Special Considerations

While appendicitis is uncommon in young children, it poses special difficulties in this age group. Young children are unable to relate a history, often have abdominal pain from other causes and may have more nonspecific signs and symptoms. These factors contribute to a perforation rate as high as 50 percent in this group.1

In pregnancy, the location of the appendix begins to shift significantly by the fourth to fifth months of gestation. Common symptoms of pregnancy may mimic appendicitis, and the leukocytosis of pregnancy renders the WBC count less useful. While the maternal mortality rate is low, the overall fetal mortality rate is 2 to 8.5 percent, rising to as high as 35 percent in perforation with generalized peritonitis. As in nonpregnant patients, appendectomy is the standard for treatment.3

Elderly patients have the highest mortality rates. The usual signs and symptoms of appendicitis may be diminished, atypical or absent in the elderly, which leads to a higher rate of perforation. More frequent perforation combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a mortality rate of up to 5 percent or more.1

Final Comment

Prompt diagnosis of appendicitis ensures timely treatment and prevents complications. Because abdominal pain is a common presenting symptom in outpatient care, family physicians serve an important role in the diagnosis of appendicitis. Obvious cases of appendicitis require urgent referral, while equivocal cases warrant further evaluation and, many times, surgical consultation.

Pain over speed bumps in diagnosis of acute appendicitis: diagnostic accuracy study

1. Helen F Ashdown, academic clinical fellow in general practice1,
2. Nigel D’Souza, specialist registrar in general surgery2,
3. Diallah Karim, foundation trainee2,
4. Richard J Stevens, senior medical statistician1,
5. Andrew Huang, consultant colorectal and general surgeon2,
6. Anthony Harnden, university lecturer in general practice1

1. ¹Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
2. ²Department of Surgery, Stoke Mandeville Hospital, Aylesbury HP21 8AL, UK

1. Correspondence to: H F Ashdown helen.ashdown{at}phc.ox.ac.uk

• Accepted 16 November 2012

Abstract

Objective To assess the diagnostic accuracy of pain on travelling over speed bumps for the diagnosis of acute appendicitis.

Design Prospective questionnaire based diagnostic accuracy study.

Setting Secondary care surgical assessment unit at a district general hospital in the UK.

Participants 101 patients aged 17-76 years referred to the on-call surgical team for assessment of possible appendicitis.

Main outcome measures Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios for pain over speed bumps in diagnosing appendicitis, with histological diagnosis of appendicitis as the reference standard.

Results The analysis included 64 participants who had travelled over speed bumps on their journey to hospital. Of these, 34 had a confirmed histological diagnosis of appendicitis, 33 of whom reported increased pain over speed bumps. The sensitivity was 97% (95% confidence interval 85% to 100%), and the specificity was 30% (15% to 49%). The positive predictive value was 61% (47% to 74%), and the negative predictive value was 90% (56% to 100%). The likelihood ratios were 1.4 (1.1 to 1.8) for a positive test result and 0.1 (0.0 to 0.7) for a negative result. Speed bumps had a better sensitivity and negative likelihood ratio than did other clinical features assessed, including migration of pain and rebound tenderness.

Conclusions Presence of pain while travelling over speed bumps was associated with an increased likelihood of acute appendicitis. As a diagnostic variable, it compared favourably with other features commonly used in clinical assessment. Asking about speed bumps may contribute to clinical assessment and could be useful in telephone assessment of patients.

Introduction

Speed bumps are a commonly used traffic calming device to reduce the speed of vehicles.1 Although controversial, traffic calming measures have been associated with a 70% decrease in injuries among child pedestrians in some areas,2 and they may be a promising intervention for reducing the overall number of road traffic injuries and deaths.3 However, speed bumps may have a useful alternative benefit in the diagnosis of acute appendicitis.

Acute appendicitis is the most common surgical abdominal emergency.4 Rapid diagnosis is important, because increased time between onset of symptoms and surgical intervention is associated with increased risk of appendiceal perforation and therefore potential peritonitis, sepsis, and death.5 However, the rate of negative appendicectomy (when appendicectomy is performed, but the appendix is found to be normal on histological evaluation4) ranges from 5% to 42%,6 and this can be associated with considerable morbidity.7 Clinical diagnosis can be challenging, particularly in the early stages of appendicitis when clinical manifestations may be quite non-specific or atypical. Different elements of history, examination, and laboratory findings have varying predictive power in the diagnosis of appendicitis,6 and algorithms and scoring systems for clinical evaluation exist,4 but appendicitis can nevertheless be easily missed.8

Patients with appendicitis have sometimes been noted to complain of a worsening of their abdominal pain when they travel over speed bumps.⇓ Some doctors ask about this routinely as part of history taking, believing it to be a highly diagnostic feature (personal communication). We sought to determine whether any evidence supports this practice and to determine its predictive power as a diagnostic sign.

Methods

We did a prospective study at a district general hospital in Buckinghamshire in the United Kingdom. Roads in the county of Buckinghamshire are almost universally surfaced in tarmac and are smooth, with any speed bumps raised from the road surface in a variety of designs and elevations. All patients aged 16 or over who had been referred to the on-call surgical team as part of their usual care, by either a general practitioner or an emergency department doctor, with suspected appendicitis were eligible. They were identified consecutively over a six month period between February and August 2012.

We asked participants to complete a questionnaire survey about their symptoms, including four specific questions related to their journey into hospital: mode of transport, whether they had travelled over speed bumps, whether they had had pain on the journey, and whether the pain changed when they went over a speed bump. We defined patients as “speed bump positive” if they had a worsening of pain from baseline over speed bumps and as “speed bump negative” if their pain stayed the same, if they were unsure, or if their pain improved on going over speed bumps. To minimise recall bias, patients had to complete the questionnaire within 24 hours of arrival in hospital and before they had been to theatre. We also recorded examination findings on admission from their notes. Two of the authors entered data on to a spreadsheet, and a third author double checked transcription.

We then followed participants through their admission to determine the outcome and whether they were taken to theatre for presumed appendicitis. For those who had been to theatre, we obtained the subsequent histology report. We used histological diagnosis of appendicitis as the reference standard, which is the usual practice in studies of appendicitis.6 One of the authors, who was blinded to all clinical details of the participants, corroborated interpretation of the histology findings. We also asked participants to provide contact details so that, if an alternative diagnosis or no diagnosis was made, we could contact them after their admission to ensure that their symptoms had resolved, to avoid missing cases of subacute or “grumbling” appendicitis. A positive or negative histological diagnosis of appendicitis was made in participants who went to theatre and had their appendix removed. We assumed participants whose symptoms resolved without surgery to have a negative diagnosis. We confirmed resolution of symptoms by telephone follow-up between two weeks and three months after admission.

In pilot data (11 cases and 21 controls) collected in 2009, the sensitivity was 82% (95% confidence interval 48% to 98%) and the specificity was 67% (43% to 85%). We used the R software package to simulate studies of varying sizes on the basis of these estimates. We calculated that 100-150 participants in the main study would be sufficient to show a likelihood ratio greater than 1.8-2.0.

We calculated the sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, with 95% confidence intervals, for the outcome diagnosis of appendicitis. When a sign was recorded as “unsure,” we considered it absent for the purposes of calculation. We restricted the primary analyses to those patients reported to have travelled over speed bumps on the route to the hospital. We also planned to compare the diagnostic accuracy of worsened pain over speed bumps with more conventional diagnostic features of appendicitis, such as migratory pain and rebound tenderness. We used the “diagt” command in Stata (Release 11) for calculations.

Results

One hundred and one patients were recruited into the study. The median age was 34 (range 17-76) years. Sixty one participants were taken to theatre for presumed appendicitis, of whom 54 had their appendix removed. Acute appendicitis was confirmed histologically in 43 of these, giving a negative appendicectomy rate of 20%.

Sixty eight participants had travelled over speed bumps. We excluded four patients from diagnostic accuracy analysis: one because histology was not available, and three because they were treated with antibiotics as an alternative to surgery, so diagnosis was not confirmed histologically. Of the 64 patients in the main analysis, 31 were recruited between 9 am and 5 pm, 24 between 5 pm and 10 pm, and nine between 10 pm and 9 am. Fifty eight patients travelled to the hospital by car and six by ambulance, of whom five had pain over speed bumps and a final diagnosis of appendicitis and one had no pain over speed bumps and no appendicitis.

Table 1⇓ shows pain over speed bumps in relation to diagnosis of appendicitis. Fifty four of 64 participants were “speed bump positive.” Thirty four participants had a confirmed diagnosis of appendicitis, 33 of whom had worsened pain over speed bumps, giving a sensitivity of 97% (85% to 100%) and a specificity of 30% (15% to 49%). The positive predictive value was 61% (47% to 74%), and the negative predictive value was 90% (56% to 100%). The likelihood ratios were 1.4 (1.1 to 1.8) for a positive test result and 0.1 (0.0 to 0.7) for a negative result. Table 2⇓ shows how this compares with other clinical variables commonly used for diagnosis of appendicitis and also assessed in our sample.

Table 1

 Pain over speed bumps in relation to appendicitis

Table 2

 Diagnostic performance (with 95% CI) of pain over speed bumps compared with other clinical diagnostic variables for appendicitis

Seven patients who were “speed bump positive” but did not have appendicitis had other important abdominal diagnoses, such as a ruptured ovarian cyst or diverticulitis. A post hoc secondary analysis of the diagnostic accuracy of pain over speed bumps for the diagnosis of important abdominal pathology requiring treatment (including appendicitis) increased the sensitivity to 98% (87% to 100%) and the specificity to 39% (20% to 61%).

Thirty three patients did not recall having travelled over speed bumps. A sensitivity analysis classifying those patients who did not recall travelling over speed bumps as having no pain over speed bumps had the effect of decreasing the sensitivity to 77% (61% to 88%) and increasing the specificity to 61% (47% to 74%), with a positive likelihood ratio of 2.0 (1.4 to 2.9) and a negative likelihood ratio of 0.4 (0.2 to 0.7) (see web extra data).

Discussion

Our results confirm that an increase in pain while travelling over speed bumps is associated with an increased likelihood of acute appendicitis. Absence of pain over speed bumps is associated with a significantly decreased likelihood of appendicitis. Although the specificity was relatively low, as a diagnostic variable pain over speed bumps compared favourably with other features commonly used in diagnostic assessment, with a better sensitivity and negative likelihood ratio than all other features assessed. Moreover, some patients who were “speed bump positive” but did not have appendicitis had other important abdominal diagnoses, such as a ruptured ovarian cyst, diverticulitis, or pelvic inflammatory disease. We hypothesise that the worsening of pain when travelling over speed bumps in appendicitis may occur because the movement involved irritates the peritoneum in a similar way to that produced by testing for rebound tenderness on examination.

Strengths and limitations of study

Strengths of our study include the standardised approach to gathering information from patients by using a questionnaire and the obtaining of this information early in their admission and thus soon after their journey. A potential weakness is that although we recruited 101 patients as planned from our sample size calculation, only 68 recalled having travelled over speed bumps, a much lower rate than in our pilot study, which may be related to a redevelopment of the hospital site. Because of this, the number used for analysis (64 patients) was less than planned, leading to moderately large confidence intervals.

The presence of pain over speed bumps may have been overestimated in some patients owing to recall bias. Patients who had pain over speed bumps would be more likely to recall having travelled over them, whereas those who had no worsening of pain would not necessarily remember them. Although the sensitivity was 97% (table 2⇑) for patients who recalled speed bumps, because 33/97 (34%) patients did not travel (or did not recall travelling) over speed bumps, this diagnostic sign is not available in all patients and would therefore detect 77% (61% to 88%) of cases of appendicitis. This compares favourably with the other diagnostic features we assessed (see web extra data). Variable exposure to speed bumps would also occur in clinical practice, so ours is a pragmatic study that shows that pain over speed bumps can be a useful diagnostic sign when available, although availability will vary.

We used histological diagnosis of appendicitis as the reference standard for diagnosis. Three patients in our sample were treated with antibiotics for presumed appendicitis while waiting for surgery but went on to make a full recovery. A systematic review published during recruitment to our study has shown that antibiotics can lead to resolution of acute appendicitis.9 We made the decision to exclude these patients from the analysis owing to the lack of a confirmed diagnosis, but a sensitivity analysis including these patients and classifying them in turn as positive or negative for a diagnosis of appendicitis made very little difference to overall results.

Comparison with other studies

Andersson (2004) did a meta-analysis of the diagnostic accuracy of clinical features of appendicitis.6 Our finding of a negative likelihood ratio of 0.1 for pain over speed bumps in the diagnosis of appendicitis outperformed not only other clinical variables in our study (as shown in table 2⇑) but also those in Andersson’s meta-analysis—migratory pain (0.52), nausea or vomiting (0.72), and rebound tenderness (0.39). Our positive likelihood ratio of 1.4 was similar to the findings of the meta-analysis for the above features. Another study, which also investigated the accuracy of various methods of diagnosis in 100 patients with possible appendicitis, found that the symptom of pain due to bumpiness in the road (which they termed the “cat’s eye symptom”) had a sensitivity of 80% and a specificity of 52%.10 The “cat’s eye symptom” had to be volunteered by the patient to be classed as positive, whereas in our study the response to speed bumps was solicited directly in a questionnaire. Our higher sensitivity of 97% but lower specificity of 30% may be related to the use of elicited rather than volunteered symptoms, for which one would predict exactly this difference in results.

Conclusions and implications

The high sensitivity of pain over speed bumps gives it a strong “rule-out value” and makes it a useful tool to use in excluding appendicitis and other important abdominal diagnoses. The low specificity, however, means that many patients with pain over speed bumps will not necessarily have appendicitis (that is, it is a poor “rule-in” test). Potential exists for it to be incorporated into clinical prediction rules for appendicitis. Our study was based in secondary care, so our results are not necessarily generalisable to a primary care population. However, pain over speed bumps could potentially have a useful role in primary care in assisting in the telephone assessment of patients with abdominal pain. As all our group of patients had already been assessed by a clinician who thought they might have appendicitis, the pre-test probability is quite high; the speed bump test might also be useful in assessment of all types of abdominal pain, not just when appendicitis is suspected. A history of pain on travelling over uneven road surfaces or potholes may provide a useful proxy for speed bumps in healthcare settings where speed bumps are less frequently found.

Although being “speed bump negative” offers some reassurance against a diagnosis of appendicitis, being “speed bump positive” certainly does not guarantee a diagnosis of appendicitis, so in this respect the myth is untrue. However, our findings suggest that questioning about speed bumps should form a routine part of the assessment of patients with possible appendicitis. Unanswered questions include whether the speed or manner of driving approach to a speed bump affects the diagnostic power.

What is already known on this topic

• Speed bumps are a commonly used traffic calming device to reduce vehicle speeds

• Clinical diagnosis of acute appendicitis can be difficult, and presence of various clinical features, such as migration of pain and rebound tenderness, can be used in assessment

• Some doctors routinely ask about pain on travelling over speed bumps as part of their clinical assessment, but no evidence base exists for this

What this study adds

• Pain on travelling over speed bumps had a high sensitivity (97%) but a low specificity (30%) for the diagnosis of appendicitis

• It compared favourably with other clinical features used in diagnosis of appendicitis, and therefore provides a useful addition, particularly in terms of excluding appendicitis

• It may also be useful for the diagnosis of other important abdominal conditions, and its use could be extended to all presentations of the “acute abdomen”

Notes

Cite this as: BMJ 2012;345:e8012

Footnotes

• We thank A K Allouni and S Kreckler for their contributions to the original idea for the project and pilot study. We also thank doctors in the surgical team at Stoke Mandeville Hospital for their assistance with recruitment.

• Contributors: HFA developed the idea and designed the study, analysed and interpreted the data, and wrote the paper. ND’S and DK participated in study design, collected the data, and helped to write the paper. RJS assisted with study design, analysed and interpreted the data, and helped to write the paper. AHuang assisted with data interpretation and helped to write the paper. AHarnden supervised HFA, assisted with study design, and helped to write the paper. All authors approved the final version of the manuscript. HFA is the guarantor.

• Funding: No formal funding. HFA is an academic clinical fellow, which is a scheme partially funded by the National Institute for Health Research. The University of Oxford acted as study sponsor and had no role in the study design, data collection, analysis or interpretation, writing of the paper, or decision to submit for publication. All authors were independent from funders and sponsors.

• Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

• Ethical approval: The study was approved by Oxford A Research Ethics Committee (reference 12/SC/0052). All participants gave informed consent before taking part.

• Data sharing: Full data are available from the corresponding author on request. Consent for data sharing was not obtained, but the presented data are anonymised and the risk of identification is low.

References

1. ↵

   Department for Transport. Traffic calming. Local Transport Note 01/07, 2007.

2. ↵

   Towner EML, Dowswell T, Mackereth C. What works in preventing unintentional injuries in children and young adolescents? An updated systematic review. Health Development Agency, 2001.

3. ↵
4. ↵
5. ↵
6. ↵
7. ↵
8. ↵
9. ↵
10. ↵

Signs You May Have Appendicitis

• Appendicitis is a disease caused by a blockage or inflammation in the appendix organ.
• If left untreated, the appendix can rupture inside of a person’s body and be life-threatening.
• Severe pain in the lower right abdomen is one of the defining symptoms of appendicitis.
• Nausea, vomiting, and low-grade fever can also be present in appendicitis, but not always.

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Appendicitis is a potentially dangerous medical condition marked by the inflammation of the appendix — the tiny, tube-shaped organ in your digestive system.

Generally, appendicitis is most common in people between ages 10 and 30, but a person could suddenly develop it at any point during their life. According to the National Institute of Health, acute appendicitis is the leading cause of emergency abdominal surgery in the US.

Typically, appendicitis comes on without much warning, and doctors aren’t completely certain about why some people get it and others don’t. Even worse, if appendicitis is left untreated, the appendix can rupture, causing a serious widespread infection, and even death.

Despite the severity of the condition, however, doctors can easily treat appendicitis by surgically removing the appendix by what’s called an appendectomy.

INSIDER spoke with Dr. Jennifer Anders, assistant professor of pediatrics at John Hopkins University School of Medicine about how to identify the most definitive signs of acute appendicitis.

If you are experiencing the following symptoms or any extreme pain, you should seek immediate medical care.

You have unexplained pain in your abdomen

Dr. Anders told INSIDER that pain in the abdomen is the most classic symptom of appendicitis.

“That tube [the appendix] is normally communicating with the big tube [the small intestine] off of the flow of digestive juices, and helping to turn food into stool in the large intestine. Fluid can move in and move out [from it],” Dr. Anders added.

When a person develops appendicitis, they feel pain because their appendix has become inflamed due to an infection or blockage. Dr. Anders said this can happen due to pieces of undigested food getting stuck, or swelling at the neck of the appendix tube.

According to The National Center for Biotechnology Information, as the appendix swells, certain nerve fibers become stimulated and travel to the spinal cord. In turn, the body sends pain signals throughout the abdominal area.

Your pain isn’t subsiding with time

The pain from appendicitis will not go away.

Daisy Daisy/Shutterstock

Unlike other conditions that cause uncomfortable sensations in the abdomen, like gastroenteritis, the pain doesn’t usually come and go in waves.

According to Dr. Anders, appendicitis pain starts as a constant, achy feeling in the abdomen, rather than an intermittent cramping sensation. And it doesn’t go away. In fact, it gets worse with time.

She told INSIDER, “It sort of starts as a vague, constant sense of pain that becomes more intense throughout the day.”

Your pain moved to a specific point in the lower-right part of your abdomen

“Over the course of the day, [appendicitis] pain will migrate or organize itself in the lower-right part of the abdomen,” said Dr. Anders.

She explained this happens because as the inflamed appendix becomes even tighter, it begins to press up against the peritoneum, or inner lining of the abdomen.

She told INSIDER, “As the tube [the appendix] starts to swell up and become thick and larger in size, it can grow to the size of the thumb. At that point, it’s tight and firm, so it’s [producing] an aching kind of pain. And then that infected sack of material starts to touch that peritoneum, or the lining of the inside of the abdomen, which causes pain in that area”

You have a low-grade fever

A low-grade fever might occur as your body’s immune system attempts to fight off infections.

Sarah Schmalbruch/INSIDER

While an elevated temperature doesn’t automatically mean appendicitis, it can be a sign of the condition if you’re experiencing another symptom, according to Dr. Anders.

Like with many other conditions, a fever greater than 99 degrees Fahrenheit can indicate the body’s immune system is trying to fight off some form of infection. Since bacteria can collect in the appendix if it is blocked, the appendix can become a breeding ground for infection to happen.

Some studies, however, have shown a fever may not always be present if you have appendicitis, so it’s important not to rule it out.

You don’t feel like eating anything

Since the appendix is part of the digestive system, experiencing appendicitis symptoms can make you feel sick to your stomach.

“People with appendicitis generally have no appetite — the thought of eating makes them feel worse,” said Dr. Anders.

In other words, if you feel like you can’t even stomach saltine crackers, you may want to consult your doctor.

On top of that, you’re throwing up

On that note, Dr. Anders said that vomiting can be another sign of acute appendicitis. This goes hand and hand with the nausea sensation the disease causes.

The National Institute of Health, however, noted that projectile vomiting usually occurs when the appendix is already ruptured, which means you need to get to a hospital as soon as possible.

You get a blood test and your white blood cell count is high

A blood test will be able to tell you whether or not your white blood-cell count is normal.

Carlos Osorio/AP

When you develop acute appendicitis, your body naturally reacts by attempting to fight off the infection. When this happens, your body produces a greater number of white blood cells.

Although there is no blood test to specifically identify appendicitis, you might want to consider asking your doctor to perform a blood test and inform you if you have an elevated number of white blood cells, pointing to a possible infection in your appendix.

You feel rebound tenderness when someone presses near your belly button

Physicians usually check for appendicitis by seeing if a patient responds with rebound tenderness when they gently press on the lower-right part of the abdomen.

Dr. Anders said, “If there’s pain when we push down, we call that tenderness.”

Rebound tenderness is a bit different, however. This means the patient feels pain in the area even after the doctor releases the pressure.

Dr. Anders told INSIDER, “When a patient has appendicitis, it [will] hurt when I push down [on the area]. But if I hold still, [sometimes] that pain subsides… Then when I let go, and everything shakes and bounces around from that process, that’s going to be very painful for somebody with appendicitis. We call it the ‘rebound’ — it’s all the stuff in the abdomen shaking and moving as it springs back into place. It’s very painful.”

You can barely move because of how badly it hurts

As appendicitis pain progresses, it generally becomes so severe that a person can barely move.

Dr. Anders told INSIDER, “Any kind of movement that jostles that tight, swollen sack around, is going to cause excruciating pain. [This includes] walking around or jumping … If a person says that they are able to jump, it’s probably not appendicitis. But if they want to stay still that’s a pretty convincing sign.”

Your pain doesn’t respond to ordinary painkillers

Common painkillers won’t diminish the pain from appendicitis.

trophygeek/Flickr

Sometimes people may mistake appendicitis pain for a less serious condition, like indigestion. This is especially the case if you’re experiencing the early stage of the disease when the pain is merely a dull ache.

But if you’ve been treating yourself with anti-inflammatory drugs or antacids and see no relief, or feel the pain getting worse, there’s a chance it could be appendicitis.

“If the pain can’t be managed by over-the-counter medicine, like acetaminophen, it’s time to go to see a doctor and get checked,” Dr. Anders told INSIDER.

Your symptoms came on quickly and with little warning

Contrary to other conditions that may persist for weeks, like irritable bowel syndrome or gas, appendicitis is fast moving.

According to Dr. Anders, appendicitis symptoms often present over the course of a 24-hour period.

Most people don’t endure the disease for more than a few days because the pain causes them to head to the emergency room. Studies show that approximately 75% of appendicitis patients typically present a full range of symptoms within that first 12- to 24-hour period.

According to Dr. Anders, if you’re experiencing a sudden unexplained pain that gets worse or any other rapid onset of symptoms, you should seek prompt medical attention.

Rovsing’s Sign – an overview

Nongastrointestinal Causes

Numerous medications can cause vomiting either by direct gastric irritation or the stimulation of nausea. Chronic nonsteroidal anti-inflammatory drugs can cause a severe gastritis that leads to ulceration and hematemesis. Common antibiotics, particularly amoxicillin–clavulanic acid and erythromycin, can cause both vomiting and diarrhea as unwanted side effects. Chemotherapeutic agents and radiation are notorious for causing nausea and vomiting. Some children develop vomiting before receiving these therapies as a behavioral response secondary to prior negative experiences.

There are several neurologic causes of vomiting. Migraine headaches can affect even young children, who may be unable to identify the location of pain, aura, or scotoma. Caregivers note only the vomiting. Motion sickness can cause significant nausea and vomiting and often exists in families with a history of migraines. Cyclic vomiting presents primarily with vomiting and abdominal pain, but children may also report headache or vertigo. Cyclic vomiting sometimes responds to cyproheptadine, antiemetics, or intravenous fluids until the episode has passed. Familial dysautonomia is an autosomal recessive autonomic neuropathy that can result in vomiting crises, along with excessive sweating, rashes, ataxia, seizures, and irritability.

Increased intracranial pressure may initially present with nausea and headache. If the intracranial pressure is from an expanding mass such as a tumor, hydrocephalus, or vascular malformation, intractable vomiting can develop. Accompanying features may include headache and visual changes. A headache that awakens a child from sleep, is constant, or worsens with Valsalva maneuvers is worrisome. Blurry vision, diplopia, and visual field cuts are also suggestive of increased intracranial pressure. Idiopathic intracranial hypertension can stimulate nausea and vomiting as well as cause headache. It has a higher incidence in obese females and in teenagers on acne medications such as isotretinoin, tetracycline, or minocycline. Subdural hematomas from accidental or nonaccidental trauma, as well as cerebral edema from trauma or infection such as meningitis, may present with vomiting before other neurologic signs are seen. Vomiting can also occur during or after a seizure or following a concussion.

Otitis media and benign paroxysmal positional vertigo (BPPV) are two otologic causes of vomiting. Otitis media can disturb the vestibular system, and the vomiting improves with treatment of the infection. In older patients, BPPV can be diagnosed by using the Dix-Hallpike maneuver to elicit vertical-torsional nystagmus characteristic of BPPV. The symptoms often respond to physical maneuvers to reposition loosened particles from the utricular macula that float in the long arm of the posterior semicircular canal and stimulate the sensation of vertigo. In young children with BPPV, cyproheptadine and other antihistamines are sometimes helpful. Sinusitis can also stimulate vomiting secondary to persistent postnasal drip. Posterior oropharyngeal bleeding from epistaxis or bleeding after a tonsillectomy and adenoidectomy can lead to hematemesis.

Infectious causes of vomiting are numerous, with the majority being viruses. Norovirus, rotavirus, enterovirus, and adenovirus often cause self-limited episodes of emesis. Bacterial causes include but are not limited to Staphylococcus aureus (toxin mediated), Bacillus cereus, Shigella, Salmonella, Escherichia coli, Yersinia enterocolitica, and Campylobacter jejuni. Group A streptococcal pharyngitis often causes vomiting in children. Appendicitis presents with nausea, vomiting, anorexia, fever, and periumbilical pain that migrates to the right lower quadrant. Children with peritonitis from a perforation or those with severe inflammation often demonstrate rebound, guarding, or a Rovsing sign on examination. Appendicitis in young children can be difficult to diagnose because they may have no signs of anorexia and appear to have only diffuse abdominal pain. Viral or bacterial meningitis also stimulates nausea andvomiting. A postviral gastroparesis can delay gastric emptying and cause vomiting and decreased appetite that can last for months. Parasitic infections, such as ascariasis, can also cause obstructions leading to vomiting.

The respiratory system is occasionally responsible for emesis. Children with pertussis can have such violent paroxysms of coughing that they have post-tussive emesis. The respiratory signs of lower lobe pneumonia in children can be overshadowed by such severe abdominal pain and emesis that children sometimes undergo evaluations for appendicitis that reveal pneumonia on the higher cuts of an abdominal computed tomography scan. Bronchiolitis or excessive crying can cause aerophagia, which can stimulate emesis.

Cardiovascular causes of vomiting are generally related to arrhythmia or heart failure. Supraventricular tachycardia in a young infant can cause irritability and feeding intolerance. A child with heart failure secondary to a ventricular septal defect or other congenital or acquired cardiac abnormality can also have emesis or feeding intolerance. Vomiting can also be a sign of heart transplant rejection.

The genitourinary system can cause vomiting in several ways. Pyelonephritis, nephrolithiasis, ureteropelvic junction obstruction, and renal insufficiency can all present at various ages with emesis. Torsion of the ovary or testis causes severe pain along with emesis in some cases. Nausea from pregnancy is a cause of vomiting not to be overlooked in teenaged girls.

The endocrine system can be implicated in vomiting in several ways. Children with diabetic ketoacidosis begin to have intractable vomiting as they become more ketotic and acidotic, leading to further dehydration and worsening of their condition. Vomiting is a prominent feature of salt-wasting congenital adrenal hyperplasia, which should be suspected in a female infant with any sign of virilization. Male infants with this form of congenital adrenal hyperplasia usually have normal genitals, and their condition may be mistaken for gastroesophageal reflux or pyloric stenosis. Addison’s disease can present with vomiting during a crisis.

Metabolic and mitochondrial diseases should also be considered in a young child or infant with persistent vomiting. Hypercalcemia, hypokalemia, hypoglycemia, and hyperammonemia can all cause emesis. Urea acid cycle defects such as ornithine transcarbamylase deficiency generally present in newborns with emesis, lethargy, coma, and death if not recognized and treated aggressively. Even those with partial defects may have more exaggerated vomiting illnesses in childhood. Aminoacidopathies such as tyrosinemia can present with vomiting in children aged 2 weeks to 1 year. Organic acidopathies such as maple syrup urine disease, isovalericacidemia, mevalonicacidemia, propionicacidemia, and methylmalonicacidemia present with vomiting in infancy. Lactic acidosis, fatty acid oxidation defects, particularly medium-chain acyl-CoA dehydrogenase deficiency, glycogen storage disease, and galactosemia have vomiting as a primary presenting feature as well. Porphyria can present with periods of vomiting, change in mental status, or rash, depending on the subtype. Mitochondrial diseases are often associated with intestinal dysmotility or pseudo-obstruction. These children often have a long history of gastroesophageal reflux, feeding intolerance, abdominal pain, constipation or diarrhea, and failure to thrive. Leigh disease, also known as subacute necrotizing encephalomyelopathy, usually presents in infancy with feeding or swallowing difficulties, failure to thrive, and vomiting.

Psychological causes of vomiting include anorexia nervosa, bulimia, hyperventilation, and severe anxiety. Accidental and nonaccidental poisoning with toxins such as lead, household cleaners, or medications such as acetaminophen, aspirin, or digitalis can stimulate emesis.

Munchausen syndrome by proxy should be suspected in cases of recurrent emesis that occurs only when a certain caregiver is present or when there are discrepancies in the case. Vomiting can be induced with drugs such as ipecac. Some medications and toxins can be found by urine, stool, or serum toxicology screens. Video surveillance is the easiest way to capture the perpetrator; however, this can be difficult to do for legal reasons, and many hospitals are not equipped for covert video surveillance. Apparent hematemesis can also be secondary to Munchausen syndrome by proxy. A transfusion with tagged red blood cells and a nuclear scan right after an episode of hematemesis can prove that the blood is not from the child.

Drug and alcohol abuse in children and teenagers can lead to emesis. Alcohol can cause emesis due to overdose as well as withdrawal. Withdrawal symptoms can begin anywhere from hours to a week after the cessation of alcohol ingestion. Patients can have tremor, anxiety, depression, nausea, vomiting, diaphoresis, tachycardia, hallucinations, seizures, and delirium tremens in severe cases. Abused opioids such as heroin, codeine, and hydromorphone can cause vomiting within hours of ingestion or during the withdrawal period, which can last for weeks. Other associated signs of withdrawal include tachycardia, irritability, pupillary dilation, diarrhea, and rhinorrhea.

Some recreational drugs can cause emesis during acute intoxication. Gamma hydroxybutyrate (GHB)—also known as Liquid Ecstasy, Liquid X, Georgia Home Boy, Grievous Bodily Harm, and Easy Lay—is a date-rape drug that causes sedation, amnesia, euphoria, and hallucinations. The more toxic effects include nausea, vomiting, loss of peripheral vision, respiratory depression, and coma. Ketamine can be ingested orally or nasally, smoked, or injected. It has dissociative effects and causes nystagmus, hallucinations, and vomiting.

Missed Appendicitis | PSNet

Case Objectives

• Appreciate the variable presentations of appendicitis
• List complications of missed appendicitis
• Understand the advantages and disadvantages of CT in diagnosing appendicitis
• Define “anchoring” and “metacognition” and state their impact on missed diagnoses
• List potential strategies to enhance patient safety in the ED

Case & Commentary: Part 1

A 37-year-old woman with no past medical history went to the emergency department (ED) complaining of vomiting and periumbilical abdominal pain for 6 hours. On physical examination, she was afebrile, with a blood pressure of 110/70 and a heart rate of 85. Her abdomen was soft, without rebound or guarding. She was diagnosed with gastroenteritis and discharged with antiemetics. She was told to return for persistent vomiting, pain, or new fever.

Abdominal pain is a common chief complaint in emergency departments, accounting for more than 6% of the approximately 100 million ED visits in the United States each year.(1,2) The most common surgical cause of abdominal pain is appendicitis, affecting 7% of people during their lifetime.(2,3) Of all ED patients with abdominal pain, however, only 1%-3% will have acute appendicitis, many of which will present atypically.(1,2) Consequently, clinicians may become accustomed to ruling out appendicitis rather than ruling it in, eventually resulting in decreased likelihood of making the diagnosis. To combat this effect, clinicians can adopt guidelines (formal or informal) to prompt consideration of highly morbid diagnoses, such as appendicitis, ectopic pregnancy, and diabetic ketoacidosis.(4) Although the frequency of misdiagnosis of appendicitis ranges from 20% to 40% in some populations, implementation of a diagnostic guideline was shown to reduce the misdiagnosis rate to about 6% in one study.(5)

Given the difficulty in diagnosing appendicitis, it would be a mistake to assume that lack of objective signs or the presence of atypical historical or laboratory features rules out serious underlying disease. For example, only a minority of patients with appendicitis will present with the classic history of abdominal discomfort migrating from the epigastrium to the periumbilical region on to the right lower quadrant. Although the white blood cell (WBC) count will be elevated in 70%-90% of patients with acute appendicitis, this test is neither sensitive nor specific enough to rule in or exclude the disease.(6,7) The presence of pain in the right lower quadrant, abdominal rigidity, and migration of pain from the periumbilical region to the right lower quadrant increases the likelihood of appendicitis.(7) Although often atypical, the history and physical exam can be helpful in assessing a patient for appendicitis. For example, the presence of vomiting before the onset of pain makes appendicitis unlikely, as does the absence of right lower quadrant pain, guarding, or fever.

Physicians who wait for clear, easily recognizable signs will miss many diagnoses. Gastroenteritis may cause crampy, intermittent pain, or may result in muscular pain from vomiting, but should not cause significant continuous pain. This diagnosis should not be made unless the patient clearly exhibits symptoms of diarrhea, vomiting, nausea, crampy abdominal pain, and/or fever, which did not appear to be true for this patient. The presence of pain should increase suspicion for serious underlying conditions, including appendicitis, even if vomiting is present. If uncertain, the clinician must decide whether imaging or continued inpatient observation is required, or whether the patient is safe to return home. In either circumstance, clear discharge instructions should be provided.

When abdominal tenderness is present, a computed tomography (CT) scan can enhance the diagnostic accuracy of appendicitis. However, if the suspicion for acute appendicitis is high, surgical consultation should not be delayed. Anecdotal but widespread concerns have been voiced about potential overreliance on CT scan by emergency physicians and surgeons. The time, expense, and radiation associated with CT is not warranted when the diagnosis can be reliably made or otherwise excluded. For example, the diagnosis of appendicitis in the man with classic right lower quadrant tenderness and other typical signs and symptoms does not require confirmatory CT scan. However, for women, in whom ovarian pathology can mimic appendicitis, and for men whose diagnosis is less certain, obtaining a CT scan is appropriate.

Although sensitivity of up to 100% has been reported for CT scans of the appendix (6), in typical practice the sensitivity is more likely to be 80%-96%.(8,9) Thus, clinicians should be aware of the possibility of false negative scans. Conversely, the specificity of appendiceal CT is not perfect. A Bayesian approach is needed: widespread use of CT in low-risk patients will lead to significant numbers of false positive test results and unnecessary appendectomies. In some cases, a period of inpatient or outpatient observation is warranted despite the CT report. Patient teaching (including thorough discharge instructions) and good communication are the routes to minimizing error.

The best approach to evaluating an ED patient with abdominal pain is to maintain suspicion for early disease, even disease not yet diagnosable, and instruct the patient accordingly. A nonspecific diagnosis of “abdominal pain” can be appropriately followed by a discussion with the patient surrounding “red flag” signs and symptoms as well as the expected course. If abdominal tenderness is absent and there is no justification for CT scan or extended hospital observation, careful instructions must include warning signs of more serious disease. Then, if the patient returns with appendicitis, the initial encounter cannot be counted as a failure, but as a success.

Case & Commentary: Part 2

The patient presented to her primary care physician’s office 2 days later with complaints of persistent abdominal pain; her vomiting had resolved. Her primary physician called the emergency department to obtain the report. On exam, she was afebrile with normal vital signs. She had a diffusely tender abdomen with some localization around the umbilicus and an unremarkable pelvic examination. A transvaginal ultrasound was scheduled for the following week. The patient was sent home, with instructions to take naproxen for the pain.

Diagnostic assumptions and prior reasoning of others can be carried along, unchallenged when the facts and conclusions of previous assessments are absorbed into subsequent diagnostic reasoning. This cognitive error of “anchoring” is a common source of emergency department error, and error in medical care more generally.(10) In the emergency department, conclusions and assessments of paramedics, nurses, and other physicians initiate assumptions about both acuity and diagnosis. An initial error can be propagated if not reassessed, leading to delayed recognition of serious disease or even mistaken diagnoses. Transitions of care are high-risk points for error, allowing insertion of “pseudo-information,” and enabling “posterior probability error,” in which diagnostic probability assessment is influenced by preexisting diagnoses.(11)

Before final patient discharge, the clinician must stop and think broadly about the case in order to minimize cognitive error. To avoid such errors, expert clinicians apply “metacognition.”(12) The caregivers ask themselves, “Given the same set of facts and circumstances, is there an alternative explanation that may be more accurate? Have all possibilities been taken into account? Are all issues properly addressed?” Applying this “big picture” assessment can prevent error.

Diagnostic error often occurs when patients present atypically.(2) Adverse events correlate with false-negative determinations. The route to improving diagnostic decision-making in ED patients with abdominal pain is to maximize diagnostic sensitivity by careful consideration of the possibility of appendicitis.

Case & Commentary: Part 3

The next day, the patient returned to the ED with persistent pain. She was seen by the same ED attending, who then asked a colleague to evaluate the case. This second ED attending performed a pelvic exam and ordered a CT scan of the abdomen and pelvis. The CT revealed a perforated appendix (Figure 1). The patient was seen by general surgery and it was decided not to take her to the operating room immediately due to the peritonitis. She was admitted and started on IV antibiotics. Her hospital stay was prolonged due to ileus. On hospital day number #8, her WBC count began to rise. A repeat CT scan revealed an intraabdominal abscess (Figure 2) “the size of an orange.” The patient underwent percutaneous drainage by interventional radiology. On hospital day #13, she was discharged to home with a plan to follow-up for elective appendectomy.

Appendiceal perforation increases the risk of wound infection, abscess formation, sepsis, wound dehiscence, pneumonia, prolonged ileus, heart failure, and renal insufficiency. Perforation leads to longer hospital stays and delayed complications such as bowel obstruction. In women, there is a five-fold increased risk of infertility.(2,13)

In lieu of a guideline to ensure consideration of key diagnoses, clinicians can adopt rules of thumb for when to step back and ask for help from a consultant or, as in the present case, a colleague. Diagnostic decision making is a probabilistic exercise that can never be perfect. Recognizing the potential for cognitive bias from prior evaluation, it was wise and admirable to obtain the input of a colleague on the second visit. Physicians are trained to be solitary clinicians, fully accountable as individuals, but tasked to work as members of a team, without training in teamwork skills. The ability to access a colleague’s expertise is critical at any stage of training or experience.

Case & Commentary: Part 4

Shortly after discharge, the abdominal pain returned. The patient returned to the ED and underwent a repeat CT scan, which revealed a small bowel obstruction. The patient went to the operating room the next day for lysis of adhesions and appendectomy. Eight days later, the patient was discharged home. She has returned to her previous state of health.

Emergency physicians often do not know the outcomes of patients. Experience does not lead to expertise, only feedback does. Implementing ways to increase feedback will enhance quality and may minimize error.(14) Especially in the emergency department, the presence of supportive feedback loops can promote quality and safety.

To enhance safety in the emergency department, a Center for Safety in Emergency Care has been established.(15) This group has formed because of the recognition that the ED is a complex, difficult, and error-prone environment marked by excessive cognitive burden, distractions, interruptions, and time pressure. Identifying optimal practices that maximize safety is an important undertaking. If we are truly going to improve ED safety and quality, we must account for all of these pressures, distractions, and challenges. The safest ED systems include highly trained caregivers, both doctors and nurses, working as a team, utilizing good communication techniques. Interruptions, computer demands, forms, documentation, phone calls, interpersonal conflicts–these all distract from an attentive, thorough, and therapeutic relationship with the patient. This relationship is critical as it forms the foundation of high quality, safe, and satisfactory patient care.

Minimizing misdiagnosis of appendicitis has always been and will remain a challenge, requiring an enlightened system of care as well as informed, expert caregivers.

James G. Adams, MD Professor and Chief, Division of Emergency Medicine Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital Chicago, Illinois

Faculty Disclosure: Dr. Adams has declared that neither he, nor any immediate member of his family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, his commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

1. McCaig LF, Ly N. National hospital ambulatory medical care survey: 2000 emergency department summary. Division of Health Care Statistics, Centers for Disease Control and Prevention. Number 326, April 22, 2002.

2. Graff L, Russell J, Seashore J, et al. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med. 2000;7:1244-55.[ go to PubMed ]

3. Peltokallio P, Tykka H. Evolution of the age distribution and mortality of acute appendicitis. Arch Surg. 1981;116:153-6.[ go to PubMed ]

4. American College of Emergency Physicians. Clinical Policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med. 2000;36:406-415.[ go to PubMed ]

5. Naoum JJ, Mileski WJ, Daller JA, et al. The use of abdominal computed tomography scan decreases the frequency of misdiagnosis in cases of suspected acute appendicitis. Am J Surg. 2002;184:587-9.[ go to PubMed ]

6. Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Engl J Med. 2003;348:236-42.[ go to PubMed ]

7. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276:1589-94.[ go to PubMed ]

8. Ege G, Akman H, Sahin A, Bugra D, Kuzucu K. Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis. Br J Radiology. 2002;75:721-5.[ go to PubMed ]

9. Maluccio MA, Covey AM, Weyant MHJ, Eachempati SR, Hydo LJ, Barie PS. A prospective evaluation of the use of emergency department computed tomography for suspected acute appendicitis. Surg Infect. 2001;2:205-11.[ go to PubMed ]

10. Kuhn GJ. Diagnostic Errors. Acad Emerg Med. 2002;9:740-750.[ go to PubMed ]

11. Beach C, Croskerry P, Shapiro M. Profiles in Patient Safety: Emergency care transitions. Acad Emerg Med. 2003;10:364-367.[ go to PubMed ]

12. Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003;41:110-120.[ go to PubMed ]

13. Mueller BA, Daling JR, Moore DE, et al. Appendectomy and the risk of tubal infertility. N Engl J Med. 1986;315:1506-8.[ go to PubMed ]

14. Croskerry P. The feedback sanction. Acad Emerg Med. 2000;7:1232-1238.[ go to PubMed ]

15. Wears RL, Croskerry P, Shapiro M, Beach C, Perry S. Center for safety in emergency care: a developing center meant for evaluation and research in patient safety. Top Health Information Management. 2002;23:1-12.

Figures

Figure 1. Perforated Appendix

Figure 2. Intra-abdominal Abscess

How do we approach an adult patient with suspected acute appendicitis?

Introduction

Acute abdominal pain is defined as pain of non-traumatic origin with a maximum duration of 5 days and it represents a common complaint of patients presenting at the emergency department (ED).1

There are many causes of acute abdominal pain that can be classified as urgent and non-urgent causes, the urgent causes require immediate treatment to prevent complications; mainly the location of pain can narrow the differential diagnosis. A complete evaluation is required to increase the diagnostic accuracy, leading to better outcomes.

The most frequent surgical emergency worldwide is acute appendicitis, with a lifetime risk of 7–8%, in low-income and middle-income countries mortality is reported as 1–4%.2 The diagnosis by clinical evaluation can be challenging in cases when the presentation is atypical and overlaps with other conditions, in these situations the use of image studies may be helpful. Delay of accurate diagnosis could result in rupture of the appendix, which is associated with worse prognosis.3 The objectives of an accurate and prompt diagnosis are lowering the normal appendectomy and perforation rates.

The authors recommend a diagnostic pathway in order to lower misdiagnosis, time to diagnosis and complications in patients in which acute appendicitis is suspected.

Initial evaluationHistory

The initial evaluation consists in history and physical examination; the differential diagnosis will be narrowed by the pain’s location, radiation, and migration. General information about onset, duration, severity, quality of pain, associated symptoms, exacerbating and remitting factors should be described.4

For appendicitis, right lower quadrant pain has the highest positive predictive value, although migration from periumbilical to right lower quadrant pain and fever also suggest the diagnosis.4 Appendicitis is also associated with gastrointestinal symptoms like nausea, vomiting, and anorexia. Variations in the anatomic location of the appendix may account for the differing presentations of the somatic phase of pain.5 The order of development of symptoms and signs in appendicitis are epigastric or periumbilical pain, anorexia, nausea, vomiting, tenderness in lower abdomen, fever, and leukocytosis.6

Gastrointestinal symptoms that develop before the onset of pain suggest a different etiology such as gastroenteritis.5

Symptoms in patients with abdominal pain that are suggestive of surgical or emergent conditions include fever, protracted vomiting, syncope or pre-syncope, and evidence of gastrointestinal blood loss.4

Physical examination

The vital signs and general appearance should be noted first in the physical examination.4 In early presentation pulse rate and body temperature may be normal or slightly elevated. The peritoneal irritation will determine the presence of the next physical findings: tenderness at or near the McBurney’s point, muscular resistance (guarding) may be felt on deep palpation, and sudden pain when the hand is quickly relieved (rebound). Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness (pain in the right lower quadrant when the left lower quadrant is palpated) are strong indicators of peritoneal irritation.5 Psoas sign and obturator sign indicates inflammation near the muscles.5 The positive and negative likehood ratios of the sings and symptoms were calculated in a meta-analysis (Table 1).7

In the physical examination for evaluation of appendicitis, digital rectal examination (DRE) has been considered necessary, it has been described that when the appendix hangs into the pelvis, abdominal findings may be absent; right-sided rectal tenderness is said to help in this situation.5 For DRE a meta-analysis found a pooled sensitivity of 0.49 (95% CI 0.42–0.56), the pooled specificity was 0.61 (95% CI 0.53–0.67), the pooled Positive Likelihood Ratio (LR+) was 1.24 (95% CI 0.97–1.58), the pooled Negative Likelihood Ratio (LR−) was 0.85 (95% CI 0.70–1.02), and the diagnostic odds ratio (DOR) was 1.46 (0.95–2.26).3 Considering sensitivity, specificity and the discomfort the DRE causes, Toshihiko T. et al. question the necessity of DRE in patients with suspected appendicitis.

Laboratory tests

When acute appendicitis is suspected after initial evaluation a white blood cell count (WBC) with differential and C-reactive protein (CRP) must be ordered. No inflammatory marker alone, such as white blood cell count, C-reactive protein, or other novel tests, including procalcitonin, can identify appendicitis with high specificity and sensitivity.2

Appendicitis was more likely in patients with a strong inflammatory response, high granulocyte counts or WBC, high proportion of PMN cells or increased CRP concentration.7

Appendicitis was likely when two or more descriptors of inflammation were increased, with a LR+ of more than 10; it was unlikely when all markers of inflammation were normal, with a LR− of less than 0.10 (Table 2).7

Role of Alvarado score

Alvarado A. developed a score in 1986 based in symptoms, signs and laboratory findings (Table 3). The predicted number of patients with appendicitis is 30% in those with score 1–4 (low-risk), 66% with 5–6 (intermediate risk) and 93% in scores 7–10 (high risk). He proposed that patients with a score of 5–6 should be observed, and a score of 7 and more requires surgery.8

An Alvarado score of 1–4 has a sensitivity of 99% in the overall population, 96% for men and 99% for women. However, a higher Alvarado scores (7–10), has limited clinical value since it has a specificity of 82% in overall population, 57% for men, 73% for women. In women the score over-predicts the probability of appendicitis and should be used with caution. As a sole decision criterion for surgery (cut point of 7) the score produces negative appendectomy rates from 13.3% to 16.2%.9

A discharge decision by ruling out acute appendicitis can be made if the patient has an Alvarado score of 1–4, but it is important to warn the patient for symptom changes that may require re-assessment. An intermediate-high risk Alvarado score (5–10) cannot be used to diagnose acute appendicitis since it has low specificity, in these patients the use of image studies should may be appropriate.

By correlation between Alvarado score and diagnostic findings in computed tomography (CT) for acute appendicitis, a score of 3 or lower had an incidence of 3.7% of acute appendicitis (96% sensitivity), and those of a score 7 or higher had an incidence of 77.7% of acute appendicitis (100% specificity). Those with a score between 4 and 6 had specificity of 94%. McKay R. recommends CT on patients with an Alvarado score from 4 to 6, in patients with 7 or more, a surgical consultation is recommended before the CT. CT is not recommended in scores of 3 or less, since it may delay diagnosis and time in ED.10

Imaging studies

In adolescent and adult patients, computed tomography (CT) has become the most widely accepted imaging strategy.2 Twelve studies were reviewed by Terasawa S. et al. in which CT and US were evaluated as diagnostic tools for acute appendicitis, finding that CT had pooled estimates of 0.94 (95% CI 0.91, 0.95) for sensitivity, 0.95 (95% CI: 0.93, 0.96) for specificity, 13.3 (95% CI: 9.9, 17.9) for the positive LR and 0.09 (95% CI: 0.07, 0.12) for the negative LR. Ultrasonography had pooled estimates of 0.86 (95% CI: 0.83, 0.88) for sensitivity, 0.81 (95% CI: 0.78, 0.84) for specificity, 5.8 (95% CI: 3.5, 9.5) for the positive LR and 0.19 (95% CI: 0.13, 0.27) for the negative LR, concluding a better diagnostic performance by CT.11

On 5-mm-section contrast-enhanced helical CT examinations, one enlarged appendix, appendicular wall thickening, peri-appendicular fat stranding, and appendicular wall enhancement were the most useful findings for diagnosing acute appendicitis.12

In cases of abdominal pain suspected to be appendicitis, imaging studies were more cost-effective than physical exam to make accurate diagnostic decisions. Tomography offers the best cost-effectiveness in prepaid system and in public health system.13 The use of CT reduces the negative appendectomy rate to 6% compared with no CT approach.2,14–16 The use of CT in the absence of an expedited imaging protocol may delay surgery, but this is not associated with increased appendicular perforation rates.17

However, CT radiation is a common concern in children and young patients, reducing the radiation without affect the accuracy which can be achieved with a low-dose CT. Low-dose CT was non-inferior to standard-dose CT with respect to negative appendectomy rates in young adults with suspected appendicitis.18

Conclusions

The diagnosis by clinical evaluation can still be challenging in cases where presentation is atypical and overlaps with other conditions, there is continuous effort in evaluating clinical, laboratory and image findings in order to make an accurate and early diagnosis. It is not recommended a diagnosis made merely by clinical evaluation since it may increase the normal appendectomy rate, also a routine CT is not recommended because unnecessary radiation exposure and increases costs in low risk situations; a systematic evaluation combining clinical evaluation, laboratory and imaging depending on Alvarado score is proposed in order to lower misdiagnosis and normal appendectomy rate. The recommend approach for us is shown in Fig. 1.

Funding

No financial support was provided.

Clinical investigation Appendicitis: polymer clamp, endoloop – Clinical Trials Register

Detailed Description

Appendicitis is defined as inflammation of the inner lining of the appendix that spreads to other parts of the appendix. [1] Signs of acute appendicitis include right lower quadrant pain that begins in the epigastrium or umbilical region and then progresses to the right iliac fossa associated with nausea, vomiting, anorexia, or fever.On examination, tenderness, rebound soreness, and protection are usually present in the right iliac fossa. Various laboratory tests for the diagnosis of appendicitis include a complete blood count, abdominal ultrasound and abdominal CT. A large study conducted at one center showed that the CT detector (MDCT) has high sensitivity and specificity (98.5% and 98%, respectively) for the diagnosis of acute appendicitis. [2] Appendicitis can occur for several reasons, such as an infection of the appendix, but the most important factor is blockage of the appendix.Left untreated, appendicitis can cause: severe complications including perforation, peritonitis, sepsis, and even death. Appendectomy is the most effective treatment for acute appendicitis and has been performed most frequently in emergency surgery worldwide. Since the introduction of laparoscopy, a minimally invasive technique has been used to perform appendectomy. According to the 2010 Guidelines of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Indications for laparoscopic appendectomy are identical to those for open appendectomy.[3] Laparoscopic appendectomy (LA) is a safe and simple operation offering well-known advantages of laparoscopy: faster postoperative recovery, good cosmetics, fewer wound complications and less postoperative pain, although the laparoscopic method is more expensive than the open method. Various methods are used for this (endloop, titanium clamps, polymer clamps and endosteplers). ligate the stump and mesentery of the appendix during laparoscopic appendectomy. Endoloops have long been widely used to ligate the mesentery, but they are expensive. and requires more experience and skills to use endopetol and in most cases 2-3 endoloops are used, which increases the cost of the operation. Modern polymer clamps are used for ligation of the stump and mesentery, which are economical and require less experience, as compared to what is required for using polymer clamps. Moreover, both of these methods do not have side effects, as has been investigated by various researchers in a previous study.[4] [5] [6] In a study conducted by S. Delibegovich and E. Matovich [4] who compared polymer clamps with a loop showed that the average duration of the operation was 47.1 ± 6.7 minutes. in the first group, where the base was fixed with a loop ligature, and amounted to 38.7 ± 5.0 min. group where the base was fixed with hem-o-lock clamps. The cost of three hem-o-lok clamps was 76.9 euros, and the cost of three ligatures inside the loop – 88.5 euros, and according to them ease of use, shorter operation time and lower cost of hem-o-lok clamps advantages of this method of attaching the base of the appendix in relation to the standard endoloop procedure.Various other studies have shown similar results. [5], [6]

Appendicitis – en.eventidwiki.com

Inflammation of the appendix

, 9000 imaging, blood tests

Appendicitis
Other names	Epitiflitis
Specialty	General Surgery
Symptoms	Pain in the lower abdomen on the right, vomiting, loss of appetite
Complications	Inflammation of the abdominal cavity, sepsis
Diagnostic method 5 Based on medical symptoms
Differential diagnosis	Mesenteric adenitis, cholecystitis, abscess of the lumbar muscle, abdominal aortic aneurysm
Care	Surgical removal of the appendix, antibiotics
Frequency	11
Deaths	50.100 (2015)

Appendicitis inflammation of the appendix.Symptoms usually include pain in the lower right abdomen, nausea, vomiting, and decreased appetite. However, about 40% of people do not have these typical symptoms. Severe complications of ruptured appendix include extensive, painful inflammation of the lining of the abdominal wall and sepsis.

Appendicitis is caused by blockage of the hollow part of the appendix. This is most often due to the calcified “stone” from the faeces. Inflamed lymphoid tissue caused by a viral infection, parasites, gallstones, or tumors can also cause blockages.This blockage results in increased pressure in the appendix, decreased blood flow to the tissues of the appendix, and the growth of bacteria within the appendix, causing inflammation. The combination of inflammation, decreased blood flow to the appendix, and enlargement of the appendix causes tissue damage and death. If this process is left untreated, the appendix can burst, releasing bacteria into the abdominal cavity, leading to increased complications.

The diagnosis of appendicitis is largely based on the person’s signs and symptoms. In cases where the diagnosis is unclear, close observation, medical imaging, and laboratory tests may be helpful.The two most common imaging techniques are ultrasound and computed tomography (computed tomography). Computed tomography has been shown to be more accurate than ultrasound in detecting acute appendicitis. However, ultrasound may be preferred as the first imaging test in children and pregnant women because of the risks associated with radiation exposure with computed tomography.

The standard treatment for acute appendicitis is surgical removal of the appendix.This can be done with an open incision in the abdomen (laparotomy) or through several smaller incisions with cameras (laparoscopy). Surgery reduces the risk of side effects or death associated with a ruptured appendix. Antibiotics can be equally effective in some cases of unruptured appendicitis. This is one of the most common and serious causes of severe abdominal pain that comes on quickly. In 2015, there were about 11.6 million cases of appendicitis, which resulted in about 50,100 deaths.In the United States, appendicitis is the most common cause of sudden abdominal pain requiring surgery. More than 300,000 people with appendicitis in the United States each year have their appendix surgically removed. Reginald Fitz is credited with being the first person to describe the condition in 1886.

Video summary (script)

Signs and symptoms

Location of McBurney point (1), located two thirds of the distance from the navel (2) to the right anterior superior iliac spine (3)

Acute appendicitis manifests itself with abdominal pain, nausea, vomiting and fever.As the appendix swells and becomes inflamed, it begins to irritate the adjacent abdominal wall. This leads to localization of pain in the right lower quadrant. This classic pain migration may not be seen in children under three years of age. This pain can be symptomatic and can be severe. Symptoms include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to light pressure (palpation). With the sudden disappearance of deep tension in the lower abdomen, severe pain occurs (Blumberg sign).If the appendix is ​​retrocecal (located behind the cecum), even deep pressure in the right lower quadrant may not cause tenderness (silent appendix). This is because the gas-distended cecum protects the inflamed process from pressure. Likewise, if the appendix lies completely within the pelvis, there is usually a complete absence of abdominal stiffness. In such cases, a digital rectal examination reveals tenderness in the rectal-cystic sac. The cough causes a pinpoint soreness in that area (McBurney point), historically called Dunphy’s sign.

Causes

Location of the appendix in the digestive system

Figure of appendicitis.

Acute appendicitis appears to result from primary obstruction of the appendix. As soon as this obstruction occurs, the appendix fills with mucus and swells. This continued production of mucus leads to an increase in pressure in the lumen and walls of the appendix. Increased pressure leads to thrombosis and blockage of small vessels, as well as stagnation of the lymphatic flow.At this stage, spontaneous recovery is rare. As the occlusion of the blood vessels progresses, the appendix becomes ischemic and then necrotic. When bacteria begin to seep through the dying walls, pus (suppuration) forms in and around the appendix. The end result is a ruptured appendix (“ruptured appendix”), causing peritonitis, which can lead to sepsis and ultimately death. These events are responsible for slowly developing abdominal pain and other commonly associated symptoms.

Pathogens include bezoars, foreign bodies, trauma, intestinal worms, lymphadenitis, and, most commonly, calcified stool, known as appendicolitis or faecalis. The emergence of plugging fecal matter has attracted attention because its presence in people with appendicitis is higher in developed than in developing countries. In addition, appendicular stool is commonly associated with complicated appendicitis. Stool congestion and retention may play a role, as demonstrated by people with acute appendicitis who have fewer bowel movements per week compared to healthy controls.

The appearance of faeces in the appendix was thought to be associated with a right-sided fecal retention reservoir in the colon and a long transit time. However, in subsequent studies, long transit times were not observed. Diverticular disease and adenomatous polyps were historically unknown, and colon cancer was extremely rare in communities where appendicitis itself was rare or absent, such as in various African communities. Studies have shown that switching to a low-fiber Western diet leads to an increased incidence of appendicitis, as well as the other aforementioned colon diseases, in these communities.It has been proven that acute appendicitis precedes colon and rectal cancer. Several studies offer evidence that low fiber intake is involved in the pathogenesis of appendicitis. This low fiber intake is due to the presence of a right-sided fecal reservoir and the fact that dietary fiber shortens transit time.

Diagnosis

Appendicitis on CT

Diagnosis is based on medical history (symptoms) and physical examination, which can be confirmed by elevated neutrophil leukocyte counts and imaging tests, if necessary.Stories fall into two categories: typical and atypical.

Typical appendicitis involves several hours of generalized abdominal pain that begins in the navel and is accompanied by anorexia, nausea, or vomiting. Then the pain is “localized” in the lower right quadrant, where the pain intensifies. It is possible that pain may be localized in the left lower quadrant in people with situs inversus totalis. The combination of pain, anorexia, leukocytosis and fever is classic.

An atypical history does not have this typical progression and may include right lower quadrant pain as the initial symptom.Irritation of the peritoneum (the lining of the abdominal wall) can lead to increased pain when moving or shaking, for example when overcoming speed bumps. An atypical history often requires imaging with ultrasound or computed tomography.

Clinical

• Symptom Aure-Rozanova: increased pain on palpation with a finger in the right small triangle (may be a positive result of Shchetkin-Bloomberg).
• Bartomier-Michelson’s sign: increased pain on palpation in the right iliac region when the subject is lying on his left side, compared to when he is lying on his back.
• Dunphy’s sign: increased pain in the right lower quadrant when coughing.
• Hamburger sign: the patient refuses to eat (anorexia is 80% sensitive to appendicitis)
• Kocher sign (kosher): from a person’s medical history, onset of pain in the umbilical region followed by displacement to the right iliac region.
• Symptom Mass: Developed and popular in the South West of England, the examiner sweeps firmly with the index and middle fingers across the abdomen from the xiphoid process to the left and right iliac fossa.A positive sign Massu is a grimace of the subject with a right-sided (and not left) swing.
• Obturator sign: the subject lies on his back, the hip and knee are bent at an angle of ninety degrees. The examiner holds the person by the ankle with one hand and the knee with the other. The examiner rotates the hip, moving the person’s ankle away from his or her body, allowing the knee to only move inward. A positive test is pain during internal rotation of the hip.
• The psoas symptom, also known as the Exemplary sign, is pain in the right lower quadrant that occurs either with passive extension of the right hip or with active flexion of the person’s right hip while supine.The resulting pain occurs due to inflammation of the peritoneum covering the iliopsoas muscles, and inflammation of the lumbar muscles themselves. Straightening the leg is painful because it stretches these muscles, while flexion of the hip activates the iliopsoas muscle and causes pain.
• Rovsing’s symptom: pain in the right lower quadrant of the abdomen with continuous deep palpation, starting from the left iliac fossa upwards (counterclockwise along the colon). It is assumed that pressure around the appendix will increase by pushing intestinal contents and air towards the ileocecal valve, causing abdominal pain on the right.
• Sign of Sitkovsky (Rosenstein): increased pain in the right iliac region during examination lies on the left side.
• Perman’s sign: In acute appendicitis, palpation in the left iliac fossa may cause pain in the right iliac fossa. Emil Samuel Perman 1856-1946 “On the indications for surgery for appendicitis and the description of cases at the Sabbatsberg hospital in Hygea, 1904.

Blood and urine tests

Although there are no laboratory tests specific to appendicitis, a complete blood count (CBC) is done to check for signs of infection.Although 70 to 90 percent of people with appendicitis may have an elevated white blood cell (WBC) count, there are many other abdominal and pelvic conditions that can cause an elevated white blood cell count. Because of their low sensitivity and specificity, leukocytes by themselves are not considered a good indicator of appendicitis.

Urinalysis usually does not detect infection, but it is important for determining pregnancy status, especially the possibility of ectopic pregnancy in women of childbearing age.Urinalysis is also important to rule out urinary tract infections as a cause of abdominal pain. The presence of more than 20 leukocytes per field of view in urine is more indicative of urinary tract disease.

Imaging

Clinical evaluation of children is important to determine which children with abdominal pain should receive immediate consultation with a surgeon and which should receive a diagnostic image. Because of the health risks of exposing children to radiation, ultrasound is the preferred first choice, and computed tomography is a legitimate follow-up if ultrasound is unsuccessful.Computed tomography is more accurate than ultrasound for diagnosing appendicitis in adults and adolescents. CT has a sensitivity of 94%, a specificity of 95%. The general sensitivity of ultrasound examination was 86%, specificity – 81%.

Ultrasound

Ultrasound of acute appendicitis

Ultrasound of the abdomen, preferably with Doppler, is useful for detecting appendicitis, especially in children. Ultrasound can show accumulation of free fluid in the right iliac fossa, as well as a visible process with increased blood flow using color Doppler and incompressibility of the process, since it is, in fact, an abscess with walls.Other secondary sonographic features of acute appendicitis include the presence of echogenic mesenteric fat surrounding the appendix and acoustic occlusion of the appendicolitis. In some cases (approximately 5%), ultrasound examination of the iliac fossa does not reveal any abnormalities, despite the presence of appendicitis. This false negative is especially true for early appendicitis before the appendix has expanded significantly. In addition, false negatives are more common in adults, who have high levels of fat and intestinal gas making it difficult to visualize the appendix.Despite these limitations, ultrasound imaging with experienced hands can often distinguish appendicitis from other conditions with similar symptoms. Some of these conditions include inflammation of the lymph nodes near the appendix or pain from other pelvic organs such as the ovaries or fallopian tubes. An ultrasound can be done in a radiology department or by an emergency doctor.

• Ultrasound: appendicitis and appendicitis

• Ultrasound: appendicitis and appendicolitis

• Ultrasound of the normal appendix for comparison

• 9000 Normal appendix

  9000Lack of compressibility indicates appendicitis.

Computed tomography

Computed tomography showing acute appendicitis (note that the appendix is ​​17.1 mm in diameter and surrounded by a fat layer)

Fecalitis, marked with an arrow, which led to acute appendicitis.

Computed tomography (CT) is often used where available, especially in people whose diagnosis is not obvious from history and physical examination.While some interpretation concerns have been identified, a 2019 Cochrane review found that the sensitivity and specificity of CT for the diagnosis of acute appendicitis in adults were high. Concerns about radiation tend to limit the use of CT in pregnant women and children, especially with the increasing use of MRI.

An accurate diagnosis of appendicitis is multilevel, with the size of the appendix having the greatest positive predictive value, while indirect signs can increase or decrease sensitivity and specificity.A size greater than 6 mm is 95% sensitive and specific for appendicitis.

However, because the appendix can be filled with feces causing intraluminal distention, this criterion has shown limited applicability in later meta-analyzes. This is in contrast to ultrasound, which makes it easier to distinguish the wall of the appendix from intraluminal feces. In such scenarios, supportive signs, such as strengthening of the intestinal walls relative to the adjacent intestine and inflammation of the surrounding fat, or the formation of fat accumulations, may aid the diagnosis.However, their absence does not exclude this. In severe cases, perforation may show an adjacent phlegmon or abscess. There may also be tight pelvic fluid deposits associated with leakage of pus or intestinal fluid. When patients are thin or younger, the relative lack of fat can make it difficult to see the appendix and the surrounding fatty strands.

Magnetic resonance imaging

The use of magnetic resonance imaging (MRI) is becoming more common in the diagnosis of appendicitis in children and pregnant patients due to the radiation dose, which, although it has almost negligible risk to healthy adults, can be harmful for kids or developing child.During pregnancy, it is more helpful in the second and third trimester, especially as the enlarging uterus displaces the appendix, making it difficult to find with ultrasound. The periappendicular ligation, which is reflected on CT by the fat band on MRI, appears as an increased fluid signal on the T2-weighted sequences. First trimester pregnancies are usually not suitable for MRI because the fetus is still in the process of organogenesis and there are no long-term studies to date regarding its potential risks or side effects.

X-ray

Appendicolitis on plain x-ray

In general, plain abdominal (PAR) x-rays are not helpful in diagnosing appendicitis and should not be done routinely in a person being screened for appendicitis. Flat abdominal scans can be useful for detecting ureteral stones, small bowel obstruction, or perforated ulcers, but these conditions are rarely confused with appendicitis. Opaque stool can be found in the lower right quadrant in less than 5% of people tested for appendicitis.Barium enema has proven to be a poor diagnostic tool for appendicitis. Although the inability to fill the appendix during a barium enema is associated with appendicitis, up to 20% of normal appendixes do not fill.

Scoring Systems

Several scoring systems have been developed to try to identify people who may have appendicitis. However, the effectiveness of scores such as the Alvarado score and the infant appendicitis score varies.

Alvarado’s score is the most famous scoring system.A score below 5 indicates against a diagnosis of appendicitis, while a score of 7 or more indicates acute appendicitis. In a person with a dubious grade of 5 or 6, computed tomography or ultrasound may be used to reduce the incidence of negative appendectomy.

points

Alvarado’s score

Pain in the migrating right iliac fossa	1 point
Anorexia	1 point
Nausea and vomiting	1 point 2
Rebound soreness of the abdomen	1 point
Fever	1 point
High leukocyte count (leukocytosis)	2 points
Left shift (segmented)
Total score	10 points

Pathology

Even in the case of clinically definite appendicitis, routine histopathological examination of appendectomy specimens is important to identify unforeseen pathologies requiring further postoperative treatment. cheniya.Notably, appendix cancer is incidentally found in about 1% of specimens after appendectomy.

Pathological diagnosis of appendicitis can be established by detecting a neutrophilic infiltrate of its own muscle tissue.

Periapendicitis, an inflammation of the tissue around the appendix, often occurs in conjunction with other abdominal abnormalities.

• Micrograph of appendicitis and periapendicitis. H&E spot.

• Micrograph of appendicitis showing neutrophils of its own muscle.H&E spot.

• Acute suppurative appendicitis with perforation (right). H&E spot.

None

Not obvious

• Serosa can be stagnant, dull and exudative.

000 Nothing visible

Classification of acute appendicitis based on macropathology and light microscopy characteristics

Template	Macropathology	Light microscopy	Image	Clinical significance
135 Acute inflammation None Only neutrophils in the lumen No ulceration or transmural inflammation		Probably not
Inflammation of the mucous membrane Acuta	Nothing is visible	in the mucous membrane, possibly in the mucosa and mucous membrane Ulceration of the mucous membrane		May be secondary to enteritis.
Purulent acute appendicitis	May not be obvious. Dull mucous membrane Blockage of superficial vessels Fibrous-purulent serous exudate in late cases Dilated appendix	Neutrophils in the mucosa, potentially submucosa, and its own Extensive inflammation Usually intramural abscesses Vascular thrombosis possible		Presumably this is the main cause of symptoms
Gangrenous / necrotizing appendicitis green wall	black	Transmural inflammation Necrotic areas Extensive mucosal ulceration		Will perforate if left untreated
Periappendicitis	Serous and subserous inflammation that does not go beyond the own muscular layer, which can be called isolated		If isolated, probably secondary to another disease
Eosinophilic	> 10 eosinophils / mm 2 in muscularis propria. No changes consistent with other types of appendicitis.		Possibly parasitic or eosinophilic enteritis.

Differential diagnosis

Coronal computed tomography of a person initially suspected of appendicitis due to pain on the right side. CT scans show an enlarged, inflamed gallbladder that reaches the right lower abdomen.

Children: gastroenteritis, mesenteric adenitis, Meckel’s diverticulitis, intussusception, Henoch-Schönlein purpura, croupous pneumonia, urinary tract infection (children with UTI may experience abdominal pain in the absence of other symptoms), new-onset Crohn’s disease or ulcerative colitis, pancreatitis.abdominal trauma from child abuse; distal intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in children with leukemia.

Women: A pregnancy test is important for all women of childbearing age because an ectopic pregnancy can have signs and symptoms similar to those of appendicitis. Other obstetric and gynecologic causes of similar abdominal pain in women include pelvic inflammatory disease, ovarian torsion, menarche, dysmenorrhea, endometriosis, and mittelschmerz (the passage of an egg through the ovaries about two weeks before menstruation).

Men: testicular torsion

Adults: new-onset Crohn’s disease, ulcerative colitis, regional enteritis, cholecystitis, renal colic, perforated peptic ulcer, pancreatitis, rectal vaginal hematoma and omentum appendagitis.

Elderly: diverticulitis, intestinal obstruction, colon carcinoma, mesenteric ischemia, flowing aortic aneurysm.

The term “pseudo-appendicitis” is used to describe a condition that mimics appendicitis.It may be related to Yersinia enterocolitica .

Management

Acute appendicitis is usually treated with surgery. Although antibiotics are safe and effective for treating uncomplicated appendicitis, 26% of people relapse within a year and ultimately required an appendectomy. Antibiotics are less effective if you have appendicolitis. Surgery is the standard approach to treating acute appendicitis, but a 2011 Cochrane review comparing appendectomy with antibiotic treatment was not updated and was withdrawn.The cost-effectiveness of surgery versus antibiotics is unclear.

Antibiotics are recommended to prevent potential postoperative complications in emergency appendectomy, and antibiotics are effective when given to the patient before, during, or after surgery.

Pain

Pain relievers (such as morphine) do not appear to interfere with the clinical diagnosis of appendicitis and should therefore be prescribed early in patient care.Historically, some general surgeons feared that analgesics might interfere with the clinical examination of children, and some have recommended not giving them until the surgeon can examine the person.

Operation

See also: Appendectomy

Removal of the inflamed appendix by open operation

Laparoscopic appendectomy.

The surgical procedure for removing the appendix is ​​called appendectomy. Appendectomy can be performed by open or laparoscopic surgery.Laparoscopic appendectomy has several advantages over open appendectomy as an intervention for acute appendicitis.

Open appendectomy

For more than a century, laparotomy (open appendectomy) has been the standard treatment for acute appendicitis. This procedure consists of removing the infected appendix through one large incision in the lower right corner of the abdomen. The incision for a laparotomy is usually 2 to 3 inches (51 to 76 mm) in length.

During open appendectomy, a person with suspected appendicitis is placed under general anesthesia so that the muscles are completely relaxed and the person becomes unconscious.A two to three inch (76 mm) incision is made in the right lower abdomen, several inches above the thigh bone. After the incision opens the abdomen and the appendix is ​​exposed, the surgeon removes the infected tissue and cuts the appendix from the surrounding tissue. After a thorough and careful examination of the infected area and checking for signs of damage or infection of the surrounding tissue. For complicated appendicitis treated with an emergency open appendectomy, an abdominal drain (a temporary tube from the abdomen outward to avoid abscess formation) may be inserted, but this may increase the hospital stay.The surgeon will begin to close the incision. This means stapling the muscles together and using surgical staples or stitches to close the skin. To prevent infection, the incision is closed with a sterile dressing or surgical tape.

Laparoscopic appendectomy

Laparoscopic appendectomy was introduced in 1983 and has become an increasingly common treatment for acute appendicitis. This surgical procedure consists of three to four abdominal incisions, each 0.25 to 0.5 inches (6.4 to 12.7 mm) long.This type of appendectomy is performed by inserting a special surgical instrument called a laparoscope into one of the incisions. The laparoscope connects to a monitor outside the body and is designed to assist the surgeon in examining an infected area in the abdomen. The other two incisions are made to specifically remove the appendix with surgical instruments. Laparoscopic surgery requires general anesthesia and can take up to two hours. Laparoscopic appendectomy has several advantages over open appendectomy, including shorter postoperative recovery, less postoperative pain, and less infection of the superficial surgical site.However, the occurrence of an intra-abdominal abscess is almost three times more frequent with laparoscopic appendectomy than with open appendectomy.

Before surgery

Treatment begins by keeping the person to be operated on from eating or drinking for a specified period, usually overnight. Intravenous infusion is used to moisturize the person who is about to have surgery. Intravenous antibiotics such as cefuroxime and metronidazole can be given early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound.Doubtful cases can become more difficult to diagnose with antibiotic treatment and benefit from serial screening. If the stomach is empty (there has been no food in the past six hours), general anesthesia is usually given. Otherwise, spinal anesthesia may be used.

Once the decision has been made to perform an appendectomy, the preparatory procedure takes one to two hours. In the meantime, the surgeon will explain the procedure for the operation and present the risks to consider when performing an appendectomy.(All surgeries have risks that need to be assessed before proceeding.) Risks vary depending on the condition of the appendix. If the appendix is ​​not ruptured, the complication rate is only about 3%, but if the appendix is ​​ruptured, the complication rate rises to almost 59%. The most common complications that can occur are pneumonia, hernia incision, thrombophlebitis, bleeding, and adhesions. Available data indicate that a delay in surgery after hospitalization does not result in a noticeable difference in outcome for a person with appendicitis.

The surgeon will explain how long the recovery should take. The hair on the abdomen is usually removed to avoid complications associated with the incision.

In most cases, patients going to surgery experience nausea and vomiting, which requires medication before surgery. Antibiotics and pain relievers can be given before appendectomy.

After surgery

Stitches the day after removal of the appendix by laparoscopic surgery

The length of hospital stay is usually several hours to several days, but can be several weeks if complications arise.The recovery process can vary depending on the severity of the condition: whether the appendix was ruptured or not prior to surgery. Recovery from appendix surgery is usually much faster if the appendix has not ruptured. It is important that people who have had surgery respect their doctor’s advice and limit physical activity so that tissues can heal faster. Recovery from an appendectomy may not require diet or lifestyle changes.

The length of hospital stay for appendicitis depends on the severity of the condition.A study in the United States found that in 2010 the average length of hospital stay for appendicitis was 1.8 days. During the stay during the ruptured appendix, the average length of stay was 5.2 days.

After surgery, the patient will be transferred to the post-anesthesia unit so that his or her vital signs can be closely monitored to identify complications related to anesthesia or surgery. Pain relievers may be given as needed.After the patients are fully awake, they are transferred to the recovery room. Most people will be offered clear liquids the day after surgery, and then they will go on a regular diet when their intestines are normal. Patients are advised to sit on the edge of the bed and walk short distances several times a day. Moving is mandatory, pain relievers can be prescribed if necessary. Full recovery from an appendectomy takes four to six weeks, but can be extended to eight weeks if the appendix has ruptured.

Prognosis

Most people with appendicitis recover quickly from surgery, but complications can arise if treatment is delayed or peritonitis occurs. Recovery time depends on age, condition, complications and other circumstances, including the amount of alcohol consumed, but usually ranges from 10 to 28 days. In young children (about ten years old), recovery takes three weeks.

The possibility of peritonitis is the reason why acute appendicitis requires prompt examination and treatment.People with suspected appendicitis may need medical evacuation. Appendectomies were sometimes performed in emergencies (i.e. not in the correct hospital) when timely medical evacuation was not possible.

Typical acute appendicitis responds quickly to appendectomy and sometimes resolves spontaneously. If appendicitis resolves spontaneously, it remains controversial whether elective interval appendectomy should be performed to prevent recurrence of appendicitis.Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and more prone to complications, even with early surgery. In any case, timely diagnosis and appendectomy give the best results with complete recovery, usually in two to four weeks. Mortality and serious complications are rare but still occur, especially if peritonitis persists and is not treated.

Talk of another object known as the appendicular lump. This happens when the appendix is ​​not removed at an early stage of infection, and the omentum and intestines adhere to it, forming a palpable lump.During this period, surgery is risky if there is no pus formation evident due to fever, toxicity, or ultrasound. Medical management treats this condition.

An unusual complication of appendectomy is “stump appendicitis”: inflammation occurs in the remnant of the appendix stump after a previous incomplete appendectomy. Cultic appendicitis can develop months to years after the initial appendectomy and can be identified using imaging techniques such as ultrasound.

Epidemiology

Mortality from appendicitis per million people in 2012

Disability-adjusted life year for appendicitis per 100,000 inhabitants in 2004

Appendicitis is most common between the ages of 5 and 40 years. In 2013, it caused 72,000 deaths worldwide, up from 88,000 in 1990.

There were almost 293,000 hospitalizations for appendicitis in the United States in 2010. Appendicitis is one of the most common emergency department diagnoses resulting in hospital admissions for children aged 5–17 years in the United States.

See also

• Death from appendicitis

Recommendations

External links

The lower abdomen hurts on the right when lying down. The lower abdomen on the right and on the left hurts – what does this mean? If the lower abdomen hurts in a woman or a man

Every person may have a stomach ache from time to time. The causes of pulling pain in a certain part of the abdomen in women and men can be completely different.We will list the main reasons for such a phenomenon as abdominal pain in this material.

Drawing pains in the lower abdomen – causes

Sometimes pain in the lower abdomen may indicate a pathology such as intestinal obstruction. As the intestinal obstruction increases and with it the stretching of this organ, the pain in the abdomen may worsen. In this case, vascular ischemia occurs on the walls of the intestine.

In women of reproductive age with acute abdominal pain, we must also take into account the likelihood of gynecological pathologies, therefore, a gynecological history and examination should be carried out.For a patient who has been treated with right lower quadrant abdominal pain, acute appendicitis is the most commonly considered diagnosis. Appendicitis is a common cause of acute abdominal pain in women of reproductive age, and appendectomy is the most common of all operations performed on these patients.

Moreover, suspected appendicitis is one of the most common surgical consultations in an outpatient or emergency setting.Appendicitis is the emergency with the highest misdiagnosis rate, although clear diagnostic and treatment strategies have been established for over 100 years. General surgeons may challenge gynecological pathologies and may need to intervene in these circumstances in women undergoing laparotomy diagnosed with acute appendicitis.

Pain in the lower abdomen may be a sign of urinary tract disease. With urinary retention in the body, intense cutting pain occurs.The true cause of such pain is determined by the doctor in the process of a detailed examination.

Renal colic can cause this pain, which is also present in the side. In this case, the specialist examines the area where the kidneys are located, and also checks the results of the urinalysis for the presence of bacteria.

A thorough understanding of the anatomy and physiology of the abdominal cavity is necessary for the correct formation of a differential diagnosis and formulation of a treatment plan. Acute appendicitis can lead to unwanted complications if the diagnosis is confused or delayed.While recent advances in surgical and diagnostic techniques can be extremely helpful in certain situations, they cannot replace the surgeon’s clinical judgment based on a good history and physical examination.

Today, as medicine becomes more dependent on laboratory and radiological results, the merit of physical examination has diminished. It is important to understand that a painstaking history and physical examination are important and can be diagnostic for many conditions, especially appendicitis.

In whatever part of the abdomen there is a feeling of pain – below, on the right or on the left – this is in any case a symptom indicating a particular disease. However, in no case can abdominal pain be a separate disease. Therefore, you cannot try to treat the pain yourself. It is necessary to consult a doctor who will first figure out the true reason why this pain has arisen.

Data consisted of early findings at admission and included history of abdominal pain, nausea, vomiting, and anorexia; Abdominal Tenderness, Defense, Rebound, Dunfi Mark, Obturator Mark, Prism Mark, and Rovsing Mark for Physical Examination; and body temperature, white blood cell count, urine microscopy and abdominal x-ray for laboratory research.Patients have not received regular abdominal ultrasound and computed tomography due to inadequate out-of-shift X-ray counseling.

Why does the stomach on the right hurt

As you know, many different muscles and organs are located inside the human abdominal cavity. In this regard, a complaint of pain in the right side of the abdomen requires careful consideration of various factors, and examination in order to identify the real cause of such pain.As a rule, a person who is experiencing pain in any part of his body, including in the abdomen, tends to take a pain relief pill as soon as possible in order to relieve his condition. This is fundamentally wrong and in some cases even unacceptable.

The same general surgeon performed the first examination and surgery on these patients. All patients underwent a routine preoperative gynecological consultation. The laparoscopic approach has not been performed due to technical inadequacy. The diagnosis of appendicitis and gynecologic pathology was made by perioperative gross evaluation.Abdominal exploration was performed in all patients with normal attachment to exclude a possible Meckel diverticulum. Peroperative gynecological consultation was obtained for patients with gynecological pathology.

According to doctors, taking pain relievers “muddies” the medical history and thus interferes with correct diagnosis and appropriate therapy. And in some situations, when the count goes on for minutes, and the person needs to be urgently saved, the patient’s life depends entirely on the immediate determination of the cause of the pain in the abdomen.

Patients with previous abdominal or gynecological surgery, patients without a normal menstrual cycle, and pregnant patients were excluded from the study. Patients with gynecological pathologies were discharged and it was suggested that they attend a gynecological clinic. All values ​​were expressed as mean ± standard deviation. Qualitative data were analyzed using the χ2 test. P values ​​less than 05 were considered statistically significant.

The average age of the patients was 4-6 years.General data were obtained for 290 patients. Two hundred and twenty-four had acute appendicitis, while 29 had perforated appendicitis and 37 had gynecological organ pathologies. All patients underwent appendectomy. Patients with normal attachment in the study who had ruptured ovarian cysts underwent cauterization, primary ovarian articulation, and cyst excision in 16, 4, and 1 patients, respectively. No postoperative mortality was observed in these patients.

Therefore, it is imperative that if any abdominal pain occurs, first get a doctor’s recommendation and then take the medication prescribed by him.

The cause of the pain in the abdomen on the right will be determined by the doctor after the examination, as well as the study of all the tests necessary in each case.

Sometimes the cause of such a symptom as pulling pain in the right side of the abdomen can be said to be such a surgical pathology as an attack of appendicitis. In this case, the only cure would be immediate surgery.

Pain during ovulation

The incidence was observed in 11 patients, 2 patients developed atelectasis, and 9 patients developed wound infection.Acute appendicitis is an important cause of acute abdominal pain. The incidence of appendicitis in men and women is 6% and 7%, respectively. Acute appendicitis is diagnosed by history and clinical findings. Laboratory findings and radiological examinations can support the diagnosis of appendicitis, but they can never rule it out. These symptoms may not be present at the same time.

The main symptoms of acute appendicitis are often perimbial pain, preceded by anorexia and nausea.Vomiting is usually seen later. Pain usually switches to the right lower abdominal quadrant 8 hours after the initial pain. According to these guidelines, a combination of clinical and laboratory evidence of characteristic acute abdominal pain, localized tenderness, and laboratory evidence of inflammation will identify the majority of patients with suspected appendicitis.

It should be noted that in some situations, pain in the right side of the abdomen may not necessarily indicate a disease of those organs that are present in the abdomen.Sometimes such pain is a sign of illness in organs located in another area of ​​the body.

Our results are shown in Figure 1. Although the clinical presentation of periumbilic pain migrating to the right lower abdominal segment is classically associated with acute appendicitis, presentation is rarely typical and diagnosis cannot always be based on medical history and physical examination alone. Normal application was observed in 8% of patients in the present study.Diagnostic errors are common, with overdiagnosis leading to negative appendectomy and delays in diagnosis leading to perforations.

Why does the stomach on the left hurt?

Abdominal pain on the left
, most often indicates any violation of the functioning of the spleen. Disruption of the spleen’s work should not be ignored, since it can be fraught with rupture of this organ. In this case, a person feels pain of strong intensity, which cannot be endured, and the skin on the abdomen turns blue sharply.In this case, a person’s life directly depends on how quickly emergency medical care will be provided to him.

Diagnostic strategies for evaluating patients with acute abdominal pain and for identifying patients with suspected appendicitis should begin with a painstaking history and physical examination. Accurate diagnosis of acute abdominal pain associated with adnexal pathologies is very important for morbidity and mortality. It is also important to choose the right treatment, which can affect the hospital stay and patient satisfaction.Moreover, the cost of the optimal treatment is important and should not be neglected.

Pain in the lower abdomen on the right and left sides, the circumstances of their development

Fertility of patients can be affected if no intervention is performed for gynecological pathologies in negative cases of appendectomy. Pelvic pain during the ovulatory cycle can occur due to a small amount of blood that drains from a ruptured ovarian follicle into the abdomen during ovulation.This pain is moderately moderate and limited, and hemoperitonum is rarely observed with normal hemostatic parameters. Thus, there is usually no need for surgery in these circumstances.

Pain in the left segment of the abdomen may also indicate the following reasons:

• Typhoid fever;
• Mononucleosis;
• Infectious processes in the intestines;
• Ulcer;
• Gastritis;
• Urolithiasis, also accompanied by increased frequency of urination;
• Diverticulitis;
• Inflammation of the pancreas, which is located in the upper left side of the abdomen;
• Female left ovarian cyst;
• Inflammation of the appendages;
• Ectopic pregnancy.

Concomitant symptoms of bowel problems may be bloating, increased gas production, and diarrhea. Along with peptic ulcer or gastritis, heartburn or painful belching is observed.

Drawing pains in the lower abdomen in women

It is imperative to make an early correct diagnosis and close monitoring in patients who are considered to have a ruptured ovarian cyst, if surgery during the study could lead to future infertility.The admission masses in adolescents contain functional and physiological cystic formations at one end of the spectrum and serious malignant tumors at the other end. The main clinical approach in these adnexal pathologies is organ preservation and fertility.

As it becomes clear from this list, each of these cases, as well as some other cases of pain in the left abdomen, require medical attention and at least a detailed examination.

Drawing pains in the lower abdomen in women

Women may experience pain in the abdomen for a variety of reasons, including:

Ovarian cyst rupture occurs due to benign or malignant cystic lesions of the ovaries.Cyst removal is a convenient treatment option for young patients. It is important not to remove the entire ovary. Ochorectomy can be performed in elderly patients. It should be borne in mind that young patients with ovarian germ cell tumors may be associated with an acute abdomen. Drying, cauterization of the bleeding site, or removal of the cyst may be done to rupture an ovarian cyst.

The hemodynamic parameters in these patients were stable and there was no need for blood transfusion. Clinical signs and symptoms are variable and include patients who are asymptomatic or patients with acute abdominal symptoms.These cysts are usually seen in one ovary and are rarely seen bilaterally. They are more common in patients who ovulate during pregnancy. They are also seen in patients with circulatory disorders and blood clotting problems, as well as in treatment with anticoagulants.

• Pregnancy;
• Menstrual cycle;
• The presence of any diseases of the reproductive system.

It is worth noting that in the early stages of pregnancy, pulling pain in the lower abdomen in a woman, unless it is accompanied by bloody discharge, is a completely normal and not dangerous phenomenon.

In the event of such an alarming symptom as the appearance of bloody discharge simultaneously with pain in the abdomen, it is worthwhile to promptly seek medical help, because such symptoms may indicate a threatened miscarriage early in pregnancy or placental abruption in the second or third trimester. Both are extremely life-threatening conditions for the mother and child that require immediate medical attention.

In general, bleeding can be stopped by removing the cyst, but sometimes it is necessary to close the ovary.All these patients had stable hemodynamics and did not require blood transfusion. The patients were at the age of 20 and in an active reproductive period, which is consistent with the literature. Torsion tendon is well known, but the cause of acute abdomen is difficult to diagnose due to variable clinical causes and symptoms, and includes a self-folding tuba.

In this study, the authors assess the severity of the right lower quadrant in abdominal pain in women of reproductive age, which remains an open problem in general surgery.This original article is very engaging and helpful. Left lower quadrant pain of an unusual cause.

If everything is more or less clear with pregnancy, then two causes of lower abdominal pain in women should be considered in more detail.

Pain during menstruation appears a few days before the start of the cycle (PMS), and can also accompany a woman of reproductive age in the middle and end of the menstrual cycle. Experts explain such pains in the female body of such a process as ovulation.Most women, however, suffer from pain in the lower abdomen just before the start of the menstrual cycle and in its first 1-2 days.

Assessment of diagnostic accuracy in appendicitis using administrative data. Current surgical therapy. 6th edition. Acute appendicitis in women of childbearing age. High negative rates of appendectomy are no longer acceptable. Acute appendicitis: This is the removal of a common application that is still there and we can reduce its speed.

Acute appendicitis in the elderly. Reassessment of appendicitis in the elderly. Abdominal vascular accidents. Acute appendicitis: current diagnosis and treatment. The effectiveness of laparoscopic surgery in the diagnosis and treatment of peritonitis. Experience in 107 cases in Mexico City. Diagnosing appendicitis: part history and physical examination.

Abdominal pain can be the cause of any inflammatory processes in one or more pelvic organs. For example, this is:

• Salpingo-oophoritis
  , t.e. inflammation of the ovaries and fallopian tubes;
• Pelvioperitonitis
  – complication of salpingo-oophoritis, the clinical picture in which resembles peritonitis;
• Endometritis
  – inflammation of the mucous membrane of the uterine cavity;
• Metroedermit
  – inflammation of the mucous and muscle tissues of the uterus;
• Parameter
  – the process of tissue damage around the uterus;
• Fibroids
  , or tumors of the uterus;
• Endometriosis
  , as well as his special case, adenomyosis is a severe pathology in which uterine cells begin to arise and spread to other internal organs, outside the uterine cavity.

All these, as well as similar diseases, can occur either by introducing an infection into the body, or as a result of abortion or diagnostic cleansing.

Image for suspected appendicitis. Acute appendicitis: contradictions in diagnosis and treatment. Although many doctors do not consider abdominal pain to be a disease, it can be very incapable. Find out why your stomach can hurt and learn how to prevent it.

Medicine does not treat abdominal pain as a disease in itself, because when it occurs, it is usually part of other symptoms or is temporary.However, while not serious, it is frustrating for those who suffer from it, sometimes even interfering with our other activities.

There is also another, no less serious cause of abdominal pain, which can be joined by such an unpleasant symptom as aching back pain, as well as pain during urination – cystitis or pyelonephritis. This is a pathology of the urinary tract, for an accurate diagnosis of which it will be necessary to consult a specialist and pass urine for tests.

As a rule, both pyelonephritis and cystitis are determined based on the results of analyzes.Both of these diseases are of infectious origin. For its treatment, antibiotics are prescribed that can defeat the infection.

Abdominal pain, in combination with bloody discharge in the first weeks of pregnancy and an increased level of hCG, can also accompany such a dangerous deviation as an ectopic pregnancy. In the event of such a complication, the woman needs urgent medical attention. Otherwise, with an ectopic pregnancy, there is a threat of death.

Thus, summing up all of the above, we can conclude that pulling pains in the lower abdomen are not always a harmless symptom that can be easily defeated by taking an anesthetic.

In some cases, such a symptom can be a signal of a serious pathology, which only a doctor can diagnose. Therefore, if you discover such a phenomenon as a pulling pain in the abdomen, it is necessary to consult a doctor in the near future for consultation, obtaining an accurate diagnosis and prescribing a treatment appropriate for your case.

De Witt’s Antacid Oral Powder

Usual Adult Dose for Dyspepsia

500 to 600 mg orally 4-6 times a day as needed, between meals and at bedtime.

Usual Adult Dose for Duodenal Ulcers

500 to 1500 mg orally 4-6 times daily as needed, between meals and at bedtime.

Usual Adult Dose for Erosive Esophagitis

500 to 1500 mg orally 4-6 times daily as needed, between meals and at bedtime.

Usual Adult Dose for Stomach Ulcers

500 to 1500 mg orally 4–6 times daily as needed, between meals and at bedtime.

Usual Adult Dose for Gastroesophageal Reflux Disease

500 to 1500 mg orally 4-6 times daily as needed, between meals and at bedtime.

Usual Adult Dose for Zollinger-Ellison Syndrome

500 to 3600 mg orally 4-6 times a day as needed, between meals and at bedtime.

Usual Adult Dose for Hyperphosphatemia

500 to 1000 mg orally 4 times a day, with meals and at bedtime. The dosage should be titrated to the serum phosphate level.

Usual Pediatric Dose for Gastrointestinal Bleeding

GI Prevention of Bleeding :

0 to 4 weeks: 1 ml / kg orally every 4 hours as needed.

From 4 weeks to 1 year: 2 to 5 ml / dose every 1-2 hours, titration at gastric pH> 3.5.

From 1 to 12 years: 5 to 15 ml / dose orally every 1 to 2 hours, titrated at gastric pH> 3.5.

Usual Pediatric Dose for Hyperphosphatemia

1 to 12 years: use only Al (OH) 3 or aluminum carbonate gel product: 50 to 150 mg / kg / day orally (as aluminum hydroxide gel (antacid powder de Vitta) in evenly distributed doses every 4-6 hours.inject; titrated to normal serum phosphate levels.

Usual Pediatric Dose for Stomach Ulcers

1 month to 1 year: 1 to 2 ml / kg / dose orally via 1-3 hours after meals and before bedtime.

From 1 year to 12 years: 5 to 15 ml orally every 3-6 hours or 1 and 3 hours after meals and at bedtime.

Precautions

Patients with renal impairment may accumulate aluminum with chronic use. Serum aluminum levels should be monitored or other antacids selected.

More comments

Patients with peptic ulcers associated with Helicobacter pylori should be considered for anti-Helicobacterial therapy (wisdom salts, metronidazole and other antimicrobial agents).

Usual Adult Dose for Osteoporosis:

2500 to 7500 mg / day orally in 2-4 doses.

Usual Adult Dose for Hypocalcemia:

900 to 2500 mg / day orally divided into 2 to 4 doses. This dose can be adjusted as needed to achieve normal serum calcium levels.

Usual Adult Dose for Dyspepsia:

300 to 8000 mg / day by mouth in 2-4 divided doses.This dose can be increased and carried over as needed to relieve symptoms of indigestion.

Maximum dose: 5500 to 7980 mg (depending on the product used). Do not exceed the maximum daily dose for more than 2 weeks unless directed by your doctor.

Usual Dose for Duodenal Ulcers:

1250 to 3750 mg / day in 2-4 divided doses. This dose can be increased and carried over as needed to relieve abdominal problems.The most important limiting factor for chronic use of calcium carbonate (oral antacid powder from de Witt) is gastric hypersecretion and acid rebound.

Usual Adult Dose for Stomach Ulcers:

1250 to 3750 mg / day in 2-4 divided doses. This dose can be increased and carried over as needed to relieve abdominal problems. The most important limiting factor for chronic use of calcium carbonate (oral antacid powder from de Witt) is gastric hypersecretion and acid rebound.

Usual Adult Dose for Erosive Esophagitis:

1250 to 3750 mg / day orally divided into 2-4 doses. The potential for acid rebound can be harmful. However, antacids are often used in the treatment of erosive esophagitis and may be helpful in reducing the acidity of stomach contents.

Maximum dose: 5500 to 7980 mg (depending on the product used). Do not exceed the maximum daily dose for more than 2 weeks unless directed by your doctor.

Usual Adult Dose for Gastroesophageal Reflux Disease:

1250 to 3750 mg / day orally divided into 2 to 4 doses. The potential for acid rebound can be harmful. However, antacids are often used in the treatment of erosive esophagitis and may be helpful in reducing the acidity of stomach contents.

Maximum dose: 5500 to 7980 mg (depending on the product used). Do not exceed the maximum daily dose for more than 2 weeks unless directed by your doctor.

Usual Pediatric Dose for Hypocalcemia:

Neonatal:

Hypocalcemia (dose dependent on clinical status and serum calcium level): Dose expressed in mg elemental calcium: 50 to 150 mg / kg / day in 4- 6 receptions; Do not exceed 1 g / day

Typically

Dose:

Calcium carbonate (De Witt antazide powder):

Children 2 to 5 years old: baby pepto, milanta (R) Children: 1 tablet (400 mg carbonate calcium (de Witt antacid powder)) if symptoms appear; Do not exceed 3 tablets per day

Children 6 to 11 years old: infant pepto, milanta (R) Children: 2 tablets (800 mg calcium carbonate (de Witt antacid powder)) if symptoms appear; Do not exceed 6 tablets per day

Children 11 years and older:

Tums (R), Tums (R) E-X: Chew 2 to 4 tablets when symptoms appear; Do not exceed 15 tablets [creamy (R)] or 10 tablets [creamy (R) E-X] per day

Tums (R) Ultra: 2 to 3 tablets chewed when symptoms appear; Do not exceed 7 tablets per day

Hypocalcemia (dose depends on clinical status and serum calcium level): dose expressed in mg of elemental calcium:

Children: 45 to 65 mg / kg / day in 4 divided doses

Treatment of hyperphosphatemia with end-stage renal failure: in children and adults: dose in mg of calcium carbonate (oral antacid powder from de Witt): 1 g per meal; increase if necessary; Range: 4 to 7 g / day

Hydrofluoric acid (HF) burns (HF concentration below 20%):

Topical: Various topical calcium preparations have been used anecdotally to treat skin exposure to HF; Calcium carbonate (test powder of antacids from de Witt) in concentrations from 2.5% to 33%; local calcium carbonate (de Witt’s test antacid powder) must be collected together.

Oral

Diarrhea

Adult: As an adjunct to rehydration therapy: up to 24 g daily can be used in divided doses. Can be used in combination with other antidiarrhea.

Refers to the following amplification: 54 mg / 5 ml; 5%; 250 mg

Usual Adult Dose:

• Nutritional Supplements
• Hypomagnesemia
• Dyspepsia
• Renal Failure Hyperphosphatemia

Usual Pediatric Dose for:

Hypomagnesemia

Hypomagnesemia

• Hypomagnesemia

Hypomagnesemia

Additional dosage information:

• Renal dose adjustment
• Liver dose adjustment
• Precautions
• Dialysis
• Further Comments

Usual Adult Dose

250 to 1500 mg / day approximately 70-420 mg / day of elemental magnesium carbonate (antacid oral powder from de Witt)) orally with meals.

Usual Adult Dose for Hypomagnesemia

1000 mg (corresponds to approximately 280 mg elemental magnesium carbonate (oral antacid powder from de Witt)) orally four times daily with meals.

Magnesium carbonate (de Witt antacid powder) is less absorbed than other forms of magnesium carbonate (De Witt antacid powder) and is therefore not usually used to treat hypomagnesemia. In general, magnesium carbonate chloride (De Witt antacid powder) of magnesium gluconate or magnesium carbonate (De Witt antacid powder) is preferred for oral replacement therapy.

Usual Adult Dose for Dyspepsia

10 ml (250 mg / 5 ml suspension) is required orally every 3-4 hours, but not more than 40 ml / day.

Magnesium Carbonate (De Witt Antacid Powder) is indicated for the temporary relief of a sour stomach, acid indigestion and indigestion associated with these symptoms. Only de Witt carbonate salts (antacid powder) are not commonly used for stomach ulcers, as the higher doses needed to control ulcers often cause diarrhea as an adverse effect.

Usual Adult Dose for Hyperphosphatemia in Renal Failure

250 mg orally three times daily with meals.

Usual Pediatric Supplement Dose

1 to 3 years: 250 mg / day (corresponds to approximately 70 mg / day of elemental magnesium carbonate (antacid oral powder from de Witt)) orally with food.

4 to 8 years: 250 to 500 mg / day (corresponds to approximately 70-140 mg / day of elemental magnesium carbonate (De witts oral antacid powder) orally with food.

9 to 13 years: 250 to 750 mg / day (corresponds to approximately 70-210 mg / day of elemental magnesium carbonate (De witts oral antacid powder) orally with meals.

14 to 18 years: 250 to 1500 mg / day (corresponds to approximately 70-420 mg / day of elemental magnesium carbonate (De witts oral antacid powder)) orally with meals.

Total Pediatric Dose for Hypomagnesemia

1 to 12 years: 35 to 70 mg / kg (corresponds to approximately 10-20 mg / kg elemental magnesium carbonate (antacid oral powder from de Witt)) orally four times a day with meals, up to 4000 mg / day.

> 12 years: 1000 mg (corresponds to approximately 280 mg of elemental magnesium carbonate (oral de witts antacid powder)) orally four times daily with meals.

Magnesium carbonate (de Witt antacid powder) is less absorbed than other forms of magnesium carbonate (De Witt antacid powder) and is therefore not usually used to treat hypomagnesemia. In general, magnesium carbonate chloride (De Witt antacid powder) of magnesium gluconate or magnesium carbonate (De Witt antacid powder) is preferred for oral replacement therapy.

Usual Pediatric Dose for Dyspepsia

From 6 to 12 years: 5 ml (250 mg / 5 ml suspension) orally every 3-4 hours as needed, not exceeding 20 ml / day.

> 12 years: 10 ml (250 mg / 5 ml suspension) is required orally every 3-4 hours, but not more than 40 ml / day.

Magnesium Carbonate (De Witt Antacid Powder) is indicated for the temporary relief of a sour stomach, acid indigestion and indigestion associated with these symptoms.Only de Witt carbonate salts (antacid powder) are not commonly used for stomach ulcers, as the higher doses needed to control ulcers often cause diarrhea as an adverse effect.

Usual Pediatric Dose for Hyperphosphatemia from Renal Failure

250 mg orally three times daily with meals.

Renal dose adjustment

Magnesium carbonate salts (von de Witt antacid powder) should be used with caution in patients with renal insufficiency due to an increased risk of hypermagnesemia.

Liver dose adjustment

No data available

Precautions

Magnesium Carbonate (oral antacid powder from de Witt) should be used with caution in patients with kidney disease due to the risk of magnesium carbonate (oral antacid powder from de Witt).

Patients should see a doctor before taking magnesium carbonate (de Witt antacid powder) for a longer period of time.

Magnesium carbonate (de Witt’s antacids) containing antacids can cause diarrhea, which can affect fluid and electrolyte balance.

Dialysis

The use of magnesium carbonate salts (de Witt-Antizide oral powder) is usually contraindicated in renal impairment. Magnesium carbonate (von de Witt antacid powder), however, can be administered as a phosphate binding agent to treat hyperphosphatemia in renal failure. Reducing the concentration of magnesium carbonate (de Witt’s antacid powder) In the dialysate, hypermagnesemia must be avoided. Serum magnesium carbonate (von de Witt antazide powder) and potassium levels should be monitored regularly and maintained within the normal range.

More comments

Magnesium carbonate salts (antacid powder) may cause diarrhea, nausea and abdominal cramps, especially at higher doses (eg> 1000 mg magnesium carbonate (De Witt ‘S Antacid herbal powder)). Dose in divided doses with food helps reduce gastrointestinal side effects.

Additional Information

Always check with your doctor to ensure that the information displayed on this page is relevant to your personal circumstances.

Medical Denial

Maximum

1-4 tabs as needed, maximum 8 tabs / day.

A vial (5 ml) of sodium bicarbonate (de Witt antacid powder) added to one liter (1000 ml) of one of the following parenteral hospira solutions raises the pH to a more physiological range. Specific pH may vary slightly from batch to batch.

Parenteral medicines should be visually inspected for particles and discoloration prior to administration, if solution and container permit.See PRECAUTIONS.

It is recommended to add a vial of sodium bicarbonate (De Witt antacid powder) to half a liter (500 ml) in order to achieve a more physiological pH of the following parenteral solutions of hospira

Note: some products, eg. Amniosyn® solutions and such lonosol® and Normosol® formulas containing dextrose are not brought to physiological pH by the addition of sodium bicarbonate (Von de Witt antacid powder). This is due to the relatively high buffer capacity of these fluids.

COMPATIBILITY and PERFORMANCE FO Sodium Bicarbonate (De Witt’s Antazida Oral Powder) + 5% SUGAR INJECTION (D5-W) Witt ‘S Antacid) (4% Sodium Bicarbonate (De Witt’ Antacid Plant Powder)) may or may not be compatible.

Below is a list of medications that are added to a liter 5% Dextrose Injection, USP (D5-W), classified according to their action with sodium bicarbonate (de Witt antacid powder) (4% sodium bicarbonate (de Witt).’s Antacid Oral Powder) additive solution).

It should be noted that the impurities were tested for physical tolerance and not pharmacological tolerance. Therefore, it would be misleading to circumvent the medical judgment that should be involved in managing a solution that appears consistent on the basis of visible haze or precipitation. The inclusion of a drug in this study of your tolerance in solution does not imply your therapeutic benefit or safety. The doctor’s decision on this matter remains.

NOTE: The compatibility information contained herein is based on studies in which only Hospira Dextrose is involved. Variational compatibility may result from lot changes or formulation changes in third-party dextrozel supplements or solutions.

Ready translation The Surgeon’s Studio / Surgeon’s Studio: Chapter 33 :: Tl.Rulate.ru

After making several phone calls in a row and arranging everything accordingly, the old chief physician Pan addressed Zheng Ren with a serious expression: “Go to the endoscopy department and look for Chief Surgeon Shi.Check if there are any missing tools and try to highlight them if possible. If you can’t, we have no choice either. I will wait for you in the office, so call me as soon as the operation is over. ”

The soldier always fulfills his duties quickly. Zheng Ren understood the old chief physician Pang’s instructions and knew that he was willing to wait in the office to save some time.

Like a soldier hiding behind enemy lines, old chief physician Pan awaited the order for a surprise attack.

Zheng Ren nodded silently.

Verbal responses were meaningless. The only thing Zheng Ren could do to repay him was to complete the operation without any errors.

Zheng Ren quickened his pace towards the third inpatient department and finally trotted to the endoscopy department.

Surgeon General Shi suppressed his surprise and asked what equipment Zheng Ren needed.

Since the endoscopy department of the main hospital of the sea city was about to invite a professor from the capital of the Empire to perform an ESD procedure in the near future, all preparations were largely completed in advance.

Basic instruments — a hook knife, an injector, dissecting forceps, and an endoscopic electric knife — were available, but the most important instrument required for resection of the inflamed appendix — the endoclip — was missing.

Chief Surgeon Shi did not need the endoclip as he simply wanted to perform a submucosal dissection.

Gritting his teeth tightly, Zheng Ren left the room, excused himself for going to the toilet, and headed to a deserted, quiet place before entering the system.

He went to the store and started looking for ESD related tools.

Zheng Ren’s heart immediately shattered when he saw the price tag — 16,000 experience points — below the full ESD kit. It was too expensive and was currently beyond his capabilities.

Helpless and depressed, a light in his head suddenly went out. Maybe he could buy the instrument separately.

Then he clicked on the endoclip and was happy to find that he could actually do it!

However, Zheng Ren had mixed feelings when he noticed the price tag — 2200 experience points — under the endoclip.

He was happy to be able to continue the operation with the found missing tool.

At the same time, he was tormented by a sense of loss. He was poor since childhood and spent almost all of his “savings” on buying surgical instruments directly, which was a huge deal for him. In fact, when he thought about it, he almost had a myocardial infarction.

He had no choice but to spend the money to regain the trust of old chief physician Pan.

Enduring intermittent heartache, Zheng Ren pressed the Buy button and saw his savings instantly go from 2332 to 132 experience points. Damn … now he was as poor as a church mouse.

After the purchase, the endoclip just appeared in his hands, and the nickel-titanium alloy gave him the illusion that he was worth the royal ransom.

How can he bring it all back to reality? Confused, Zheng Ren asked the system loudly and, as expected, there was no response from the cold, unfeeling system.

Maybe he should try and get back to reality. Gripping the endoclip tightly like a drowning man on a straw, Zheng Ren mentally returned to the real world.

Opening his eyes, Zheng Ren felt something hard and cold in his hands.

2 Good. He could return to reality any instrument purchased in the system.

Surgeon General Shi was stunned when he noticed that Zheng Ren had returned with an endoclip and asked out of curiosity, “Little Zheng, do you have any friends working for a medical equipment company? Johnson & Johnson or Philips? ”

Domestic manufacturers have not yet started the production of this kind of medical instruments due to the limited use within the country and the lack of significant profits.Thus, international companies, with Johnson & Johnson in the lead market, will manufacture and import them into China.

Medical sales reps would never discuss this kind of advanced medical instrument with Zheng Ren, who, judging by his age, was a junior physician. Even the top residents were not qualified to start discussing this issue with sales representatives.

The only person entitled to use the newly developed equipment or technology was the senior consultant, or at least the deputy chief of the medical team.

Zheng Ren returned with an endoclip after a few minutes away, so logically he should have had a friend who worked as a sales representative for one of these international companies.

Chief Surgeon Shi’s assumption was reasonable, but he would never have guessed the existence of a medical system in Zheng Ren’s mind — a system that easily fell into rage over trifles and threatened to wipe its master off the face of the earth if provoked.

3 “no.Last time I was at a conference and got interested in it, so I bought it later, ”Zheng Ren replied casually.

2 Chief Surgeon Shi remained in doubt. Who buys a single, high-value instrument for use in a surgical apparatus? What will it do with it when it does not serve any function in surgery, when used alone? Take it home and keep it?

However, it was clear that Zheng Ren did not want to tell the truth. Having no choice, he cast an envious look at the new, polished and graceful endoclip, drooling with envy.

– Chief Physician Pan, all equipment is ready. When can we start the operation? ”Zheng Ren dialed old Chief Physician Pan’s phone number and reported the situation.

“Okay, I’m on my way.” Old Chief Physician Pan hung up immediately after Zheng Ren told him the news.

A few minutes later, Zheng Ren’s cell phone rang. It was the old chief physician Pan, who told him to get ready for the operation and said that the patient was already on the way to the endoscopy unit.

The Chief Surgeon of the Shea Endoscopy Department also received a call from the Head of the Medical Administration Department, as the hospital management appreciated this patient and wanted the Endoscopy Department to prepare everything in advance. The chief even told Chief Surgeon Shi that General Secretary Chen was currently on his way to Xi City Main Hospital to supervise the operation with the director of the hospital.

The endoscopy unit was immediately turned upside down as everyone started making preoperative preparations as soon as they could.

The old chief doctor Pan was the first to arrive on the scene. He just stood silently next to Zheng Ren, like a strong and reliable anchor, without asking Zheng Ren again if he was confident in the operation.

After the chief of medical administration brought the chief anesthesiologist to the endoscopy unit, the atmosphere in the room began to turn gloomy.

Surgeons from the Department of General Surgery arrived at the scene with the patient, who was lying on a stretcher with her legs dangling from them.The lady was too tall.

Chief Surgeon Liu had a grim expression. He had a bad feeling — Zheng Ren knew how to properly perform the operation.

Like an arrow on a drawn string, it was too late for Chief Surgeon Liu to voice his objection.

The patient was lying on the operating table for endoscopy, and the preoperative informed consent documents had to be signed by the hospital director and General Secretary Chen, so worrying at the moment was pointless.

Zheng Ren glanced at the countdown timer in the upper right corner of his vision — four hours and fifteen minutes remaining.

Ten minutes later, Director Xiao and General Secretary Chen arrived at the Endoscopy Unit.

Despite being a surgeon for the upcoming surgery, Zheng Ren sat in the corner of the office without any hint of presence.

On the left side of the long table sat Xiao Kemin, the hospital director, Fu Guangshi, deputy director for clinical work, old chief physician Pan, and various consultants from the general surgery, endoscopy, and anesthesiology departments.On the right side of the long table were General Secretary Chen, the Director of the Chancery, and the Agent and Patient Assistant.

Director Xiao was the first to start the discussion

“The city values ​​the patient very much, so Chief Surgeon Liu from the General Surgery Department will explain her condition.”

A short phrase, but it was spoken with force.

“The patient is diagnosed with simple acute appendicitis. She underwent three days of conservative treatment, which was ineffective.Soreness is noted in the right iliac fossa, and this morning we found a rebound of soreness, suggesting increased severity and the possibility of perforation. ” There were dark circles under the bloodshot eyes of Chief Surgeon Liu, making him appear depressed and depressed.

Only a few of them knew that his condition was the result of a night battle with Zheng Ren. Those who did not know about this thought that he was really exhausting himself for the patient.

Surgeon General Liu hesitated a little and said regretfully, as if possessed by a drama queen, “The general surgery department has discussed this case many times, and we have come to the conclusion that conservative treatment is no longer a viable option.She needs to have surgery as soon as possible. ”

“Chief Surgeon Liu, may I ask, what is your plan of surgery?” Asked a well-mannered middle-aged man with glasses on the right.

“We can do open appendectomy or laparoscopic appendectomy.” Chief Surgeon Liu did not even try to mention Zheng Ren’s surgical technique. – Judging by the patient’s condition, I recommend an open appendectomy. Since her subcutaneous layer is thin, we can make about a three to four centimeter incision, and she will be able to walk after one day of rest.Recovery can be expected in five to six days. ”

– Uh … – the expected recovery time exceeded the requirements of the organizing committee of the “new idea” model competition, but this was an expert’s medical opinion. They had to listen to him.

Most of them had the right sense of priorities. The outburst of anger at this point would not be of any benefit to the patient.

The patient’s agent and general secretary Chen meant the same — it would be a shame if the patient missed the ending.