Open Access Review

Article DOI: 10.7759/cureus.8562

Acute Appendicitis Review: Background,

Epidemiology, Diagnosis, and Treatment
Michael Krzyzak 1 , Stephen M. Mulrooney 2

1. Internal Medicine, Staten Island University Hospital - Northwell Health, New York, USA 2.
Gastroenterology, Staten Island University Hospital - Northwell Health, New York, USA

Corresponding author: Michael Krzyzak, [email protected]

Abstract
Appendicitis is a common occurrence in both the adult and pediatric populations. The
condition most commonly occurs between the ages of 10 and 20 years with a lifetime risk of
8.6% and 6.7% for males and females respectively. Its diagnosis focuses on clinical presentation
and imaging modalities classified according to scoring systems such as the Alvarado scoring
system. A number of imaging modalities can be used, with CT being the most common one. For
acute appendicitis, surgical intervention is considered to be the gold standard of treatment.
However, recent research has focused on other modalities of treatment including antibiotics
and endoscopic retrograde appendicitis therapy (ERAT) to avoid surgical complications.

Categories: Internal Medicine, Gastroenterology, General Surgery

Keywords: appendicitis, acute appendicitis, gastroenterology

Introduction And Background

The word appendicitis stems from Latin, combining appendix and -itis, and it means the
inflammation of the appendix. The term appendix was coined in the 1540s to describe an
elongated outgrowth of an internal organ [1]. Appendicitis was first described in 1759 by
Metiever, but it was believed at the time that the appendix was not the origin of the disease
process and it was termed perityphlitis, typhlitis, paratyphlitis, or extra-peritoneal abscess of
the right iliac fossa [2]. From the early 20th century onwards, appendicitis originated from
obstruction leading to the secretion of fluids by the appendix. An early study demonstrated, by
inserting a manometric recording device (Figure 1), that higher pressures resulted in
histologically evident hypercellularity and exudate pattern correlating with appendicitis [3].
Early mortality secondary to appendicitis was reported to be 26% [4].

Received 05/06/2020
Review began 05/12/2020
Review ended 05/26/2020
Published 06/11/2020

© Copyright 2020
Krzyzak et al. This is an open access
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How to cite this article

Krzyzak M, Mulrooney S M (June 11, 2020) Acute Appendicitis Review: Background, Epidemiology,
Diagnosis, and Treatment. Cureus 12(6): e8562. DOI 10.7759/cureus.8562
 FIGURE 1: Manometric recording device*
*[3]

The anatomy of the appendix has been described as narrow and long, passing upward behind
the cecum, to the left behind the ileum and mesentery, or downward and inward into the pelvis.
The average size is 1-9 inches. It is held by the mesentery and comprises three layers: organ
sera, submucosa, and mucous [5].

From the early days onwards, the timeliness of diagnosis was considered to be critical to
reducing mortality rates related to appendicitis. The clinical diagnosis was developed to
determine if appendicitis is present. Charles McBurney labeled the precise spot to be 1.5-2
inches from the right anterior superior spinous process of the ilium on a line drawn to the
umbilicus [4]. We now call this clinical sign the McBurney’s point.

Review
Epidemiology
Appendicitis occurs most commonly between the ages of 10 and 20 years and it has a male-to-
female ratio of 1.4:1. The lifetime risk is 8.6% for males and 6.7% for females in the United
States [6]. Studies have indicated an association between acute appendicitis and the

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 manifestation of colorectal cancer. In fact, 2.9% of patients who suffered from acute
appendicitis were found to have colorectal cancer compared to 0.1% of those who did not [7]. In
patients who are 55 years and older, acute appendicitis was found to be associated with right-
sided neoplasm. The overall diagnosis of appendicitis, whether resected or treated
conservatively, was associated with an overall increase in colorectal cancer rate. Hence,
patients who are 55 years and older suffering from acute appendicitis should follow up to
receive colorectal cancer screening [8].

Diagnosis
The initial presentation involves periumbilical colicky pain around the midgut. Localized pain
coincides with the parietal peritoneum irritation. The pain intensifies over a period of 24 hours,
accompanied by nausea, vomiting, and loss of appetite [6]. In 3.5% of appendicitis
presentations, left iliac fossa deep palpation elicits pain in the right iliac fossa, which is termed
Rovsing’s sign [9]. If the patient is found to have a positive Rovsing's sign, a barium swallow is
then employed to confirm the diagnosis. Barium swallow was initially found to be 95% accurate
[10].

Currently, diagnosis is made by helical CT and graded compression color Doppler

ultrasonography [11]. A diagnosis can be made based on persistent right lower quadrant pain
and a visualized appendix greater than 6 mm in diameter [12]. New studies point toward the
efficacy of MRI, indicating 96-96.8% sensitivity and a 96-97.4% specificity [13,14]. Enabling this
new modality will allow for patients such as children to avoid exposure to radiation and
intravenous contrast medium, while still providing diagnostic accuracy. This finding foresees
future first-line testing in children and possibly the general population.

The Alvarado scoring system is one of the most frequently used scoring systems to determine
the need for surgical intervention for appendicitis (Table 1).

Feature Score

Migratory right iliac fossa pain 1

Nausea/vomiting 1

Anorexia 1

Tenderness in right iliac fossa 2

Rebound tenderness in right iliac fossa 1

Elevated temperature 1

Leukocytosis 2

Shift to the left of neutrophils 1

TABLE 1: Alvarado scoring system

Scores of 1-4 indicate "discharged home", scores of 5-6 signify being "observed", and scores of 7-
10 indicate the need to "undergo emergent surgery" [15,16]. The sensitivity and specificity of
the Alvarado scoring system are reported to be 93.5% and 80.6%, respectively [17]. A simplified

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 scoring system known as the Appendicitis Inflammatory Response scoring system involves
eight variables (Table 2). These variables are vomiting, right-lower-quadrant pain, rebound
tenderness, muscular defense, WBC count, proportion neutrophils, C-reactive protein (CRP),
and body temperature [18].

Feature Score

Vomiting 1

Pain in right inferior fossa 1

Rebound tenderness or muscular defense Light 1

Medium 2

Strong 3

Body temperature >38.5 °C 1

Polymorphonuclear leukocytes 70–84% 1

>85% 2

WBC count 10.0–14.9 x 10 9/L 1

≥15.0 x 10 9/L 2

CRP concentration 10–49 g/L 1

>50 g/L 2

TABLE 2: Appendicitis Inflammatory Response scoring system

WBC: white blood cell; CRP: C-reactive protein

Scores of 0-4 suggest "discharged home", scores of 5-8 mean being "observed", and scores of 9-
12 indicate the need to "undergo surgery". In a study comparing the Appendicitis Inflammatory
Response scoring system to the Alvarado scoring system, the sensitivity of the Appendicitis
Inflammatory Response scoring system was found to be 93% compared to 90% with the
Alvarado scoring system, with specificity reported to be 85% compared to 55%, respectively
[19]. Other scoring systems have also emerged including Fenyo, Eskelinen, Tzakis, and Raja
Isteri Pengiran Anak Saleha Appendicitis (RIPASA) [20].

Treatment
Early treatment of appendicitis focused on surgery. In 1883, Abraham Groves performed the
first elective appendectomy [21]. In 1886, Reginald Fitz published the first paper describing
early diagnosis and treatment of appendicitis [22]. In 1894, Charles McBurney described an
incision parallel to the right rectus muscle oblique at approximately 1-4 inches [4]. This
incision, known as the McBurney-McArthur muscle-splitting incision, was found to be
associated with the lowest mortality [23]. Four advantages have been described with respect to
using this technique: it provides easy direct access to the inflamed organ, drains can be placed
laterally with sutures needed only on the peritoneum, the incision can be closed without risk of

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 hernia, and, finally, access to cases of obstruction can be obtained without passing through
additional structures [23].

During the mid-20th century, as surgical advances began to reduce complications, some studies
examined whether surgery was necessary or whether a conservative route was safer and more
efficacious [24]. Lower morbidity was found with a conservative route compared to the operative
route [25]. Antibiotics were added to prevent infections. With bacillus coli being isolated from
the appendix, the addition of a sulfonamide antibiotic was employed. Sulfanilamide was first
used in 1940, and it was administered intraperitoneally as a local antibiotic. Mortality after five
years was noted to be 0.4% [26]. Since 1959, studies have been examining the possibility of
treatment with antibiotics solely. A 37% recurrence rate has been reported, indicating that
antibiotics should be reserved for high-risk candidates [27].

In the 1990s, European investigators revisited the treatment of appendicitis by using

antibiotics. It was found that 80% of preoperative diagnosis of appendicitis was correct with
only one in six found to be having perforated appendicitis [28]. It is suggested that
uncomplicated appendicitis may resolve with antibiotic treatment alone [29]. Reports show that
appendicitis treated with antibiotics has a 91% success rate in the short term with 71%
becoming appendectomy-free by one year [30]. In the United States, conservative management
with antibiotics prior to surgical intervention has demonstrated positive results [31]. Forgoing
or postponing surgical intervention enables treatment without surgical complications and have
demonstrated patients being capable of an expedited return to work in comparison to surgical
intervention [30,32].

Current guidelines continue to focus on early appendectomy. Uncomplicated appendicitis can

be delayed in the hospital by 12-24 hours. On the other hand, early surgical intervention is
thought to be associated with a lower risk of perforation [14]. Conservative treatment with
antibiotics was found to be 18% less effective than surgical treatment [33]. Given substantial
crossover in studies, it is recommended to continue to pursue surgical intervention as the first-
line therapy [34]. Future studies employing different antibiotic regimens, both oral and
intravenous, need to be conducted to examine the efficacy of antibiotics and explore the
possibility of forgoing surgery for patients suffering from uncomplicated appendicitis [35]. Non-
operative management has been found to have a high success rate of 86.1% [36]. On the other
hand, the five-year recurrence of appendicitis in patients treated with antibiotics for acute
appendicitis has been found to be 39.1% [37].

Other modalities are emerging as a treatment for acute appendicitis. Endoscopic retrograde
appendicitis therapy (ERAT) employs endoscopic intervention in order to drain pus, extract
fecalith, and stent when necessary. Of note, 93.8-95% of patients reported no recurrence
following this method of treatment [38,39]. Laparoscopic appendectomy is another modality
that enables same-day discharge; it was introduced by Semm in 1983 [40]. Patients who were
discharged the same day after laparoscopic appendectomy were found to have lower rates of
readmission compared with those who were hospitalized [41]. Other advantages include lower
cost, lower risk of wound infections, and shorter recovery time [42-44].

Conclusions
Appendicitis has been studied and treated for over a century. Diagnosis is based on imaging
findings and clinical presentation. Currently, CT and graded compression color Doppler
ultrasonography are generally employed to aid in the diagnosis. MRI has shown great promise
as an alternative, with the added advantage of avoiding radiation exposure. Treatment is
currently based on surgical intervention although future research looks to focus on more
conservative measures such as antibiotics or other modalities. Antibiotic treatment has
demonstrated efficacy in the short term but recurrence is likely in the long term. Some newer

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 modalities of treatment have made it possible to forgo surgery by employing endoscopic
intervention. Surgical advances with the use of laparoscopy enable same-day discharges, lower
cost, fewer complications, and shorter recovery times.

Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors
declare the following: Payment/services info: All authors have declared that no financial
support was received from any organization for the submitted work. Financial relationships:
All authors have declared that they have no financial relationships at present or within the
previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or
activities that could appear to have influenced the submitted work.

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