Lactology Foundation

Acute Appendicitis

In patients with abdominal pain, acute appendicitis must always be considered in the differential diagnosis. In classical cases diagnosis is simple, but it may be very difficult in patients with atypical symptoms.

Clinical Features
The pain initially starts epigastrically and is only localized in the right lower quadrant after a few hours. It is rarely very strong. The pressure point depends on the localization of the appendix, which can be very variable. The McBurney point (middle of a line drawn between the navel and anterior superior iliac spine) is most frequently sensitive to pressure. Another pain localization in the right lower quadrant or even the right epigastric region (with a highly displaced appendix) does not preclude appendicitis (consider situs inversus in rare cases). With a pelvic position of the appendix, rectal examination, which should always be part of the clinical examination for suspected appendicitis, is decisive. Rebound tenderness is always present, except in very early stages, and reflects the degree of peritoneal involvement.
Diagnosis
Leukocytosis is generally present.
Nausea and vomiting are common. Fever is generally not high with the rectal temperature being significantly higher than the axillary temperature. Constipation is generally present; diarrhea is rarely encountered initially. Sonography is frequently helpful.

Differential Diagnosis of Pain in the Right Lower Quadrant
In cases of pain with acute onset in the right lower quadrant the first considerations should be hernia and nephrolithiasis. In women, gynecological diseases must also be considered in the differential diagnosis. In rare cases acute infections with involvement of the mesenteric lymph nodes (particularly in children) may mimic appendicitis (e. g., viral infections, yersiniosis). Other causes are diverticulitis (Meckel, cecum), Crohn disease, ileocecal tuberculosis, carcinomas, and invagination. Diseases of neighboring organs are occasionally localized in the right ileocecal region: cholecystitis, pancreatitis, gastric or
intestinal perforation, pyelitis, and hypostatic abscess in spinal tuberculosis. It may be more difficult to distinguish a right pelvic vein thrombosis if there is no thrombosis of the lower extremities. Further, diseases such as pneumonia, pleuritis, etc. that can initially present with pain in the right lower quadrant before the classical symptoms develop must always be considered. Undetermined epigastric complaints that gradually become midabdominal, hypogastric or ileocecal pain may be a manifestation of lymphadenitis from toxoplasmosis. The liver and spleen may also be slightly enlarged. Leukopenia is typical; sometimes cervical lymph nodes are palpable. Fever is sometimes absent. The diagnosis must be serologically confirmed. Certain drugs (e.g., NSAIDs or potassium chloride tablets) may cause circular stenosing small-intestine ulcers with typical clinical symptoms. Colicky abdominal pain, primarily postprandial, with nausea and vomiting, is the leading symptom. This pain may persist for days, weeks, or even months if the medication is continued, intestinal perforations may occur.

Differential Diagnosis of Hypogastric Pain
Hypogastric pain is generally caused by urogenital diseases. Hernias and hip-joint diseases must also be considered. Mucous colitis (a category of Irritable Bowel Syndrome [IBS]) can also present with intense pain, primarily localized in the left or right lower quadrants. A contracted iliac colon and absence of any peritoneal irritation with the excretion of mucosa and membranes point to this diagnosis, which however, like IBS, represents a di-
agnosis by exclusion. Colorectal cancer and diverticulitis are the leading causes of hypogastric pain in patients over 40 years of age.