The concern has always been that IV analgesia will mask an ongoing intraabdominal catastrophe, leading the surgeon to miss the diagnosis and potentially endanger the patient. This dogma has been challenged recently, however. In fact, it has been demonstrated that IV analgesia results in a significant pain reduction without concurrent normalizing effects on the abdominal examination. There is strong evidence suggesting that contrary to traditional teaching, it is, in fact, safe to administer opioid analgesics in the setting of surgical evaluation of acute abdomen without increasing the chance of misdiagnosis (1, 2, 3, 4).

Typical. Appendicitis typically occurs in people in their second or third decade, is slightly more common in men than women (3:2), and usually affects previously healthy patients (5). The classic pain begins as a dull periumbilical discomfort, then settles in the RLQ of the abdomen as a sharp pain occurring over a short time, as in the present case. Typical appendicitis is often diagnosed by the patient; roughly half of the cases are atypical, however, and can elude even the most experienced surgeon.

In addition to appendicitis, there are a number of gynecologic conditions that can cause RLQ pain. These include pelvic inflammatory disease (PID), ectopic pregnancy, ovarian cyst rupture, Mittelschmerz, endometriosis, ovarian torsion, and ovarian vein thrombosis. Other possible diagnoses include Crohn’s disease, right colon diverticulitis, cholecystitis, perforated ulcer, and renal or ureteral calculi.

In a prospective study of 118 women, several factors were found to be associated with PID: longer duration of symptoms; nausea, vomiting, or both; history of venereal disease; cervical motion tenderness; adnexal tenderness; isolated peritoneal signs in RLQ abdomen.

The chandelier sign describes exquisite tenderness of the cervix during pelvic examination.

The appendix is a 10-cm hollow tube attached to the cecum. Its intraabdominal location depends on the way it is attached by the mesoappendix. The symptoms vary according to the location of the inflamed portion and the affected contiguous structures, in the order of frequency: the low cecal position, the pelvic position, and the retrocecal position (5).

Charles McBurney (1845-1914) was an American surgeon who, in 1889, described the classic location of sharp pain on the spot “very exactly between an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from the bony prominence to the umbilicus” (5).

Maybe. Some surgeons maintain that the clinical diagnosis of appendicitis by a surgeon is sufficient without any radiologic study before surgery. The occasional discovery of normal appendix at the time of surgery may be considered an acceptable false positive clinical diagnosis in order to minimize the occasional error of false negative diagnosis that would result in delayed operation, ruptured appendicitis, and associated complications.

On the other hand, ultrasonography (US) and computed tomography (CT) scans have demonstrated efficacy. US has a sensitivity of 75% to 90%, a specificity of 86% to 100%, a positive predictive value of 89% to 93%, and an overall accuracy of 90% to 94%. CT scanning is even more accurate, with a sensitivity of 90% to 100%, a specificity of 91% to 99%, and a positive predictive value of 95% to 97%. For the vast majority of patients who present with typical appendicitis, however, obtaining a CT scan may only delay the time of operation and may prove to be unnecessary in the end. It also adds to the cost of care (6).

A reasonable approach is to reserve the use of radiologic studies for patients with an atypical presentation or in patient populations in whom the possibility of a misdiagnosis is greater: young sexually active females with high likelihood of PID, pregnant women (US), and elderly patients with confounding factors. For patients with a classic presentation of appendicitis, radiologic studies are unnecessary (7,8).

Laparoscopic appendectomy is superior to the open approach in terms of decreased postoperative wound infections and recovery time. In a large review, patients who underwent laparoscopic appendectomy were found to be as follows when compared with patients who underwent open appendectomy:

But the laparoscopic appendectomy was inferior to the open appendectomy in the following ways:

The reviewers concluded that the laparoscopic appendectomy would be advantageous over the open appendectomy in most cases of suspected appendicitis, except in patients in whom laparoscopy is contraindicated or unfeasible, in patients with gangrene, and patients with perforated appendicitis. In these patients, the laparoscopic approach carries a higher risk of intraabdominal infections (9).