Appendicitis differential diagnosis: Difference between revisions

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==Differentiating Appendicitis from other Diseases==
==Differentiating Appendicitis from other Diseases==
Since appendicitis presents as the general symptom of [[abdominal pain]], appendicitis must be differentiated from other diseases and disorders causing similar pain and symptoms.  This differentiation can be done according to four categories: surgical, urological, gynaecological, and medical.<ref name="Humes2006">{{cite journal|last1=Humes|first1=D J|title=Acute appendicitis|journal=BMJ|volume=333|issue=7567|year=2006|pages=530–534|issn=0959-8138|doi=10.1136/bmj.38940.664363.AE}}</ref>  
*Appendicitis can be differentiated from other diseases that cause [[Abdominal pain|lower abdominal pain]] and [[fever]] like [[diverticulitis]], [[inflammatory bowel disease]], [[colon cancer]], [[cystitis]], and [[endometritis]].<ref name="pmid17573742">{{cite journal| author=Laurell H, Hansson LE, Gunnarsson U| title=Acute diverticulitis--clinical presentation and differential diagnostics. | journal=Colorectal Dis | year= 2007 | volume= 9 | issue= 6 | pages= 496-501; discussion 501-2 | pmid=17573742 | doi=10.1111/j.1463-1318.2006.01162.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17573742  }} </ref><ref>Hardin, M. Acute Appendicitis: Review and Update. ''Am Fam Physician".1999, Nov 1;60(7):2027-2034''</ref><ref name="pmid8596552">{{cite journal| author=Hanauer SB| title=Inflammatory bowel disease. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 13 | pages= 841-8 | pmid=8596552 | doi=10.1056/NEJM199603283341307 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8596552  }} </ref><ref name="hhh">Cystitis-acute. MedlinePlus.https://www.nlm.nih.gov/medlineplus/ency/article/000526.htm Accessed on February 9, 2016</ref><ref name="nlm">Prostatitis - bacterial. NLM Medline Plus 2016. https://www.nlm.nih.gov/medlineplus/ency/article/000519.htm. Accessed on March 2, 2016</ref><ref name="pmid27107781">{{cite journal |vauthors=Ford GW, Decker CF |title=Pelvic inflammatory disease |journal=Dis Mon |volume=62 |issue=8 |pages=301–5 |year=2016 |pmid=27107781 |doi=10.1016/j.disamonth.2016.03.015 |url=}}</ref>
 
{| class="wikitable"
! colspan="2" rowspan="2" |Diseases
! colspan="2" |Symptoms
! colspan="3" |Signs
! colspan="2" |Diagnosis
! rowspan="2" |Comments
|-
!Abdominal pain
!Bowel habits
!Rebound tenderness
!Guarding
!Genitourinary signs
!Lab findings
!Imaging
|-
| rowspan="5" |GI diseases
|[[Diverticulitis]]
|LLQ
|[[Constipation]]
Or
 
[[Diarrhea]]
| -
| +
|<nowiki>+ </nowiki>
|
* [[Leukocytosis]]
|CT scan shows evidence of [[inflammation]]
|
|-
|[[Appendicitis]]
|LLQ / RRQ
|Constipation
| +
| +
| -
|
* [[Leukocytosis]]
|Ultrasound shows evidence of [[inflammation]]
|[[Nausea and vomiting|Nausea & vomiting]],[[decreased appetite]]
|-
|[[Inflammatory bowel disease]]
|LLQ
|Bloody diarrhea
|<nowiki>-</nowiki>
| -
| -
|
* Leukocytosis
|
|[[Colonoscopy]] and tissue sampling are recommended for differentiating between [[Crohn's disease]] and [[ulcerative colitis]].
|-
|[[Colon carcinoma]]
|LLQ
|Constipation
 
| -
| -
| -
|
* Serum [[carcino-embryogenic antigen]] 
* Low Vit b12
* [[Hypercalcemia]]
|CT scan, x-ray and MRI used to show [[metastasis]]
|
|-
|[[Strangulated hernia]]
|LLQ
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* No specific tests
|
* CT scan used to detect the [[hernia]] and to show if it is single or multiple
|
|-
| rowspan="3" |Gentiourinary diseases
|[[Cystitis]]
|LLQ
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
* Suprapubic tenderness
|
* [[Pyuria]]
* Presence of [[nitrites]] and leukocyte estrase
|
* X ray is done to probe the suspicion of emphysematous cystitis.
* CT scan shows gas in the [[Urinary bladder|bladder]] in cases of emphysematous cystitis.
|
|-
|[[Prostatitis]]
|LLQ
 
Groin pain
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* Tender and enlarged
|
* Serum [[Prostate specific antigen|PSA]] elevated
* [[Leukocytosis]]
* Elevated [[C-reactive protein|CRP]]
|
* CT scan shows [[edema]] and enlarged [[prostate]]
* [[Abscess]] may be observed
|
|-
|[[Pelvic inflammatory disease]]
|Bilateral
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
| -
|
* Purulent vaginal discharge
|
* [[Nucleic acid amplification technique|Nucleic acid amplification tests]] is the best laboratory test for PID.
|[[Transvaginal ultrasound|Transvaginal utrasonography]]
|
|-
| rowspan="2" |Gynecological diseases
|[[Endometritis]]
|LLQ
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|
* No specific tests
|
* Ultrasound is helpful to rule out other differential diagnosis such as pelvic abscess, thrombosis and masses
|
* Vaginal discharge
 
* Vaginal bleeding
|-
|[[Salpingitis]]
|LLQ/ RLQ
|
| +/-
| +/-
|
|
* Leukocytosis
|Pelvic ultrasound
|
* Vaginal discharge
|}
 
 
 
 
*Since appendicitis presents as the general symptom of [[abdominal pain]], appendicitis must be differentiated from other diseases and disorders causing similar pain and symptoms.  This differentiation can be done according to four categories: surgical, urological, gynaecological, and medical.<ref name="Humes2006">{{cite journal|last1=Humes|first1=D J|title=Acute appendicitis|journal=BMJ|volume=333|issue=7567|year=2006|pages=530–534|issn=0959-8138|doi=10.1136/bmj.38940.664363.AE}}</ref>  




Revision as of 18:07, 31 July 2017

Appendicitis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

Appendicitis must be differentiated from other causes of abdominal pain such as acute gastroenteritis and luminal obstruction. Age group can be another factor used to differentiate appendicitis.

Differentiating Appendicitis from other Diseases

Diseases Symptoms Signs Diagnosis Comments
Abdominal pain Bowel habits Rebound tenderness Guarding Genitourinary signs Lab findings Imaging
GI diseases Diverticulitis LLQ Constipation

Or

Diarrhea

- + + CT scan shows evidence of inflammation
Appendicitis LLQ / RRQ Constipation + + - Ultrasound shows evidence of inflammation Nausea & vomiting,decreased appetite
Inflammatory bowel disease LLQ Bloody diarrhea - - -
  • Leukocytosis
 Colonoscopy and tissue sampling are recommended for differentiating between Crohn's disease and ulcerative colitis.
Colon carcinoma LLQ Constipation - - - CT scan, x-ray and MRI used to show metastasis
Strangulated hernia LLQ - - - -
  • No specific tests
  • CT scan used to detect the hernia and to show if it is single or multiple
Gentiourinary diseases Cystitis LLQ - + -
  • Suprapubic tenderness
  • X ray is done to probe the suspicion of emphysematous cystitis.
  • CT scan shows gas in the bladder in cases of emphysematous cystitis.
Prostatitis LLQ

Groin pain

- - -
  • Tender and enlarged
Pelvic inflammatory disease Bilateral - + -
  • Purulent vaginal discharge
 Transvaginal utrasonography
Gynecological diseases Endometritis LLQ - + - +
  • No specific tests
  • Ultrasound is helpful to rule out other differential diagnosis such as pelvic abscess, thrombosis and masses
  • Vaginal discharge
  • Vaginal bleeding
Salpingitis LLQ/ RLQ +/- +/-
  • Leukocytosis
 Pelvic ultrasound
  • Vaginal discharge



  • Since appendicitis presents as the general symptom of abdominal pain, appendicitis must be differentiated from other diseases and disorders causing similar pain and symptoms. This differentiation can be done according to four categories: surgical, urological, gynaecological, and medical.[7]


Classification of acute abdomen based on etiology Presentation Symptoms Signs Diagnosis Comments
Fever Abdominal Pain Jaundice Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Common causes of Peritonitis Primary Peritonitis Spontaneous bacterial peritonitis + Diffuse - - - Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
 Ultrasound for evaluation of liver cirrhosis -
Secondary Peritonitis Perforated gastric and duodenal ulcer + Diffuse - + + N
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
 Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Acute cholangitis + RUQ + - - N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + RUQ + - - Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric +/- - - N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Acute appendicitis + RLQ - + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + LLQ +/- + - Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation
Acute salpingitis + LLQ/ RLQ - +/- +/- N Leukocytosis Pelvic ultrasound Vaginal discharge
Hollow Viscous Obstruction Small intestine obstruction - Diffuse - + +/- Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia +/- Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis +/- Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma
Gynaecological Causes Ovarian Cyst Complications Torsion of the cyst - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding


Surgical

Urological

Gynaecological

Medical

Other Causes Mimicking Appendicitis at any Age

In general, acute gastroenteritis can often be mistaken for appendicitis. Luminal obstructions can also mimic signs of appendicitis.[8] In particular, luminal obstruction caused by:

In Children

In Adults

In Elderly Patients

References

  1. ↑ Laurell H, Hansson LE, Gunnarsson U (2007). "Acute diverticulitis--clinical presentation and differential diagnostics". Colorectal Dis. 9 (6): 496–501, discussion 501-2. doi:10.1111/j.1463-1318.2006.01162.x. PMID 17573742.
  2. ↑ Hardin, M. Acute Appendicitis: Review and Update. Am Fam Physician".1999, Nov 1;60(7):2027-2034
  3. ↑ Hanauer SB (1996). "Inflammatory bowel disease". N Engl J Med. 334 (13): 841–8. doi:10.1056/NEJM199603283341307. PMID 8596552.
  4. ↑ Cystitis-acute. MedlinePlus.https://www.nlm.nih.gov/medlineplus/ency/article/000526.htm Accessed on February 9, 2016
  5. ↑ Prostatitis - bacterial. NLM Medline Plus 2016. https://www.nlm.nih.gov/medlineplus/ency/article/000519.htm. Accessed on March 2, 2016
  6. ↑ Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.
  7. ↑ Humes, D J (2006). "Acute appendicitis". BMJ. 333 (7567): 530–534. doi:10.1136/bmj.38940.664363.AE. ISSN 0959-8138.
  8. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:40 ISBN 1591032016

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