Appendicitis differential diagnosis: Difference between revisions

Jump to navigation Jump to search
No edit summary
m (Bot: Removing from Primary care)
 
(36 intermediate revisions by 14 users not shown)
Line 1: Line 1:
{{Appendicitis}}
__NOTOC__
{{CMG}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Appendicitis]]
{{CMG}}; {{AE}} {{FH}}


==Overview==
==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==
==Differentiating Appendicitis from other Diseases==
Since Appendicitis presents as the general symptom of [[Abdominal pain]], Appendicitis must be differentiated from other causes of abdominal painDifferentiating appendicitis from other diseases can be done according to age group:
*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>


===In children:===
{| class="wikitable"
*[[Gastroenteritis]]  
! colspan="2" rowspan="2" |Diseases
*[[Mesenteric adenitis]]
! colspan="2" |Symptoms
*[[Meckel's diverticulum]]
! colspan="3" |Signs
*[[Intussusception]]
! colspan="2" |Diagnosis
*[[Henoch-Schõnlein purpura]]
! rowspan="2" |Comments
*Lobar [[pneumonia]]
|-
!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 [[vitamin 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>


===In adults:===
{| align="center"
*[[Regional enteritis]]
|-
* [[Renal colic]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Perforated [[peptic ulcer]]
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
* [[Testicular torsion]]
! colspan="2" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" | Classification of acute abdomen based
* [[Pancreatitis]]
on etiology
* [[Rectus sheath hematoma]]
! colspan="1" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Presentation
* [[Pelvic inflammatory disease]]
! colspan="8" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Clinical findings
* [[Ectopic pregnancy]]
! colspan="2" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Diagnosis
* [[Endometriosis]]
! colspan="1" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" | Comments
* Torsion/rupture of [[ovarian cyst]]
|-
* Ruptured [[Graafian follicle]]
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Fever
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" |Rigors and Chills
! align="center" style="background:#4479BA; color: #FFFFFF;" |Abdominal Pain
! align="center" style="background:#4479BA; color: #FFFFFF;" |Jaundice
! align="center" style="background:#4479BA; color: #FFFFFF;" |Hypotension
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Guarding
! align="center" style="background:#4479BA; color: #FFFFFF;" |Rebound Tenderness
! align="center" style="background:#4479BA; color: #FFFFFF;" |Bowel sounds
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Lab Findings
! align="center" style="background:#4479BA; color: #FFFFFF;" |Imaging
|-
| colspan="2" rowspan="8" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Common causes of  
Peritonitis
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Spontaneous bacterial peritonitis]]  
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ascitic fluid [[PMN]]>250 cells/mm<small>³</small>


===In the elderly:===
* Culture: Positive for single organism
*[[Diverticulitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound for evaluation of liver cirrhosis
* [[Intestinal obstruction]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
* [[Colonic carcinoma]]
|-
* [[Mesenteric infarction]]
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Perforated [[Gastric ulcer|gastric]] and [[duodenal ulcer]]
* Leaking [[aortic aneurysm]].
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ascitic fluid
**[[LDH]] > serum [[LDH]]
** Glucose < 50mg/dl
** Total protein > 1g/dl


===Other causes mimicking appendicitis at any age===
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Air under [[diaphragm]] in upright [[CXR]]
In general: <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:40 ISBN 1591032016</ref>  
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Upper GI [[endoscopy]] for diagnosis
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Acute suppurative cholangitis
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Acute cholangitis
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Abnormal [[LFT]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows [[biliary]] dilatation
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute Cholecystitis|Acute cholecystitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Hyperbilirubinemia]]
* [[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows gallstone and evidence of inflammation
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Murphy's sign|Murphy’s sign]]
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |  [[Acute pancreatitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[Epigastric]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[amylase]] / [[lipase]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of [[inflammation]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Pain radiation to back
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute appendicitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | RLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of [[inflammation]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]], [[decreased appetite]]
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Diverticulitis|Acute diverticulitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound shows evidence of inflammation
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
| colspan="2" rowspan="5" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Hollow Viscous Obstruction
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Small intestine obstruction
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Abdominal X-ray|Abdominal X ray]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]] associated with [[constipation]], [[Abdominal distension|abdominal distention]]
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gall stone disease|Gall stone '''disease''']]/'''Cholelithiasis'''
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Volvulus]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and [[Abdominal x-ray|abdominal X ray]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]] associated with [[constipation]], [[Abdominal distension|abdominal distention]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Biliary colic]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[bilirubin]] and [[alkaline phosphatase]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Renal colic]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Flank pain]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Hematuria]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Colicky [[abdominal pain]] associated with [[Nausea and vomiting|nausea & vomiting]]
|-
| rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Vascular Disorders
| rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ischemic causes
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Periumbilical
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]] and [[lactic acidosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]], normal physical examination
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ischemic colitis|Acute ischemic colitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]]
|-
| rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hemorrhagic causes
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ruptured abdominal aortic aneurysm]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Unstable hemodynamics
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intra-abdominal or [[retroperitoneal hemorrhage]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Anemia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of [[trauma]]
|-
| rowspan="5" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gynaecological Causes
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Fallopian tube
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Salpingitis|Acute salpingitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | LLQ/ RLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Pelvic ultrasound]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Vaginal discharge]]
|-
| rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ovarian cyst]] complications and endometrial disease
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Torsion of the cyst
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset sever pain with [[nausea and vomiting]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Endometriosis
| -
|
|RLQ/LLQ
| -
|
| +/-
| +/-
|N
|Normal
|Laproscopy
|Menstrual-associated symptoms, pelvic
symptoms
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cyst rupture
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset sever pain with [[nausea and vomiting]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pregnancy
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ruptured [[ectopic pregnancy]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Positive [[pregnancy test]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of missed period and [[vaginal bleeding]]
|-
| rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |
| colspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Irritable Bowel Syndrome
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| align="left" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[Diagnosis|Clinical diagnosis]]
* ROME III/IV criteria
* [[Pharmacological|Pharmacologic]] studies based criteria
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* High [[dietary fiber]]


* [[Gastroenteritis|Acute Gastroenteritis]]
* [[Osmotic]] [[laxatives]]
* Luminal obstruction:
* [[Antispasmodic]]<nowiki/>drugs
*:* [[Barium]]
|-
*:* Fecaliths
|}
*:* [[Foreign body]]
===Differentials to be considered In Children for appendicitis===
*:* Fruit seeds
*[[Mesenteric adenitis]]
*:* [[Hypertrophy]] of the [[lymphatic tissue]]
*[[Meckel's diverticulum]]
*:* [[Parasites]]
*[[Intussusception]]
*:* [[Stricture]]
*[[Henoch-Schõnlein purpura]], and [[lobar pneumonia]]


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}
|}
 
[[Category:Emergency medicine]]
[[Category:Surgery]]
[[Category:Gastroenterology]]

Latest revision as of 20:27, 29 July 2020

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 - + -
  • 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 Clinical findings Diagnosis Comments
Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Common causes of

Peritonitis

Spontaneous bacterial peritonitis + Diffuse Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis -
Perforated gastric and duodenal ulcer + Diffuse + + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Acute suppurative cholangitis + + RUQ + + + + ±
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
Hollow Viscous Obstruction Small intestine obstruction Diffuse + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Gall stone disease/Cholelithiasis ±
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 Fallopian tube Acute salpingitis + LLQ/ RLQ ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic

symptoms

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
Irritable Bowel Syndrome - Diffuse - - - - N

Clinical diagnosis

-

Differentials to be considered In Children for appendicitis

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.

Template:WH Template:WS