Appendicitis differential diagnosis

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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

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.

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 Ascitic fluid LDH > serum LDH 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 Hyperbilirubinemia Leukocytosis 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 Intestinal obstruction Intussusception Acute cholecystitis Perforated peptic ulcer Mesenteric adenitis Colonic/appendicular diverticulitis Pancreatitis Rectus sheath hematoma Urological Right ureteric colic Right pyelonephritis Urinary tract infection Gynaecological Ectopic pregnancy Ruptured ovarian follicle Torted ovarian cyst Salpingitis/pelvic inflammatory disease Medical Gastroenteritis Pneumonia Terminal ileitis Diabetic ketoacidosis Porphyria 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. In particular, luminal obstruction caused by: Barium Fecaliths Foreign body Fruit seeds Hypertrophy of the lymphatic tissue Parasites Stricture In Children Mesenteric adenitis Meckel's diverticulum Intussusception Henoch-Schõnlein purpura, and lobar pneumonia In Adults Renal colic Perforated peptic ulcer Testicular torsion Pancreatitis Pelvic inflammatory disease Ectopic pregnancy Endometriosis Torsion/rupture of ovarian cyst In Elderly Patients Diverticulitis Intestinal obstruction Colonic carcinoma Mesenteric infarction Leaking aortic aneurysm References