Appendicitis differential diagnosis

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

Overview[edit | edit source]

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[edit | edit source]

Appendicitis can be differentiated from other diseases that cause lower abdominal pain and fever like diverticulitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis.^[1]^[2]^[3]^[4]^[5]^[6]

Diseases		Symptoms		Signs			Diagnosis		Comments
Diseases		Abdominal pain	Bowel habits	Rebound tenderness	Guarding	Genitourinary signs	Lab findings	Imaging	Comments
GI diseases	Diverticulitis	LLQ	Constipation Or Diarrhea	-	+	+	Leukocytosis	CT scan shows evidence of inflammation
	Appendicitis	LLQ / RRQ	Constipation	+	+	-	Leukocytosis	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	-	-	-	Serum carcino-embryogenic antigen Low vitamin B12 Hypercalcemia	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	Pyuria Presence of nitrites and leukocyte estrase	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	Serum PSA elevated Leukocytosis Elevated CRP	CT scan shows edema and enlarged prostate Abscess may be observed
	Pelvic inflammatory disease	Bilateral	-	+	-	Purulent vaginal discharge	Nucleic acid amplification tests is the best laboratory test for PID.	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
Gynecological diseases	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
Classification of acute abdomen based on etiology		Presentation	Fever	Rigors and Chills	Abdominal Pain	Jaundice	Hypotension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
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	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
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
	Ischemic causes	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
	Hemorrhagic causes	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 ROME III/IV criteria Pharmacologic studies based criteria	-	High dietary fiber Osmotic laxatives Antispasmodicdrugs

Differentials to be considered In Children for appendicitis[edit | edit source]

References[edit | edit source]

↑ 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.
↑ Hardin, M. Acute Appendicitis: Review and Update. Am Fam Physician".1999, Nov 1;60(7):2027-2034
↑ Hanauer SB (1996). "Inflammatory bowel disease". N Engl J Med. 334 (13): 841–8. doi:10.1056/NEJM199603283341307. PMID 8596552.
↑ Cystitis-acute. MedlinePlus.https://www.nlm.nih.gov/medlineplus/ency/article/000526.htm Accessed on February 9, 2016
↑ Prostatitis - bacterial. NLM Medline Plus 2016. https://www.nlm.nih.gov/medlineplus/ency/article/000519.htm. Accessed on March 2, 2016
↑ Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.
↑ Humes, D J (2006). "Acute appendicitis". BMJ. 333 (7567): 530–534. doi:10.1136/bmj.38940.664363.AE. ISSN 0959-8138.

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[pmid17573742-1] 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

[pmid8596552-3] Hanauer SB (1996). "Inflammatory bowel disease". N Engl J Med. 334 (13): 841–8. doi:10.1056/NEJM199603283341307. PMID 8596552.

[hhh-4] Cystitis-acute. MedlinePlus.https://www.nlm.nih.gov/medlineplus/ency/article/000526.htm Accessed on February 9, 2016

[nlm-5] Prostatitis - bacterial. NLM Medline Plus 2016. https://www.nlm.nih.gov/medlineplus/ency/article/000519.htm. Accessed on March 2, 2016

[pmid27107781-6] Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.

[Humes2006-7] Humes, D J (2006). "Acute appendicitis". BMJ. 333 (7567): 530–534. doi:10.1136/bmj.38940.664363.AE. ISSN 0959-8138.

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