Appendicitis differential diagnosis

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

## Overview

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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

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* 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

|
|
|
|

Abdominal pain  | Bowel habits  | Rebound tenderness  | Guarding  | Genitourinary signs  | Lab findings  | Imaging
GI diseases  | Diverticulitis | LLQ  | Constipation

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

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  |

* 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
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

* ROME III/IV criteria
* Pharmacologic studies based criteria

| \-  |

* High dietary fiber

* Osmotic laxatives
* Antispasmodicdrugs

### Differentials to be considered In Children for appendicitis

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* Mesenteric adenitis
* Meckel's diverticulum
* Intussusception
* Henoch-Schõnlein purpura, and lobar pneumonia

## References

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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.CS1 maint: Multiple names: authors list (link)
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.

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