appendicitis - wikipedia, the free encyclopedia

AppendicitisClassification and external resources

An acutely inflamed and enlarged appendix, slicedlengthwise.

ICD-10 K35 (http://apps.who.int/classifications/icd10/browse/2010/en#/K35) - K37(http://apps.who.int/classifications/icd10/browse/2010/en#/K37)

ICD-9 540 (http://www.icd9data.com/getICD9Code.ashx?icd9=540)-543(http://www.icd9data.com/getICD9Code.ashx?icd9=543)

DiseasesDB 885 (http://www.diseasesdatabase.com/ddb885.htm)

MedlinePlus 000256 (http://www.nlm.nih.gov/medlineplus/ency/article/000256.htm)

eMedicine med/3430 (http://www.emedicine.com/med/topic3430.htm) emerg/41(http://www.emedicine.com/emerg/topic41.htm#) ped/127(http://www.emedicine.com/ped/topic127.htm#) ped/2925

AppendicitisFrom Wikipedia, the free encyclopedia

Appendicitis is a condition characterized by inflammation of the appendix. It is classified as amedical emergency and many cases require removal of the inflamed appendix, either bylaparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of ruptureleading to infection and inflammation of the intestinal lining (peritoneum) and eventual sepsis,clinically known as peritonitis which can lead to circulatory shock.[1] Reginald Fitz first describedacute and chronic appendicitis in 1886,[2] and it has been recognized as one of the most commoncauses of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form ofappendicitis is known as "rumbling appendicitis".[3]

The term "pseudoappendicitis" is used to describe a condition mimicking appendicitis.[4] It can beassociated with Yersinia enterocolitica.[5]

Contents

1 Signs and symptoms2 Causes3 Diagnosis

3.1 Clinical3.2 Blood and urine test3.3 Imaging3.4 Scoring systems3.5 Pathology3.6 Differential diagnosis

4 Management4.1 Pain4.2 Surgery

5 Prognosis6 Epidemiology7 Society and culture

7.1 Cost8 References

Appendicitis - Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Appendicitis

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(http://www.emedicine.com/ped/topic2925.htm#)

MeSH C06.405.205.099(http://www.nlm.nih.gov/cgi/mesh/2013/MB_cgi?mode=&term=Appendicitis&field=entry#TreeC06.405.205.099)

Location of the appendix in thedigestive system

9 External links

Signs and symptoms

Pain first, vomiting next and fever last has been described as the classic presentation of acuteappendicitis. Since the innervation of the appendix enters the spinal cord at the same level as theumbilicus (belly button), the pain begins stomach-high. Later, as the appendix becomes moreswollen and irritates the adjoining abdominal wall, it tends to localize over several hours into theright lower quadrant, except in children under three years. This pain can be elicited through various signs andcan be severe. Signs include localized findings in the right iliac fossa. The abdominal wall becomes verysensitive to gentle pressure (palpation). Also, there is severe pain on sudden release of deep pressure in thelower abdomen (rebound tenderness). In case of a retrocecal appendix (appendix localized behind the cecum),however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), thereason being that the cecum, distended with gas, protects the inflamed appendix from the pressure. Similarly,if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity. In suchcases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes pointtenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix.If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion ofperitonitis, requiring urgent surgical intervention.[6]

Causes

On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstructionof the appendix lumen (the inside space of a tubular structure).[7][8] Once this obstruction occurs, the appendix subsequently becomes filled withmucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, andstasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and thennecrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of thiscascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death.

The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis, and, most commonly, calcified fecal deposits known asappendicoliths or fecaliths[9] The occurrence of obstructing fecaliths has attracted attention since their presence in patients with appendicitis issignificantly higher in developed than in developing countries,[10] and an appendiceal fecalith is commonly associated with complicatedappendicitis.[11] Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in


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patients with acute appendicitis compared with healthy controls.[12] The occurrence of a fecalith in the appendix seems to be attributed to aright-sided fecal retention reservoir in the colon and a prolonged transit time.[13] From epidemiological data, it has been stated that diverticulardisease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt from appendicitis.[14][15] Also, acuteappendicitis has been shown to occur antecedent to cancer in the colon and rectum.[16] Several studies offer evidence that a low fiber intake isinvolved in the pathogenesis of appendicitis.[17][18][19] This is in accordance with the occurrence of a right-sided fecal reservoir and the fact thatdietary fiber reduces transit time.[20]

Diagnosis

Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Histories fall intotwo categories, typical and atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the umbilicus for several hours,associated with anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant (or the left lower quadrant in patients with situsinversus totalis), where tenderness develops. The combination of pain, anorexia, leukocytosis, and fever is classic. Atypical histories lack this typicalprogression and may include pain in the right lower quadrant as an initial symptom. Atypical histories often require imaging with ultrasound and/orCT scanning.[21]

Clinical

Aure-Rozanova sign

Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg's sign) - typical in retrocecal position of theappendix.[22]

Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressurecauses the severe pain on the site indicating positive Blumberg's sign and peritonitis.[23]

Bartomier-Michelson's sign

Increased pain on palpation at the right iliac region as patient lies on his/her left side compared to when patient was on supine position.

Dunphy's sign

Increased pain in the right lower quadrant with coughing.[24]


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Kocher's (Kosher's) sign

From the history given, the appearance of pain in the epigastric region or around the stomach at the beginning of disease with a subsequent shift to theright iliac region.

Massouh sign

Main article: Massouh sign

This sign, developed in and popular in southwest England, describes a firm swish of the examiners index and middle finger across the patientsabdomen from xiphoid sternum to first the left and then the right iliac fossa. A positive Massouh sign is a grimace of the patient upon a right sided(and not left) sweep, because initial stage appendicitis usually causes localised irritation of the well-innervated peritoneum.

Obturator sign

Main article: Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle (called the obturator sign) can be demonstrated by flexing andinternal rotation of the hip. This maneuver will cause pain in the hypogastrium.

Psoas sign

Main article: Psoas sign

Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with either the passive extension of the patient's right hip (patient lyingon left side, with knee in flexion) or by the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of theperitoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because itstretches these muscles, while flexing the hip activates the iliopsoas and therefore also causes pain.

Rovsing's sign

Main article: Rovsing's sign

Continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon) may cause pain in the right iliac fossa, bypushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix.[25]

Sitkovskiy (Rosenstein)'s sign


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Increased pain in the right iliac region as patient lies on his/her left side.

Blood and urine test

Most people suspected of having appendicitis would be asked to do a blood test. Half of the time, the blood test is normal, so it is not that useful indiagnosing appendicitis.

Two forms of blood tests are commonly done: Full blood count (FBC), also known as complete blood count (CBC), is an inexpensive and commonlyrequested blood test. It involves measuring the blood for its richness in red blood cells, as well as the number of the various white blood cellconstituents in it. The number of white cells in the blood is usually less than 10,000 cells per cubic millimeter. An abnormal rise in the number ofwhite blood cells in the blood is a crude indicator of infection or inflammation going on in the body. Such a rise is not specific to appendicitis alone. Ifit is abnormally elevated, with a good history and examination findings pointing towards appendicitis, the likelihood of having the disease is higher. Inpregnancy, elevation of white blood cells may be normal, without any infection present.

C-reactive protein (CRP) is an acute-phase response protein produced by the liver in response to any infection or inflammatory process in the body.Again, like the FBC, it is not a specific test. It is another crude marker of infection or inflammation. Inflammation at ANY site can lead to a rise inCRP. A significant rise in CRP, with corresponding signs and symptoms of appendicitis, is a useful indicator in the diagnosis of appendicitis. If theCRP continues to be normal after 72 hours of the onset of pain, the appendicitis likely will resolve on its own without intervention. A worsening CRPwith good history is a sure signal of impending perforation or rupture and abscess formation.

A urine test in appendicitis is usually normal. It may, however, show blood if the appendix is rubbing on the bladder, causing irritation. It is importantto rule out an ectopic pregnancy in women of childbearing age.

Imaging

Appendicitis in children is common enough to merit special attention. Because of the health risks of exposing children to radiation, many medicalsocieties recommend that in confirming a diagnosis with children the ultrasound is a preferred first choice with x-rays being a legitimate follow-upwhen warranted.[26][27][28] CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has asensitivity of 94%, specificity of 95%. Ultrasonography had an overall sensitivity of 86%, a specificity of 81%.[29]

XRay

In 10% of patients with appendicitis, plain abdominal X-ray may demonstrate hard formed feces in the lumen of the appendix (fecolith). It is agreedthat the finding of Fecolith in the appendix on X-ray alone is a reason to operate to remove the appendix, because of the potential to cause worseningsymptoms. In this respect, a plain abdominal X-ray may be useful in the diagnosis of appendicitis, though plain abdominal X- ray is no longerrequested routinely in suspected cases of appendicitis. An abdominal X-ray may be done with a barium enema contrast to diagnose appendicitis.Barium enema is whitish fluid that is passed up into the rectum to act as a contrast. It will usually fill the whole of the large bowel. In normal


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Ultrasound image of an acuteappendicitis

A CT scan demonstrating acuteappendicitis (note the appendix has adiameter of 17.1mm and there issurrounding fat stranding.)

appendix, the lumen will be present and the barium fills it up and is seen when the X-ray film is shot. In appendicitis, the lumen of the appendix willnot be visible on the barium film.

Ultrasound

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children,and shows free fluid collection in the right iliac fossa, along with a visible appendix without blood flow incolor Doppler. In some cases (15% approximately), however, ultrasonography of the iliac fossa does notreveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitisbefore the appendix has become significantly distended and in adults where larger amounts of fat and bowelgas make actually seeing the appendix technically difficult. Despite these limitations, sonographic imaging inexperienced hands can often distinguish between appendicitis and other diseases with very similar symptoms,such as inflammation of lymph nodes near the appendix or pain originating from other pelvic organs such asthe ovaries or fallopian tubes.

Computed tomography

Where it is readily available, CT scan has become frequently used, especially in adults whose diagnosis is notobvious on history and physical examination. Concerns about radiation, however, tend to limit use of CT inpregnant women and children. A properly performed CT scan with modern equipment has a detection rate(sensitivity) of over 95%, and a similar specificity. Signs of appendicitis on CT scan include lack of oralcontrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm incross-sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye). The inflammationcaused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT,providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when theappendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patientsand in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning ismade clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT fordiagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgeryfrom 20% in the pre-CT era to only 3% according to data from the Massachusetts General Hospital.

Scoring systems

Alvarado score

A number of clinical and laboratory-based scoring systems have been devised to assist diagnosis. The most widely used is Alvarado score. A score


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A fecalith marked by the arrow whichhas resulted in acute appendicitis.

Migratory right iliac fossa pain 1 pointAnorexia 1 point

Nausea and vomiting 1 pointRight iliac fossa tenderness 2 points

Rebound tenderness 1 pointFever 1 point

Leukocytosis 2 pointsShift to left (segmented neutrophils) 1 point

Total score 10 points

Alvarado score

Micrograph of appendicitis andperiappendicitis. H&E stain.

below 5 is strongly against a diagnosis of appendicitis,[30]

while a score of 7 or more is strongly predictive of acuteappendicitis. In patients with an equivocal score of 5 or 6, aCT scan is used to further reduce the rate of negativeappendicectomy.

Tzanakis scoring

Tzanakis scoring: Tzanakis and colleagues, in 2005published a simplified system, now called the Tzanakisscoring system for appendicitis, to aid the diagnosis ofappendicitis. It incorporates the presence of four variablesmade up of specific signs and symptoms (presence of rightlower abdominal tenderness = 4 points and reboundtenderness = 3), laboratory findings (presence of whiteblood cells greater than 12,000 in the blood = 2), as well as ultrasound findings (presence of positive ultrasound scan findings of appendicitis = 6), towhich scores are allocated, in the computing of a scoring to predict the presence of appendicitis.The maximum score is a total score of 15; where a patient scores 8 or more points, there is greater than 96% chance that appendicitis exists.

Pathology

The definitive diagnosis is based on pathology. The histologic findings of appendicits are neutrophils in themuscularis propria.

Periappendicits, inflammation of tissues around the appendix, is often found in conjunction with otherabdominal pathology.[31]

Differential diagnosis

In children: Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, Henoch-Schnleinpurpura, lobar pneumonia, urinary tract infection (abdominal pain in the absence of other symptoms can occurin children with UTI), new-onset Crohn's disease or ulcerative colitis, pancreatitis, and abdominal trauma fromchild abuse; distal intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in children withleukemia;

In women: A pregnancy test is important in all women of child bearing age, as ectopic pregnancies and appendicitis present similar symptoms. Othercauses menarche, dysmenorrhea, pelvic inflammatory disease, endometriosis, Mittelschmerz (the passing of an egg in the ovaries approximately two


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Micrograph ofappendicitisshowingneutrophils inthe muscularispropria. H&Estain.

Inflamed appendix removal by opensurgery

weeks before an expected menstruation cycle).

In men: testicular torsion;

In adults: new-onset Crohn's disease, ulcerative colitis, regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectussheath hematoma;

In elderly: diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.

Management

Acute appendicitis is typically managed by surgery however in uncomplicated cases antibiotics are both effective and safe.[32]

While antibiotics are effective for treating uncomplicated appendicitis 20% of people had a recurrence within a year and requiredeventual appendectomy.[32]

Pain

Pain medications (such as morphine) do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given earlyin the persons care.[33] Historically there were concerns among some general surgeons that analgesics would affect the clinical exam in children andthus some recommended that they not be given until the surgeon in question was able to examine the person for themselves.[33]

Surgery

See also: Appendectomy

The surgical procedure for the removal of the appendix is called an appendicectomy. Laparoscopic removal(via three small incisions with a camera to visualize the area of interest in the abdomen) seem to have someadvantages over an open procedures especially in young females and the obese.[34]

Laparotomy

Laparotomy is the traditional type of surgery used for treating appendicitis. This procedure consists in theremoval of the infected appendix through a single larger incision in the lower right area of the abdomen.[35]

The incision in a laparotomy is usually 2 to 3 inches (51 to 76 mm) long. This type of surgery is used also forvisualizing and examining structures inside the abdominal cavity and it is called exploratory laparotomy.


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Laparoscopic appendectomy.

During a traditional appendectomy procedure, the patient is placed under general anesthesia to keep themuscles completely relaxed and to keep the patient unconscious. The incision is two to three inches (76 mm)long and it is made in the right lower abdomen, several inches above the hip bone.[36] Once the incision opensthe abdomen cavity and the appendix is identified, the surgeon removes the infected tissue and cuts theappendix from the surrounding tissue. After the surgeon inspects carefully and closely the infected area andthere are no signs that surrounding tissues are damaged or infected, he will start closing the incision. Thismeans sewing the muscles and using surgical staples or stitches to close the skin up. In order to preventinfections the incision is covered with a sterile bandage.

The entire procedure does not last longer than an hour if complications do not occur.

Laparoscopic surgery

The newer method to treat appendicitis is the laparoscopic surgery. This surgical procedure consists of making three to four incisions in the abdomen,each 0.25 to 0.5 inches (6.4 to 13 mm) long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of theincisions. The laparoscope is connected to a monitor outside the patient's body and it is designed to help the surgeon to inspect the infected area in theabdomen. The other two incisions are made for the specific removal of the appendix by using surgical instruments. Laparoscopic surgery also requiresgeneral anesthesia and it can last up to two hours. The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there is noincision on the external skin[37] and SILS (Single incision laparoscopic Surgery) where a single 2.5 cm incision is made to perform the surgery. Thisfinding was very significant to the appendicitis patients and now thousands of people every year survive.

Pre surgery

The treatment begins by keeping the patient away from eating or drinking in preparation for surgery. An intravenous drip is used to hydrate thepatient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce thespread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assesswith antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usuallyused. Otherwise, spinal anaesthesia may be used.

Once the decision to perform an appendectomy has been made, the preparation procedure takes approximately one to two hours. Meanwhile, thesurgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. With all surgeriesthere are certain risks that must be evaluated before performing the procedures. However, the risks are different depending on the state of theappendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises toalmost 59%.[38] The most usual complications that can occur are pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesions. Recentevidence indicates that a delay in obtaining surgery after admission results in no measurable difference in patient outcomes.[39]

The surgeon will also explain how long the recovery process should take. Abdomen hair is usually removed in order to avoid complications that may


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The stitches the day after having hisappendix removed by laparoscopicsurgery

appear regarding the incision. In most of the cases patients experience nausea or vomiting which requires specific medication before surgery.Antibiotics along with pain medication may also be administrated prior to appendectomies.

After surgery

Hospital lengths of stay typically range from a few hours to a few days, but can be a few weeks ifcomplications occur. The recovery process may vary depending on the severity of the condition, if theappendix had ruptured or not before surgery. Appendix surgery recovery is generally a lot faster if theappendix did not rupture.[40] It is important that patients respect their doctor's advice and limit their physicalactivity so the tissues can heal faster. Recovery after an appendectomy may not require diet changes or alifestyle change.

After surgery occurs, the patient will be transferred to an postanesthesia care unit so his or her vital signs canbe closely monitored to detect anesthesia- and/or surgery-related complications. Pain medication may also beadministered if necessary. After patients are completely awake, they are moved into a hospital room torecover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular dietwhen the intestines start to function properly. Patients are recommended to sit up on the edge of the bed andwalk short distances for several times a day. Moving is mandatory and pain medication may be given ifnecessary. Full recovery from appendectomies takes about four to six weeks, but can be prolonged to up toeight weeks if the appendix had ruptured.

Prognosis

Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs.Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually isbetween 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks.

The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient mayhave to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e., outside of a properhospital), when a timely medical evaluation was impossible.

Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, itremains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypicalappendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. Ineither condition, prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severecomplications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked aboutquite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump.


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Disability-adjusted life year forappendicitis per 100,000 inhabitants in2004.[42]

nodata

lessthan 2.5

2.5-5

5-7.5

7.5-10

10-12.5

12.5-15

15-17.5

17.5-20

20-22.5

22.5-25

25-27.5

morethan 27.5

During this period, operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition.

An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a priorincomplete appendectomy.[41]

Epidemiology

Appendicitis is most common between the ages of 5 and 40.[43] The median age is 28. It tends to affect males,those in lower income groups, and, for unknown reasons, people living in rural areas.[44]

Society and culture

Cost

While appendectomy is a standard surgical procedure, its cost has been found to vary considerably,particularly in the United States. A 2012 study from the University of California, San Francisco published inthe Archives of Internal Medicine analyzed 2009 data from nearly 20,000 adult patients treated forappendicitis in California hospitals. Researchers examined only uncomplicated episodes of acuteappendicitis that involved visits for patients 18 to 59 years old with hospitalization that lasted fewer thanfour days with routine discharges to home. The lowest charge for removal of an appendix was $1,529 and thehighest $182,955, almost 120 times greater. The median charge was $33,611.[45][46]

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External links

CT of the abdomen showing acute appendicitis (http://www.claripacs.com/case/CL0012)Anatomy of Appendix and Appendicits | Medchrome (http://medchrome.com/basic-science/anatomy/anatomy-appendix-appendicitis/)Podcast on the management of appendicitis (http://www.learncolorectalsurgery.com/Podcasts.php)Appendicitis and Appendectomy author Dennis Lee, M.D. editor Jay Marks, M.D. - MedicineNet.com (http://www.medicinenet.com/appendicitis/article.htm), Doctor Produced information plus Patient Discussions provided by MedicineNet.comAppendicitis - MayoClinic.com (http://www.mayoclinic.com/invoke.cfm?id=DS00274), from the Web site of the Mayo ClinicAppendicitis, history, diagnosis and treatment (http://www.surgeons.org.uk/general-surgery-tutorials/appendicitis.html) by Surgeons NetEducationAppendicitis Research (http://appendicitis.researchtoday.net) Latest research from the literature on appendicitisAcute and Suppurative Appendicitis (http://xnet.kp.org/permanentejournal/spring98pj/appendicitis.html) from the Spring 1998 issue of ThePermanente Medical JournalAppendicitis Update (http://www.appendicitisreview.com) Complete information including laparoscopic appendectomyHistory of Appendicitis Vermiformis: Its diseases and treatment. (http://www.innominatesociety.com/Articles/History%20of%20Appendicitis.htm) By Arthur C. McCarty, M.D.How to Recognize the Symptoms of Appendicitis, a how-to article from wikiHowAppendicitis: Acute Abdomen and Surgical Gastroenterology (http://www.merck.com/mmpe/sec02/ch011/ch011e.html) from the MerckManual Professional (Content last modified September 2007)Abdominal Emergencies, 'Surgical Abdomen'.By DR David Bednarczyk; Pediatric Surgery (http://www.kco.unibe.ch/daten_e/pathologien/abdo.html)

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