Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review

Abstract

Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.

Single-incision laparoscopic appendectomy versus traditional three-hole laparoscopic appendectomy for acute appendicitis in children by senior pediatric surgeons: a multicenter study from China

“…Some scholars believe that because all operation instruments are used at the same site, the traditional “triangular operation” method cannot be applied smoothly, and there are certain deficiencies in visual field exposure and operational accuracy ( 30 ). This viewpoint may greatly limit the development of this technology.…”

Compilation of Evidence Supporting the Role of a T Helper 2 Reaction in the Pathogenesis of Acute Appendicitis

“…Most of them are tolerated by the organism, but some can elicit an allergic reaction. By analogy with bronchospasm in asthma, luminal appendicular obliteration can be provoked by muscularwall appendicular contraction, in response to an antigen, and the sequence of events can lead to ischemia, gangrene and necrosis [47,48]. Any segment of the intestine can be involved in this process, but the appendix is more susceptible, because its smaller caliber allows for the obstruction to more easily occur [45].…”

The Vermiform Appendix and Its Pathologies

“…In addition, different atypical presentations of appendicitis have been reported, including left-sided abdominal pain localized in the left upper quadrant (in patients with gut malrotation or situs inversus), diarrhea (in advanced appendicitis, especially in patients with inter enteric abscesses), severe right hemiscrotal pain (in adult males), genitourinary complaints (in adult females), and strangulated inguinal hernia with non-specific symptoms (in the elderly). Moreover, pregnant patients may present with a series of uncommon symptoms, including gastroesophageal reflux, malaise, pelvic pain, epigastric discomfort, indigestion, flatulence, dysuria, and altered bowel habits [7,23,24]. Thus, diagnosing acute appendicitis is a challenging task in which clinicians must be aware of anatomical variations of the appendix, take into consideration both typical and atypical symptoms, and confirm their suspicions with appropriate imaging studies to provide treatment promptly [25].…”

“…Acute appendicitis is by far the most common pathology of the appendix and one of the most frequent causes of acute abdominal surgery, as most cases, especially those developing appendicoliths (fecoliths), require urgent removal of the inflamed appendix. With a poorly expandable wall that may become ruptured, the inflamed appendix can release its contents into the abdominal cavity, resulting in peritonitis [3,6,7]. Pathologies related to congenital anomalies include appendicular agenesis (complete absence of the vermiform appendix), appendix duplications (existence of more than one appendix, partially or integrally), appendiceal diverticulosis (occurrence of one or more appendiceal diverticula), volvulus of the appendix (abnormal twisting of the appendix on itself), location of the appendix in an unusual position due to its malrotation or situs inversus, hypoplasia of the appendix, or appendix fistulizing into the umbilicus [8].…”