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Adult Appendicitis: James M. Wagner, MD, discusses the clinical examination for adult appendicitis.
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Adult Appendicitis: James M. Wagner, MD, discusses the clinical examination for adult appendicitis.
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>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. James Wagner about adult appendicitis, a condition that should be considered in patients who present with abdominal pain. Dr. Wagner, why don't you introduce yourself to our listeners. >> I sure will, Joan. My name is Jim Wagner. I work at the University of Texas Southwestern Medical School in Dallas, Texas. >> Dr. Wagner, what do we know about the prevalence of adult appendicitis, and are there important demographic characteristics?
>> The prevalence falls between 1 and 25%. A lot of the variance of that, those two numbers, is because of the quality of the studies available to answer that question, but also a large proportion of the variance is because it really depends a lot on these demographic characteristics that you asked about. Specifically, where the patient is being evaluated is a large variable; that is, patients that are being evaluated for abdominal pain in an emergency room have a higher prevalence, whereas those being evaluated in a clinic have a lower prevalence of appendicitis.
In addition, age plays a big role. The younger the patient, the more likely appendicitis will be the ultimate diagnosis, whereas older patients have a lower likelihood of appendicitis. And then there are other confounding factors in women that can make something that otherwise would appear to be a textbook case of appendicitis to be something else, in fact. >> Which symptoms increase the probability of adult appendicitis?
>> Well, I think the first thing that should be said is that appendicitis should be considered in any patient presenting with abdominal pain, no matter where and what venue the patient presents. That is to say even though the prevalence may be lower in ambulatory care settings and in older populations, its morbidity and mortality is so high that it must be considered just for utilitarian reasons. And then secondly I'd add that there is an acronym that has kind of risen to the top in the literature. It shows up over and over again every year as kind of the clinical decision rule against which all others must be measured, and this is the MANTRELS acronym that came from the Alvarado score.
And MANTRELS is an acronym, M standing for migration; A, anorexia; N, nausea; T, tenderness; R, right lower quadrant pain, or rebound tenderness; E is elevation of temperature; and L is leukocytosis; and S is a shift to the left of that leukocytosis. Just a couple explanations of what might not be otherwise obvious.
By the migration in M, we're talking about the classic migration of the periumbilical, vague pain of appendicitis that then migrates down to the right lower quadrant and becomes a very localized pain when the parietal peritoneum becomes inflamed. That's the classic natural history of appendicitis that we've all learned and that's manifest in that migration part of that MANTRELS acronym.
I think the rest of the components of that acronym are pretty self-explanatory. Now what's nice about this MANTRELS acronym is it's easy to remember and it's easy to score. All of the different components that I've listed are given a score of one, except for two, and that's right lower quadrant tenderness and leukocytosis. Those are assigned a score of two. And then adding up all the positive components of that acronym, if one receives a score of seven or greater, that is considered positive.
And what needs to be kept in mind is that the practical implication of a positive MANTRELS score has been shown in the literature to approximate a positive likelihood ratio of about 3.1. And for those that are not real used to using likelihood ratios, positive or negative, 3.1 is a respectable score, but not an overwhelmingly impressive score. Just to kind of give an example of how that might be used, if somebody did have a prevalence -- a prior probability, I should say, of appendicitis of 25%, say, for example, they were a young person presenting in an emergency room setting, then performance of the MANTRELS acronym on this patient, if it were positive, would result in a post-test probability of only 50 or 60%.
And so it doesn't necessarily clinch the diagnosis, but it certainly is helpful moving it from the 25% likelihood up to the greater than -- more likely than not likelihood. >> What are the key elements of the physical examination for appendicitis? In particular, it would be helpful for you to explain how clinicians can elicit the psoas sign, and the obturator sign. And these are nicely illustrated in the online section on adult appendicitis in the Rational Clinical Examination by Figure 5-1 and Figure 5-2.
>> Everybody remembers from anatomy that the psoas is the muscle that makes up a large proportion of that posterior wall of the retroperitoneum. So any motion of that muscle will irritate inflammation that might be back there and cause an increase in pain. So the corollary to that is anytime that muscle is stretched or flexed, it would result in an increase in pain. So the two primary ways of doing the psoas test, which is doing exactly that, either stretching or flexing that psoas muscle, are to -- for the passive flexing of the muscle you can have the patient roll over into the left lateral decubitus position and gently pull their knee and thigh posteriorly, their right knee and thigh posteriorly, so that that psoas muscle is stretched.
And if that results in an increase of abdominal pain, that's very suggestive of a retroperitoneal inflammation, from any cause, not just appendicitis. But if the suspicion is appendicitis, then that would be very much corroborative of that diagnosis. The second way to do the psoas sign is to ask the patient to flex the psoas, and that would be to position them on their back, ask them to raise their right leg in a straight position off the bed, and in fact, apply some pressure on that knee, on that leg, such that the hip flexors, of which the psoas is one of the major contributors to the flexion of the hip, are flexed.
And so that, again, will cause an increase of irritation of any inflammation that's in that retroperitoneal space and would raise the likelihood of appendicitis in an appropriate individual. The obturator sign takes us from the retroperitoneum down into the pelvis, and we -- in women we can do a pelvic exam. In both genders we can do a rectal exam, and those are extremely important in anybody with abdominal pain, or lower abdominal pain or pelvic pain, but they only offer a very limited evaluation, examination of that pelvic peritoneal cavity.
And this is where the psoas sign comes in. Again, remembering our anatomy, the obturator muscle crosses across the obturator foramen in the pelvis and comes and inserts on the lesser trochanter. So if we flex the right hip and then internally rotate the hip, that is move -- grab the ankle, grab the knee, move the knee internal to the ankle such that the ankle comes out and the knee moves medially, that will internally rotate that hip.
That will pull that lesser trochanter laterally, and hence, it will tense the obturator muscle. And any increase in pain that the patient has been reporting in the right lower quadrant or vague abdominal, lower abdominal pain, or generally abdominal pain, would suggest that the etiology of that pain has something to do with inflammation down in the pelvis. And the reason this may suggest appendicitis, most of us think of the appendix up in the abdominal cavity, above the brim of the pelvis, but we also recognize that there's a wide variance in where exactly that appendix might actually lay.
It may be behind the cecum, it may be down in the pelvis, it may be higher, it may be over to the left side a little bit more. So there's a lot of variance of where that appendix rests. And if it is inflamed, it's going to cause pain and inflammation in the surrounding area. So if, in fact, a patient does have a pelvic appendix and appendicitis, then the obturator sign may be one of the few signs that will be positive and corroborate a diagnosis of appendicitis.
So for those reasons, those anatomic reasons, I think those are important tests and so easy to do, so quick to do, and yet such a high yield. >> What is the reference standard test for adult appendicitis? >> I personally believe that the reference standard still is surgically proven appendicitis, and by surgically proven appendicitis, I believe that means either open exploration or a laparoscopy. Either way would satisfy me in terms of making a diagnosis of appendicitis.
But there has been a lot of literature published over the last several years about the use of CT in evaluating and even confirming appendicitis, and I think it is a powerful tool, but I also believe that it's falling a little bit out of favor now. There's been a couple of studies now that have looked at what the use of CT has done in terms of the natural history of a patient that does have appendicitis.
And there was recent study that came out in the American College of Surgeons that showed that the use of CT actually increased what they call the bed-to-knife time; that is, how long did it take for somebody with appendicitis to get into the operating room and get that definitive treatment. And so while physicians had all of their traditional tools at their disposal, including MANTRELS and obturator sign and the psoas sign, if they felt compelled to get a CT, it really did extend the amount of time it took for the patient to get the definitive treatment, without really adding much to the suspicion or the clinical management of the patient.
So I think the reference standard, in my opinion, is still surgically proven appendicitis, as I've defined it. >> I'd like to thank you, Dr. Wagner, for this overview of adult appendicitis. And for additional information about this topic, JAMAevidence subscribers can consult the online section on this topic in the Rational Clinical Examination. This has been Joan Stephenson of JAMA talking with Dr. James Wagner for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. James Wagner about adult appendicitis, a condition that should be considered in patients who present with abdominal pain. Dr. Wagner, why don't you introduce yourself to our listeners. >> I sure will, Joan. My name is Jim Wagner. I work at the University of Texas Southwestern Medical School in Dallas, Texas. >> Dr. Wagner, what do we know about the prevalence of adult appendicitis, and are there important demographic characteristics?
>> The prevalence falls between 1 and 25%. A lot of the variance of that, those two numbers, is because of the quality of the studies available to answer that question, but also a large proportion of the variance is because it really depends a lot on these demographic characteristics that you asked about. Specifically, where the patient is being evaluated is a large variable; that is, patients that are being evaluated for abdominal pain in an emergency room have a higher prevalence, whereas those being evaluated in a clinic have a lower prevalence of appendicitis.
In addition, age plays a big role. The younger the patient, the more likely appendicitis will be the ultimate diagnosis, whereas older patients have a lower likelihood of appendicitis. And then there are other confounding factors in women that can make something that otherwise would appear to be a textbook case of appendicitis to be something else, in fact. >> Which symptoms increase the probability of adult appendicitis?
>> Well, I think the first thing that should be said is that appendicitis should be considered in any patient presenting with abdominal pain, no matter where and what venue the patient presents. That is to say even though the prevalence may be lower in ambulatory care settings and in older populations, its morbidity and mortality is so high that it must be considered just for utilitarian reasons. And then secondly I'd add that there is an acronym that has kind of risen to the top in the literature. It shows up over and over again every year as kind of the clinical decision rule against which all others must be measured, and this is the MANTRELS acronym that came from the Alvarado score.
And MANTRELS is an acronym, M standing for migration; A, anorexia; N, nausea; T, tenderness; R, right lower quadrant pain, or rebound tenderness; E is elevation of temperature; and L is leukocytosis; and S is a shift to the left of that leukocytosis. Just a couple explanations of what might not be otherwise obvious.
By the migration in M, we're talking about the classic migration of the periumbilical, vague pain of appendicitis that then migrates down to the right lower quadrant and becomes a very localized pain when the parietal peritoneum becomes inflamed. That's the classic natural history of appendicitis that we've all learned and that's manifest in that migration part of that MANTRELS acronym.
I think the rest of the components of that acronym are pretty self-explanatory. Now what's nice about this MANTRELS acronym is it's easy to remember and it's easy to score. All of the different components that I've listed are given a score of one, except for two, and that's right lower quadrant tenderness and leukocytosis. Those are assigned a score of two. And then adding up all the positive components of that acronym, if one receives a score of seven or greater, that is considered positive.
And what needs to be kept in mind is that the practical implication of a positive MANTRELS score has been shown in the literature to approximate a positive likelihood ratio of about 3.1. And for those that are not real used to using likelihood ratios, positive or negative, 3.1 is a respectable score, but not an overwhelmingly impressive score. Just to kind of give an example of how that might be used, if somebody did have a prevalence -- a prior probability, I should say, of appendicitis of 25%, say, for example, they were a young person presenting in an emergency room setting, then performance of the MANTRELS acronym on this patient, if it were positive, would result in a post-test probability of only 50 or 60%.
And so it doesn't necessarily clinch the diagnosis, but it certainly is helpful moving it from the 25% likelihood up to the greater than -- more likely than not likelihood. >> What are the key elements of the physical examination for appendicitis? In particular, it would be helpful for you to explain how clinicians can elicit the psoas sign, and the obturator sign. And these are nicely illustrated in the online section on adult appendicitis in the Rational Clinical Examination by Figure 5-1 and Figure 5-2.
>> Everybody remembers from anatomy that the psoas is the muscle that makes up a large proportion of that posterior wall of the retroperitoneum. So any motion of that muscle will irritate inflammation that might be back there and cause an increase in pain. So the corollary to that is anytime that muscle is stretched or flexed, it would result in an increase in pain. So the two primary ways of doing the psoas test, which is doing exactly that, either stretching or flexing that psoas muscle, are to -- for the passive flexing of the muscle you can have the patient roll over into the left lateral decubitus position and gently pull their knee and thigh posteriorly, their right knee and thigh posteriorly, so that that psoas muscle is stretched.
And if that results in an increase of abdominal pain, that's very suggestive of a retroperitoneal inflammation, from any cause, not just appendicitis. But if the suspicion is appendicitis, then that would be very much corroborative of that diagnosis. The second way to do the psoas sign is to ask the patient to flex the psoas, and that would be to position them on their back, ask them to raise their right leg in a straight position off the bed, and in fact, apply some pressure on that knee, on that leg, such that the hip flexors, of which the psoas is one of the major contributors to the flexion of the hip, are flexed.
And so that, again, will cause an increase of irritation of any inflammation that's in that retroperitoneal space and would raise the likelihood of appendicitis in an appropriate individual. The obturator sign takes us from the retroperitoneum down into the pelvis, and we -- in women we can do a pelvic exam. In both genders we can do a rectal exam, and those are extremely important in anybody with abdominal pain, or lower abdominal pain or pelvic pain, but they only offer a very limited evaluation, examination of that pelvic peritoneal cavity.
And this is where the psoas sign comes in. Again, remembering our anatomy, the obturator muscle crosses across the obturator foramen in the pelvis and comes and inserts on the lesser trochanter. So if we flex the right hip and then internally rotate the hip, that is move -- grab the ankle, grab the knee, move the knee internal to the ankle such that the ankle comes out and the knee moves medially, that will internally rotate that hip.
That will pull that lesser trochanter laterally, and hence, it will tense the obturator muscle. And any increase in pain that the patient has been reporting in the right lower quadrant or vague abdominal, lower abdominal pain, or generally abdominal pain, would suggest that the etiology of that pain has something to do with inflammation down in the pelvis. And the reason this may suggest appendicitis, most of us think of the appendix up in the abdominal cavity, above the brim of the pelvis, but we also recognize that there's a wide variance in where exactly that appendix might actually lay.
It may be behind the cecum, it may be down in the pelvis, it may be higher, it may be over to the left side a little bit more. So there's a lot of variance of where that appendix rests. And if it is inflamed, it's going to cause pain and inflammation in the surrounding area. So if, in fact, a patient does have a pelvic appendix and appendicitis, then the obturator sign may be one of the few signs that will be positive and corroborate a diagnosis of appendicitis.
So for those reasons, those anatomic reasons, I think those are important tests and so easy to do, so quick to do, and yet such a high yield. >> What is the reference standard test for adult appendicitis? >> I personally believe that the reference standard still is surgically proven appendicitis, and by surgically proven appendicitis, I believe that means either open exploration or a laparoscopy. Either way would satisfy me in terms of making a diagnosis of appendicitis.
But there has been a lot of literature published over the last several years about the use of CT in evaluating and even confirming appendicitis, and I think it is a powerful tool, but I also believe that it's falling a little bit out of favor now. There's been a couple of studies now that have looked at what the use of CT has done in terms of the natural history of a patient that does have appendicitis.
And there was recent study that came out in the American College of Surgeons that showed that the use of CT actually increased what they call the bed-to-knife time; that is, how long did it take for somebody with appendicitis to get into the operating room and get that definitive treatment. And so while physicians had all of their traditional tools at their disposal, including MANTRELS and obturator sign and the psoas sign, if they felt compelled to get a CT, it really did extend the amount of time it took for the patient to get the definitive treatment, without really adding much to the suspicion or the clinical management of the patient.
So I think the reference standard, in my opinion, is still surgically proven appendicitis, as I've defined it. >> I'd like to thank you, Dr. Wagner, for this overview of adult appendicitis. And for additional information about this topic, JAMAevidence subscribers can consult the online section on this topic in the Rational Clinical Examination. This has been Joan Stephenson of JAMA talking with Dr. James Wagner for JAMAevidence.
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