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Appendicitis
Classification and external resources
ICD-10 K35. - K37.
ICD-9 540-543
DiseasesDB 885
MedlinePlus 000256
eMedicine med/3430  emerg/41 ped/127 ped/2925
MeSH C06.405.205.099

Appendicitis (or epityphlitis) is a condition characterized by inflammation of the appendix. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings K00-K93 - Diseases of the digestive system (K00-K14 Diseases of oral cavity salivary glands and jaws ( Disorders of Tooth development and Eruption K00-K93 - Diseases of the digestive system (K00-K14 Diseases of oral cavity salivary glands and jaws ( Disorders of Tooth development and Eruption The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens In Human anatomy, the appendix (or vermiform appendix; also cecal (or caecal appendix; also vermix) is a blind ended tube connected to the All cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. A laparotomy is a surgical procedure involving an incision through the Abdominal wall to gain access into the Abdominal cavity. Laparoscopic surgery, also called Minimally invasive surgery (MIS, bandaid surgery, Keyhole surgery, or pinhole surgery Untreated, mortality is high, mainly due to peritonitis and shock. Peritonitis is defined as Inflammation of the Peritoneum (the Serous membrane which lines part of the abdominal cavity and some of the Viscera [1] Reginald Fitz first described acute appendicitis in 1886,[2] and it has been recognized as one of the most common causes of acute abdomen pain worldwide.

An acutely inflamed and enlarged appendix, sliced lengthwise
An acutely inflamed and enlarged appendix, sliced lengthwise

Contents

Causes

Location of the appendix in the digestive system
Location of the appendix in the digestive system

On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen[3][4]. Digestion is the breaking down of chemicals in the body into a form that can be absorbed A lumen (Lat lūmen, an opening or light (pl lumina is the inside space or lining of a tubular structure such as an artery or intestine Once this obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. In vertebrates mucus is a slippery secretion produced by and covering Mucous membranes It is a viscous Colloid containing Antiseptic enzymes (such as Thrombosis is the formation of a blood Clot ( Thrombus) inside a Blood vessel, obstructing the flow of Blood through the Circulatory The lymphatic system in Vertebrates is a network of conduits that carry a clear fluid called Lymph. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. In Medicine, ischemia ( Greek ισχαιμία, isch- is restriction hema or haema is Blood) is a restriction Necrosis (in Greek Νεκρός = "dead" is the name given to unnatural Death of cells and living tissue. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The Bacteria ( singular: bacterium) are a large group of unicellular Microorganisms Typically a few Micrometres in length bacteria have Pus is a whitish-yellow yellow or yellow-brown substance produced during Inflammatory responses of the body that can be found in regions of Pyogenic bacterial The end result of this cascade is appendiceal rupture causing peritonitis, which may lead to septicemia and eventually death. Peritonitis is defined as Inflammation of the Peritoneum (the Serous membrane which lines part of the abdominal cavity and some of the Viscera Sepsis is a serious medical condition characterized by a whole-body inflammatory state (called a Systemic inflammatory response syndrome or SIRS caused Death is the termination of the biological functions that define living Organisms It refers both to a specific Among the causative agents, such as foreign bodies, trauma, intestinal worms, and lymphadenitis, the occurrence of an obstructing fecalith has attracted attention. Treatment of physical trauma is described here and in First aid. Intestinal parasites are Parasites that populate the Gastro-intestinal tract. Lymphadenopathy is a term meaning "disease of the Lymph nodes. A fecaloma, also called fecalith and coprolith, ie stones made of Feces, is a hardening of feces into stones of varying size inside the colon The prevalence of fecaliths in patients with appendicitis is significantly higher in developed than in developing countries[5], and an appendiceal fecalith is commonly associated with complicated appendicitis[6]. Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls[7]. The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time[8]. From epidemiological data it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt for appendicitis[9][10]. Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum[11]. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis[12][13][14]. This is in accordance with the occurrence of a right sided fecal reservoir and that dietary fiber reduces transit time[15].

Symptoms

Symptoms of acute appendicitis can be classified into two types, typical and atypical. [1] The typical history includes pain starting centrally (periumbilical) before localizing to the right iliac fossa (the lower right side of the abdomen); this is due to the poor localizing (spatial) property of visceral nerves from the mid-gut, followed by the involvement of somatic nerves (parietal peritoneum) as the inflammation progresses. Abdominal pain can be one of the Symptoms associated with transient disorders or serious disease Right iliac fossa (RIF is an anatomical term that refers to the right-inferior part of the surface of the human Abdomen. The pain is usually associated with loss of appetite and fever, although the latter isn't a necessary symptom. Fever (also known as pyrexia, from the Greek pyretos meaning fire or a febrile response, from the Latin word Febris Nausea or vomiting may occur also the feeling of drowsiness and the feeling of general bad health. Nausea ( Latin: Nausea, Greek:, " Sea-sickness " also called wamble) is the sensation of unease and discomfort Vomiting (also called throwing up, emesis) is the forceful expulsion of the contents of one's Stomach through the Mouth and sometimes the With the typical type, diagnosis is easier to make, surgery occurs earlier and findings are often less severe. [1]

Atypical symptoms may include pain beginning and staying in the right iliac fossa, diarrhea and a more prolonged, smoldering course. In Medicine, diarrhea, also spelled diarrhoea (see spelling differences) is frequent loose or liquid Bowel movements Acute diarrhea If an inflamed appendix lies in contact with the bladder, there is frequency of micturition. Urination, also known as micturition, voiding, and more rarely emiction, is the process of disposing Urine from the Urinary bladder With post-ileal appendix, marked retching may occur.

Signs

These include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Palpation used as part of a Physical examination in which an object is felt (usually with the hands of a Healthcare practitioner to determine its size shape firmness Also, there is rebound tenderness. Rebound tenderness is a clinical sign that a doctor may detect in physical examination of a patient's Abdomen. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. The cecum or caecum (from the Latin caecus meaning Blind) is a pouch connected to the Ascending colon of the Large Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. McBurney's point is the name given to the point over the right side of the human Abdomen that is one-third of the distance from the ASIS ( Anterior superior iliac spine If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention. Peritonitis is defined as Inflammation of the Peritoneum (the Serous membrane which lines part of the abdominal cavity and some of the Viscera Other signs are:

Rovsing's sign

Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. Also known as: Rovsing's symptom named after Niels Thorkild Rovsing. This sign is used in the diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the right lower quadrant of the abdomen. [16]

Psoas sign

Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with the right hip flexed for pain relief.

Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip. The obturator internus muscle originates on the medial surface of the Obturator membrane, the Ischium near the membrane and the rim of the pubis. This manouvre will cause pain in the hypogastrium. The hypogastrium (or hypogastric region, or pubic region) is an area of the Human abdomen residing below the Umbilicus.

Investigations

Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Atypical histories often require imaging with ultrasound and/or CT scanning. [1] A pregnancy test is vital in all women of child bearing age, as ectopic pregnancies mimic appendicitis. An ectopic pregnancy is a Complication of pregnancy in which the fertilized Ovum is implanted in any tissue other than the uterine wall The consequences of missing an ecoptic pregnancy are serious, and potentially life threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men), should be appreciated.

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children. In some cases (15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis. The iliac fossa is a large smooth concave surface on the internal surface of the ilium (part of the Hip bone) This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult. Despite these limitations, in experienced hands sonographic imaging 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 as the ovaries or fallopian tubes. Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens A Lymph node ( lɪmf noʊd is an organ consisting of many types of cells and is a part of the Lymphatic system.

In places where it is readily available, CT scan has become the diagnostic test of choice, especially in adults whose diagnosis is not obvious on history and physical. Computed tomography (CT is a Medical imaging method employing Tomography. (The use of CT in pregnant women and children is significantly limited, however, by concerns regarding radiation exposure. ) 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 oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in diameter on cross section), and appendiceal wall enhancement (IV dye). The inflammation caused 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 the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20% in the pre-CT era to only 3% according to data from the Massachusetts General Hospital.

According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of 94%, specificity of 95%, a positive likelihood ratio of 13. 3 (CI, 9. 9 to 17. 9), and a negative likelihood ratio of 0. 09 (CI, 0. 07 to 0. 12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81%, a positive likelihood ratio of 5. 8 (CI, 3. 5 to 9. 5), and a negative likelihood ratio of 0. 19 (CI, 0. 13 to 0. 27). PMID 15466771


Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of appendiceal rupture among patients with acute appendicitis according to a cohort study. Matrix metalloproteinases (MMPs are Zinc -dependent Endopeptidases other family members are Adamalysins Serralysins and Astacins Appendicitis (or epityphlitis) is a condition characterized by Inflammation of the appendix. A cohort study or panel study is a form of Longitudinal study used in Medicine and Social science. [17] MMP-1 was higher in gangrenous (p<0. 05) and perforated appendicitis (p<0. 01) compared with controls. MMP-9 was most abundantly expressed in inflamed appendix and reached a tenfold higher expression in all groups with appendicitis compared with controls (p<0. 001).


A number of clinical and laboratory based scoring systems have been devised to assist diagnosis. The most widely used is Alvarado score. The Alvarado score is a clinical scoring system used in the diagnosis of Appendicitis.

Alvarado score

Symptoms
Migatory right iliac fossa pain 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Signs
Right iliac fossa tenderness 2 points
Rebound tenderness 1 point
Fever 1 point
Laboratory
Leucocytosis 2 points
Shift to left (segmented neutrophils) 1 point
Total score 10 points

A score of 7 or more is strongly predictive of acute appendicitis. The iliac fossa is a large smooth concave surface on the internal surface of the ilium (part of the Hip bone) Nausea ( Latin: Nausea, Greek:, " Sea-sickness " also called wamble) is the sensation of unease and discomfort Vomiting (also called throwing up, emesis) is the forceful expulsion of the contents of one's Stomach through the Mouth and sometimes the In Medicine, tenderness is Pain or Discomfort when an affected area is touched Rebound tenderness is a clinical sign that a doctor may detect in physical examination of a patient's Abdomen. Fever (also known as pyrexia, from the Greek pyretos meaning fire or a febrile response, from the Latin word Febris Leukocytosis is a raised white blood cell count (the Leukocyte count above the normal range Neutrophil granulocytes, generally referred to as neutrophils, are the most abundant type of White blood cells in humans and form an essential part of the
In patients with an equivocal score of 5-6, CT scan further reduces the rate of negative appendicectomy.

Treatment

The treatment begins by keeping the patient from eating or drinking anything, even water, in preparation for surgery. Fasting is primarily the act of willingly abstaining from some or all Food, Drink, or both for a period of time An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. In modern usage an antibiotic is a Chemotherapeutic agent with activity against Microorganisms such as Bacteria, fungi or Protozoa Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.

The surgical procedure for the removal of the appendix is called an appendicectomy (also known as an appendectomy). Surgery (from the χειρουργική cheirourgikē, via chirurgiae meaning "hand work" is a medical specialty that uses operative manual and instrumental An appendicectomy (or appendectomy) is the surgical removal of the Vermiform appendix. Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to visualize the area of interest in the abdomen. Laparoscopic surgery, also called Minimally invasive surgery (MIS, bandaid surgery, Keyhole surgery, or pinhole surgery If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc. , conversion to open laparotomy may be necessary. An open laparotomy incision if required most often centers on the area of maximum tenderess, McBurney's point, in the right lower quadrant. McBurney's point is the name given to the point over the right side of the human Abdomen that is one-third of the distance from the ASIS ( Anterior superior iliac spine A transverse or a gridiron diagonal incision is used most commonly.

In March 2008, an American woman had her appendix removed via her vagina, in a medical first [1]

According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure. In Statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses The Cochrane Collaboration is a group of over 11500 volunteers in more than 90 countries who apply a rigorous systematic process to review the effects of interventions tested in biomedical Laparoscopic surgery, also called Minimally invasive surgery (MIS, bandaid surgery, Keyhole surgery, or pinhole surgery Laparoscopic surgery, also called Minimally invasive surgery (MIS, bandaid surgery, Keyhole surgery, or pinhole surgery Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio 0. Laparoscopic surgery, also called Minimally invasive surgery (MIS, bandaid surgery, Keyhole surgery, or pinhole surgery An appendicectomy (or appendectomy) is the surgical removal of the Vermiform appendix. The odds ratio is a measure of Effect size particularly important in Bayesian statistics and Logistic regression. 45; CI 0. 35 to 0. 58), but the incidence of intraabdominal abscesses was increased (odds ratio 2. The odds ratio is a measure of Effect size particularly important in Bayesian statistics and Logistic regression. 48; CI 1. 45 to 4. 21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1. 1 day (CI 0. 6 to 1. 5). Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of laparoscopic procedures were significantly higher, the costs outside hospital were reduced. Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups. [18]


There is debate whether Emergent Appendicectomy (within 6 hours of admission) reduces the risk of perforation or complication versus Urgent Appendicectomy (greater than 6 hours after admission). An appendicectomy (or appendectomy) is the surgical removal of the Vermiform appendix. An appendicectomy (or appendectomy) is the surgical removal of the Vermiform appendix. According to a retrospective case review study [19] no significant differences in perforation rate among the two groups were noted (P=. 397). Various complications (abscess formation, re-admission) showed no significant differences (P=0. 667, 0. 999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to the next day does not significantly increase the risk of perforation or other complications. An appendicectomy (or appendectomy) is the surgical removal of the Vermiform appendix.


Surgery may last from 15 minutes in typical appendicitis in thin patients to several hours in complicated cases. Hospital lengths of stay usually range from overnight to a matter of days (rarely weeks in complicated cases. ) The pain is not always constant, in some cases it can stop for a day and then come back.

Differential diagnosis

In children:

In adults:

In elderly:

Prognosis

Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Peritonitis is defined as Inflammation of the Peritoneum (the Serous membrane which lines part of the abdominal cavity and some of the Viscera

Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 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 may have to undergo a medical evacuation. Medical evacuation, often termed MEDEVAC or medivac, is the timely and efficient movement and en route care provided by medical personnel to the wounded being Appendectomies have occasionally been performed in emergency conditions (i. e. outside of a proper hospital), when a timely medical evaluation was impossible.

Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked about quite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump. 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 prior, incomplete appendectomy. [20]

References

  1. ^ a b c d Hobler, K. (Spring 1998). "Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement". Permanente Medical Journel 2 (2).  
  2. ^ Fitz, RH. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Am J Med Sci 1886; 92:321
  3. ^ Wangensteen OH, Bowers WF. Significance of the obstructive factor in the genesis of acute appendicitis. Arch Surg 1937;34:496-526
  4. ^ Pieper R, Kager L, Tidefelt U. Obstruction of appendix vermiformis causing acute appendicitis: An experimental study in rabbit. Acta Chir Scand 1982;148:63-72
  5. ^ Jones BA, Demetriades D, Segal I, Burkitt DP. The prevalence of appendiceal fecaliths in patients with and without appendicitis: A comparative study from Canada and South Africa. Ann Surg 1985;202:80-2
  6. ^ Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet 1990;171:185-8
  7. ^ Arnbjoernson E. Acute appendicitis related to fecal stasis. Ann Chir Gynecol 1985;74:90-3
  8. ^ Raahave D, Christensen E, Moeller H. Origin of acute appendicitis: Fecal retention in colonic reservoirs: A case control study. Surg Infect 2007;8:55-61
  9. ^ Burkitt DP. The aethiology of appendicitis. Br J Surg 1971;58:695-9
  10. ^ Segal I, Walker ARP. Diverticular disease in urban Africans in South Africa. Digestion 1982;24:42-6
  11. ^ Arnbjoernson E. Acute appendicitis as a sign of a colorectal carcinoma. J Surg Oncol 1982;20:17-20
  12. ^ Burkitt DP, Walker ARP, Painter NS. Effect of dietary fibre on stools and transit-times, and its role in the causation of disease. Lancet 1972;300:1408-12
  13. ^ Adamis D, Roma-Giannikou E, Karamolegou K. Fiber intake and childhood appendicitis. Int J Food Sci Nutr 2000;51:153-7
  14. ^ Hugh TB, Hugh TJ, "Appendicectomy — becoming a rare event?" MJA 2001; 175: 7-8
  15. ^ Gear JSS, Brodribb AJM, Ware A. Fiber and bowel transit times. Br J Nutr 1981;45:77-82
  16. ^ N. T. Rovsing: Indirektes Hervorrufen des typischen Schmerzes an McBurney's Punkt. Ein Beitrag zur diagnostik der Appendicitis und Typhlitis. Zentralblatt für Chirurgie, Leipzig, 1907, 34: 1257-1259.
  17. ^ Solberg A, Holmdahl L, Falk P, Palmgren I, Ivarsson ML (2008). "A local imbalance between MMP and TIMP may have an implication on the severity and course of appendicitis". Int J Colorectal Dis: 611. doi:10.1007/s00384-008-0452-x. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 18347803.  
  18. ^ Sauerland S, Lefering R, Neugebauer EA (2004). "Laparoscopic versus open surgery for suspected appendicitis". Cochrane Database Syst Rev (4): CD001546. doi:10.1002/14651858.CD001546.pub2. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15495014.  
  19. ^ Yardeni D, Hirschl RB, Drongowski RA, Teitelbaum DH, Geiger JD, Coran AG (2004). "Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night?". J. Pediatr. Surg. 39 (3): 464–9; discussion 464–9. doi:10.1016/j.jpedsurg.2003.11.020. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15017571.  
  20. ^ Liang MK, Lo HG, Marks JL (2006). "Stump appendicitis: a comprehensive review of literature". The American surgeon 72 (2): 162–6. PMID 16536249.  

External links

Dictionary

appendicitis

-noun

  1. (pathology) inflammation of the vermiform appendix
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