Tip appendicitis: clinical implications and management.
ABSTRACT Tip appendicitis describes a rare condition involving inflammatory changes of the distal appendix. We discuss the significance and management of this entity when it is identified on computed tomography (CT) imaging.
CT scans performed at our institution between 2003 and 2007 were reviewed to identify cases of tip appendicitis. Patients were divided into 2 groups, determined by the confirmation of appendicitis on histopathology. Radiological findings and the clinical courses of both groups were documented and compared using univariate analysis.
Of 18 patients with the CT finding of tip appendicitis, appendicitis was ultimately confirmed in 39%. Patients in this group had a higher rate of right lower quadrant (RLQ) tenderness (100% vs 55%, P = .04), leukocytosis (14.2 vs 10.5, P = .03), and clinical suspicion for acute appendicitis (43% vs 0%, P = .02). There were no complications or re-admissions.
The CT finding of tip appendicitis can be managed conservatively in a subset of patients with low clinical suspicion for acute appendicitis.
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ABSTRACT: BACKGROUND: Acute appendicitis is the most common surgical abdominal disease in the emergency room. Although the diagnosis is clinical the complementary tests may be useful in doubt. AIM: To evaluate the main laboratory tests in patients with acute appendicitis, as well as its relationship with the evolutionary stage of the disease. METHODS: Prospective evaluation of patients with acute appendicitis who underwent surgical treatment. RESULTS: A total of 179 patients participated in this study, most were male. The mean age was 26 years. For leukocyte count 46.9% had values <15.000mm3. The mean percentage of polymorphonuclear cells was 81,7%, 1,2% of sticks, 1% eosinophils, lymphocytes 12,8% and 2,9% monocytes. C-reactive protein was required for 54 patients. It was <10 mg/dl in 19, between 10 and 50 mg/dl in 24 and greater than or equal to 50 mg/dl in 11. Regarding the evolutionary phase 64% patients had early stage (stages 1 and 2), 16,2% stage 3 and 35 stage 4. A total of 57% of patients with white blood cell count greater than or equal to 20.000/mm3 had appendicular perforation (p<0,05). The percentage of polymorphonuclear leukocytes from patients with early stages was lower than the later stages (79,8% and 85,1%, respectively), with p<0,05. Patients with advanced stages of acute appendicitis, the number of lymphocytes was lower than the initial stages (9,3% and 14,8%, respectively), with p<0,05. 94% of patients with C-reactive protein values <10 mg/dl showed early stages of appendicular inflammation (p<0,05). CONCLUSION: A significant association among total and differential leukocyte count, C-reactive protein values and evolutionary phase of appendiceal inflammation was found in this prospective analysis.Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery. 06/2012; 25(2):88-90.
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ABSTRACT: Acute appendicitis is a common surgical emergency in the paediatric population. Computed tomography (CT) has been shown to have high accuracy and low operator dependence in the diagnosis of appendicitis. However, with increased concerns regarding CT usage in children, ultrasound (US) is the imaging modality of choice in patients where appendicitis is suspected. This review describes and illustrates the step-wise graded-compression technique for the visualisation of the appendix, the normal and pathological appearances of the appendix, as well as the imaging characteristics of the common differentials. • A step-wise technique improves the chances of visualisation of the appendix. • There are often several causes for the non-visualisation of the appendix in children. • A pathological appendix has characteristic US signs, with several secondary features also identified. • There are multiple common differentials to consider in the paediatric patient.Insights into imaging. 08/2013;
Tip appendicitis: clinical implications and management
Haggi Mazeh, M.D.a, Irene Epelboym, B.A.b, Jill Reinherz, M.D.c,
Alexander J. Greenstein, M.D., M.P.H.b, Celia M. Divino, M.D.b,*
aDepartment of General Surgery, Hadassash-Hebrew University Medical Center, Jerusalem, Israel;bDepartment of
General Surgery, Mount Sinai School of Medicine;cDepartment of Radiology, Mount Sinai School of Medicine, New
York, NY, USA
BACKGROUND: Tip appendicitis describes a rare condition involving inflammatory changes of the
distal appendix. We discuss the significance and management of this entity when it is identified on
computed tomography (CT) imaging.
METHODS: CT scans performed at our institution between 2003 and 2007 were reviewed to identify
cases of tip appendicitis. Patients were divided into 2 groups, determined by the confirmation of
appendicitis on histopathology. Radiological findings and the clinical courses of both groups were
documented and compared using univariate analysis.
RESULTS: Of 18 patients with the CT finding of tip appendicitis, appendicitis was ultimately
confirmed in 39%. Patients in this group had a higher rate of right lower quadrant (RLQ) tenderness
(100% vs 55%, P ? .04), leukocytosis (14.2 vs 10.5, P ? .03), and clinical suspicion for acute
appendicitis (43% vs 0%, P ? .02). There were no complications or re-admissions.
CONCLUSIONS: The CT finding of tip appendicitis can be managed conservatively in a subset of
patients with low clinical suspicion for acute appendicitis.
© 2009 Elsevier Inc. All rights reserved.
In 1886, Reginald Fitz coined the term “appendicitis,”
and proposed that early surgical intervention is essential in
treatment of the disease.1More than 100 years later, acute
appendicitis still remains one of the most common causes
for acute abdominal pain necessitating surgery.2
Generally, if the patient presents with the typical signs
and symptoms of right lower quadrant (RLQ) pain and
tenderness, nausea, vomiting, and anorexia, in the setting of
fever and leukocytosis, especially with a left shift, the de-
cision to operate cannot be contested. On the other hand,
with clinically equivocal cases of appendicitis, computed
tomography (CT) is currently recommended as the preferred
diagnostic tool in adults.3Classic CT findings of acute
appendicitis include a dilated appendix with associated im-
aging findings of periappendiceal/rlq inflammatory changes,
fat stranding, and the presence of an appendicolith.4
There are instances, however, when the inflammation is
focally confined to the distal portion of the appendix, an
entity known as tip appendicitis. In acute appendicitis, an
obstruction at the origin of the appendix has been well
described and documented as the precipitating factor for the
inflammatory cascade eventually resulting in the familiar
constellation of events that constitute the disease process.5,6
In fact, a radiologically normal proximal portion is consid-
ered to be an exclusion criterion.7,8In contrast, the patho-
physiology in tip appendicitis is much less clear. The true
prevalence of this condition is not known, but several case
The first two authors contributed equally to this work.
* Corresponding author. Tel.: ?1-212-241-5499; fax: ?1-212-410-
E-mail address: Celia.Divino@msnyuhealth.org
Manuscript received February 20, 2008; revised manuscript April 4,
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved.
The American Journal of Surgery (2009) 197, 211–215
reports cite the prevalence of clinically diagnosed and
pathologically confirmed tip appendicitis to be as high
Due to the rarity of this entity, only a handful cases have
been described in the surgical literature, and the clinical
significance of this diagnosis remains to be clarified. Does
every instance of tip appendicitis diagnosed by CT neces-
sarily require surgery for definitive treatment, or is watchful
waiting appropriate in some cases? Using our experience
with 18 cases of CT-diagnosed tip appendicitis, we attempt
to define for the clinician the recommendations for the
management of tip appendicitis.
After obtaining the approval of the Institutional Review
Board of the Mount Sinai School of Medicine, a review of
all radiology reports for CT scans of the abdomen/pelvis
from January 2003 through June 2007, including pediatric
patients, was performed using the keywords tip or distal in
association with appendicitis.
The CT reports and images were subsequently reviewed
by a staff radiologist. Specific data was collected from the
images regarding the characteristics of the proximal appen-
dix, distal appendix, surrounding tissue changes, RLQ
lymphadenopathy, and the presence or lack of an appendi-
colith. Patients were excluded from the study if the tip of the
appendix was not identified or if there was a radiological
diagnosis of perforated appendix. For the purposes of this
study, the standard criterion of 6 mm was considered to be
normal caliber for an appendix. The diagnosis of tip or distal
appendicitis was made in patients according to the criteria
presented in Table 1.
Once the radiological diagnosis of tip appendicitis was
confirmed, careful review of all electronic and paper records
was performed. Patients were then divided into 2 groups.
The first group included patients who were operated on and
whose extracted appendix demonstrated acute appendicitis
on final histopathology. This group was titled “positive
appendicitis.” All pathology reports were reviewed. The
second group included all the patients who were not oper-
ated on and all of those that were operated on and found not
to have an inflamed appendix. This group was titled “neg-
ative appendicitis.” For each group, the clinical course and
evolution of symptoms from admission to discharge were
noted, including type of intervention, use of antibiotics, and
complications. In addition, re-operations and re-admissions
after discharge were documented.
For those patients evaluated by a surgical consult, a
grading system was used to aid in the tabulation of the
results. If the surgeon felt that the diagnosis of appendicitis
was unlikely, a score of 0 was given; for possible appendi-
citis, the patient received the score of 1, and for probable
appendicitis, a score of 2 was given. An Alvarado score
(Table 2) was also calculated for every patient.
To identify differences between the acute tip appendicitis
and the non-acute groups, univariate analysis, using chi-
square or t test as appropriate, was used to compare the
groups by demographic, complication, and postoperative
course criteria. Statistical calculations were completed us-
ing statistical software SPSS version 11.5 (SPSS, Inc, Chi-
cago, IL) and a P value less than .05 was considered to
represent statistical significance for all comparisons.
A total of 26 patients were initially identified by the
database search. From the group, only 18 cases met the
inclusion criteria. Four cases were excluded by radiological
criteria, due to lack of visualization of the entire appendix,
and 4 more were excluded on the basis of having perforated
appendicitis. The average age of all patients was 38 years
(range 5–70 years), with a male to female ratio of 1 to 2.
After examining the operative reports and the final pa-
thology reports, 7 patients (39%) were identified to have
acute appendicitis by histopathology. The average appendix
diameter on final pathology was 9.1 mm. Five cases were
described as acute appendicitis and 2 cases showed early
appendicitis. Each of the 2 patients with early appendicitis
had an Alavarado’s score of 8, while surgery consult score
was 2 (definite appendicitis) for one of them and 1 (probable
Criteria for the diagnosis of tip appendicitis
description (at least one
Distal appendix description
(all criteria needed)
Normal caliber (6 mm or less)
Dilated (at least 7 mm)
Lack of luminal air or contrast
Free fluid in the right lower
description (at least one
Nausea and vomiting
212The American Journal of Surgery, Vol 197, No 2, February 2009
appendicitis) for the other. The CT findings for the 2 pa-
tients were similar and included a normal proximal appen-
dix that filled with contrast, distal dilatation of 7 mm, and
surrounding tissue inflammatory changes. The appendix di-
ameters on pathology were 10 mm and 9 mm. Clinical and
radiological comparison between the 2 cases of early ap-
pendicitis and the 5 cases of acute appendicitis failed to
reveal any significant differences.
Within the negative appendicitis group (11 patients,
61%), 5 (45%) patients were discharged from the emer-
gency department after a documented improvement in
symptoms. Five patients (45%) were admitted for observa-
tion with a median length of stay of 2.1 days. Of the 5
patients who were admitted, 3 were admitted to the medi-
cine service with an alternative diagnosis (2 with urinary
tract infection and 1 with lymphoma). Their abdominal
symptoms resolved and they did not require any surgical
intervention. Two patients were admitted to the surgery
service for observation. Both were initially treated with
intravenous fluids and kept nothing per os (NPO). One of
the patients also received intravenous antibiotics (ticarcillin/
clavulanate) for 24 hours, and was discharged after 72 hours
with documented improvement and after a regular diet was
tolerated. The second patient improved rapidly without an-
tibiotic treatment, oral diet was resumed after 12 hours, and
the patient was discharged home after 24 hours. This patient
had a repeat visit to the emergency department 12 days after
the initial admission and was again evaluated for abdominal
pain. The patient was found to have high-grade constipation
on obstructive series. No repeat CT was performed, and the
patient was discharged home with no further visits to the
emergency department. All of the other patients had no
repeat symptoms or emergency visits during a mean fol-
low-up of 15.7 months. Of the 11 patients with negative
appendicitis, only 1 patient (9%) received an operation. The
patient had a normal appendix removed while infarction of
the omentum in the RLQ was found to be the cause of his
A summary of the demographic data is presented in
Table 3. Age, male to female ratio, number of comorbidities,
and past surgical history were similar between the 2 groups,
with differences not reaching statistical significance.
The clinical data, including the patients’ admission his-
tory and physical data, as well as relevant laboratory values,
are presented in Table 4. Statistically significant differences
between the positive appendicitis and the negative appen-
(n ? 7)
(n ? 11)
Age, y (mean, range)
No. of comorbidities
No. of patients with
history (n, %)
1.14 (0–3)3.09 (0–9).11
4 (57%)9 (82%).08
Clinical dataPositive appendicitis (n ? 7)Negative appendicitis (n ? 11)
Hours of pain (mean, range)
Location–RLQ (n, %)
Nausea (n, %)
Vomiting (n, %)
Diarrhea (n, %)
Fever (n, %)
Chills (n, %)
Urinary symptoms (n, %)
Gynecological symptoms (n, %)
Maximum temperature (°C, mean, range)
Heart range (mean, range)
Tenderness–RLQ (n, %)
Peritoneal signs (no.)
WBC (mean, range)
Positive urinalysis (n, %)
Surgery consult (n, %)
Definite appendicitis per surgical consult (n, %)
Surgical consult score (mean, range)
Alvarado’s score (mean, range)
WBC ? white blood cell count.
213H. Mazeh et al.Management of tip appendicitis
dicitis groups included the presence of nausea (86% vs 18%,
P ?.01), tenderness to palpation in the RLQ (100% vs 55%,
P ? .04), and a significantly higher white blood cell count
(14.2 vs 10.5/?L, P ? .03).
The likelihood of appendicitis as presented by the surgi-
cal consult as well as by Alvarado’s score was also statis-
tically significant between the 2 groups (Table 4). A score of
2 (probable appendicitis) on the surgeon’s consult scale was
given to 43% of the patients in the positive appendicitis
group versus 0% in the negative appendicitis group (P ?
.02). Alvarado’s score was also higher in the positive ap-
pendicitis group (6.86 vs 3.09, P ?.01).
Radiological data are presented in Table 5. Findings
were similar between the 2 groups with regard to caliber of
the visualized appendix, presence of free fluid, lymphadenop-
athy, evidence of an appendicolith, and filling of the appendix
with contrast or air. In addition, no alternative diagnoses
were given to any of the patients in either of the groups. The
only statistically significant difference was the presence of
inflammatory change in the positive appendicitis group
(71% vs 9%, P ?.01).
For all patients, there were no readmissions and no com-
plications. Of the patients who were admitted, the average
length of stay was not statistically significant between the 2
groups (2.1 days vs 1.8 days, P ? .51).
Acute appendicitis is the most common surgical emer-
gency in the United States.2,8Every year, more than
250,000 cases of acute appendicitis are diagnosed. Up to 7%
of the total population will have appendicitis at some point
during their lifetime, with peak incidence of the condition
being between 10 and 30 years of age.10The definitive
treatment for acute appendicitis is surgical removal, and
given the risks of postponing therapy, many surgeons will
err on the side of operating, tolerating a 20% to 30% rate of
negative exploration.11,12However, even an operation as
frequently and commonly performed as an appendectomy is
not without its inherent complications, and so it is not
surprising that newer and more accurate means of diagnos-
ing acute appendicitis are continually sought, and various
guidelines are drafted that attempt to objectively stratify
patients into well-defined intervention versus observation
groups, in an effort to reduce the number of surgeries
performed unnecessarily.13In the era of liberal use of im-
aging (specifically CT scans), the rate of negative appen-
dectomies has dropped to 2.5% to 23%.14However, this
drop has in turn been accompanied by an inherent increase
in rare radiological findings.
It is important to recognize that although acute tip ap-
pendicitis is a rare entity; its appearance will undoubtedly
increase with the increasing and widespread use of CT
imaging. As it involves some of the same processes that
make inflammation of the entire appendix a treacherous
disease, tip appendicitis does have the potential to carry the
same degree of morbidity and disability, thus carrying im-
portant clinical implications.
Unfortunately, because tip appendicitis is such a rare
condition, defined guidelines for management do not yet
exist and current literature discussing this condition is lim-
ited to descriptive studies. Lim et al reported their experi-
ence with 20 patients with focal appendicitis confined to the
tip, identified over a 4-year period from a total of 443
confirmed appendicitis cases (prevalence of 4.5%).9Simi-
larly, Rao et al found 14 cases of tip appendicitis out of a
total 180 acute appendicitis on CT, in a 17-month period.15
Both of these studies, however, lack clinical and surgical
perspective, and are limited to radiology description.
In our case series, we report our experience with 18
patients with acute inflammation of the tip of the appendix,
of which only 7 (39%) were operated on and were found to
have acute appendicitis on final histopathology. One patient
was taken to the operating room but was found to have a
normal appendix and an infarcted omentum in the RLQ. The
remaining 10 patients, who were either observed in the
hospital or discharged from the emergency department, did
not require operative management and did not suffer any
recurrent symptoms, nor were did they need further surgical
management at follow-up.
Interestingly, in all instances, the radiological findings
were equivocal between the 2 groups and did not serve to
assure the final diagnosis. Therefore, the decision to operate
was made on the basis of clinical suspicion in light of the
overall constellation of signs and symptoms exhibited by
The question we attempt to address at the present time is
how to manage a patient who is found to have radiologic
evidence of distal appendicitis. In this retrospective analy-
sis, only 38% of the patients had histologically confirmed
appendicitis, even though all of them were found to have
radiological evidence of acute disease. This is in stark con-
trast to the specificity of a finding of acute appendicitis on
CT that has historically ranged from 80% to 98%.3,16–18
(n ? 7)
(n ? 11)
Appendix caliber (mean,
Free fluid (n, %)
changes (n, %)
Lymphadenopathy (n, %)
Appendicolith (n, %)
Contrast in proximal
appendix (n, %)
Air in proximal appendix
4 (57%)6 (55%).91
2 (29%)3 (27%).95
214The American Journal of Surgery, Vol 197, No 2, February 2009
This difference highlights the need to distinguish between
the 2 entities, but interestingly, in our study, no single
variable, sign, symptom, or laboratory value appeared to
be sufficient to determine if the patient who is found to have
radiological evidence of tip appendicitis needs immediate
surgery. Instead, similar to acute appendicitis, if the con-
sulting surgeon felt that the overall picture was consistent
with that of acute inflammation, the patient went to surgery.
On the other hand, when some of the findings were mild or
the patient did not seem to fit the criteria commonly used as
indicative of classic appendicitis, observation was recom-
mended and carried out successfully in all patients. Inter-
estingly, when Alvarado’s scoring system19was used to
objectively define the probability of acute appendicitis,
there was a statistically significant difference in the total
score between the 2 groups. This can potentially serve as a
criterion upon which the decision to operate can be defined
more confidently in future cases encountered in clinical
One limitation of this study is that the true status of the
appendix in the patients who were not operated on in the
negative appendicitis group is not available. It is possible
that some of these patients had resolving appendicitis. As
with any retrospective study, recall bias may be a potential
weakness, and because tip appendicitis is such a rare con-
dition, the numbers we examined may not be sufficient to
confidently lay out recommendations for future practice.
However, one of the strengths of this study is that it reaf-
firms the role of the clinical examination and the surgeon’s
judgment in making the decision to operate on suspected
appendicitis. In addition, it provides a foundation upon
which watchful waiting can be substantiated in certain
Tip appendicitis is a rare radiological finding that can
safely be managed conservatively in a subset of patients
with low clinical suspicion for acute appendicitis. Typical
symptoms, laboratory results, and the surgeon’s suspicion
should prompt surgery, whereas a discrepancy between his-
tory and physical examination and radiological findings
should be regarded as negative for appendicitis.
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