Differential Diagnoses - source: Harrisons

The presence of a malodorous vaginal discharge and gram negative intracellular

diplococci are pathognomonic for PID. Pain on movement of the cervix is also more specific for
PID but may occur in appendicitis if perforation has occurred or if the appendix lies adjacent to
the uterus or adnexa. Rupture of a graafian follicle (mittelschmerz) occurs at midcycle and will
produce pain and tenderness more diffuse and usually of a less severe degree than in
appendicitis. Rupture of a corpus luteum cyst is identical clinically to rupture of a graafian follicle
but develops about the time of menstruation. The presence of an adnexal mass, evidence of
blood loss, and a positive pregnancy test help differentiate ruptured tubal pregnancy. Twisted
ovarian cyst and endometriosis are occasionally difficult to distinguish from appendicitis. In all
these female conditions, ultrasonography and laparoscopy may be of great value.
Acute mesenteric lymphadenitis and acute gastroenteritis are the diagnoses usually given
when enlarged, slightly reddened lymph nodes at the root of the mesentery and a normal
appendix are encountered at operation in a patient who usually has right lower quadrant
tenderness. Retrospectively, these patients may have had a higher temperature, diarrhea, more
diffuse pain and abdominal tenderness, and a lymphocytosis. Between cramps, the abdomen is
completely relaxed. Children seem to be affected more frequently than adults. Some of these
patients have infection with Y. pseudotuberculosis or Y. enterocolitica, in which case the diagnosis
can be established by culture of the mesenteric nodes or by serologic titers (Chap. 159). In
Salmonella gastroenteritis, the abdominal findings are similar, although the pain may be more
severe and more localized, and fever and chills are common. The occurrence of similar
symptoms among other members of the family may be helpful. Regional enteritis (Crohn's
disease) is usually associated with a more prolonged history, often with previous exacerbations
regarded as episodes of gastroenteritis unless the diagnosis has been established previously.
Often an inflammatory mass is palpable. In addition, acute cholecystitis, perforated ulcer,
acute pancreatitis, acute diverticulitis, strangulating intestinal obstruction, ureteral
calculus, and pyelonephritis may present diagnostic difficulties.

Source: Medscape
The overall accuracy for diagnosing acute appendicitis is approximately 80%, which corresponds
to a mean negative appendectomy rate of 20%. Diagnostic accuracy varies by sex, with a range of 7892% in male patients and 58-85% in female patients.
The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant
(RLQ) pain, and vomiting occurs in only 50% of cases. Vomiting that precedes pain is suggestive of
intestinal obstruction, and the diagnosis of appendicitis should be reconsidered.
The differential diagnosis of appendicitis is often a clinical challenge because appendicitis can
mimic several abdominal conditions (see Differentials).[14] Patients with many other disorders present with
symptoms similar to those of appendicitis, such as the following:

Pelvic inflammatory disease (PID) or tubo-ovarian abscess

Endometriosis
Ovarian cyst or torsion
Diverticulitis
Crohn disease
Colonic carcinoma
Rectus sheath hematoma

Cholecystitis
Bacterial enteritis
Mesenteric adenitis and ischemia
Omental torsion
Biliary colic
Renal colic
Urinary tract infection (UTI)
Gastroenteritis
Enterocolitis
Pancreatitis
Perforated duodenal ulcer

Misdiagnosis in women of childbearing age

Appendicitis is misdiagnosed in 33% of nonpregnant women of childbearing age. The most frequent misdiagnoses
are PID, followed by gastroenteritis and urinary tract infection. In distinguishing appendiceal pain from that
of PID, anorexia and onset of pain more than 14 days after menses suggests appendicitis. Previous
PID, vaginal discharge, or urinary symptoms indicates PID. On physical examination, tenderness outside

the RLQ, cervical motion tenderness, vaginal discharge, and positive urinalysis support the
diagnosis of PID.
Although negative appendectomy does not appear to adversely affect maternal or fetal health, diagnostic delay with
perforation does increase fetal and maternal morbidity. Therefore, aggressive evaluation of the appendix is warranted
in pregnant women.
The level of urinary betahuman chorionic gonadotropin (beta-hCG) is useful in differentiating appendicitis from early
ectopic pregnancy. However, with regard to the WBC count, physiologic leukocytosis during pregnancy makes
this study less useful in the diagnosis than at other times, and no reliable distinguishing WBC parameters are cited in
the literature.

Misdiagnosis in children
Appendicitis is misdiagnosed in 25-30% of children, and the rate of initial misdiagnosis is inversely related to the age
of the patient. The most common misdiagnosis is gastroenteritis, followed by upper respiratory infection

and lower respiratory infection.

Children with misdiagnosed appendicitis are more likely than their counterparts to have vomiting before pain onset,
diarrhea, constipation, dysuria, signs and symptoms of upper respiratory infection, and lethargy or irritability. Physical
findings less likely to be documented in children with a misdiagnosis than in others include bowel sounds; peritoneal
signs; rectal findings; and ear, nose, and throat findings.

Considerations in elderly patients

Appendicitis in patients older than 60 years accounts for 10% of all appendectomies. The incidence of misdiagnosis
is increased in elderly patients.
Older patients tend to seek medical attention later in the course of illness; therefore, a duration of symptoms in
excess of 24-48 hours should not dissuade the clinician from the diagnosis. In patients with comorbid conditions,
diagnostic delay is correlated with increased morbidity and mortality.

Differential Diagnoses

Abdominal Abscess
Cholecystitis and Biliary Colic
Constipation
Crohn Disease

Diverticular Disease
Ectopic Pregnancy
Endometriosis
Gastroenteritis
Gastroenteritis, Bacterial
Inflammatory Bowel Disease
Meckel Diverticulum
Mesenteric Ischemia
Mesenteric Lymphadenitis
Omental Torsion
Ovarian Cysts
Ovarian Torsion
Pediatrics, Intussusception
Pelvic Inflammatory Disease
Renal Calculi
Spider Envenomations, Widow
Urinary Tract Infection, Female
Urinary Tract Infection, Male