Acute Appendicitis in Adults - Clinical Manifestations and Differential Diagnosis

16/05/2016
Acuteappendicitisinadults:Clinicalmanifestationsanddifferentialdiagnosis
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Author
RonaldFMartin,MD
SectionEditor
MartinWeiser,MD
DeputyEditor
WenliangChen,MD,PhD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Apr2016.|Thistopiclastupdated:Feb05,2016.
INTRODUCTIONAppendicitis,aninflammationofthevestigialvermiformappendix,isoneofthemost
commoncausesoftheacuteabdomenandoneofthemostfrequentindicationsforanemergentabdominal
surgicalprocedureworldwide[1,2].
Theclinicalmanifestationsanddiagnosisofappendicitisinadultswillbereviewedhere.Themanagementof
appendicitisinadultsandappendicitisinpregnancyandchildrenarediscussedseparately.(See"Management
ofacuteappendicitisinadults"and"Acuteappendicitisinpregnancy"and"Acuteappendicitisinchildren:
Clinicalmanifestationsanddiagnosis".)
ANATOMYThevermiformappendixislocatedatthebaseofthececum,neartheileocecalvalvewherethe
taeniacoliconvergeonthececum(figure1)[3,4].Theappendixisatruediverticulumofthececum.Incontrast
toacquireddiverticulardisease,whichconsistsofaprotuberanceofasubsetoftheentericwalllayers,the
appendicealwallcontainsallofthelayersofthecolonicwall:mucosa,submucosa,muscularis(longitudinal
andcircular),andtheserosalcovering[5].
Theappendicealorificeopensintothececum.Itsbloodsupply,theappendicealartery,isaterminalbranchof
theileocolicartery,whichtraversesthelengthofthemesoappendixandterminatesatthetipoftheorgan
(figure2)[4].
Theattachmentoftheappendixtothebaseofthececumisconstant.However,thetipmaymigratetothe
retrocecal,subcecal,preileal,postileal,andpelvicpositions.Thesenormalanatomicvariationscancomplicate
thediagnosisasthesiteofpainandfindingsontheclinicalexaminationwillreflecttheanatomicpositionofthe
appendix.
ThepresenceofBandTlymphoidcellsinthemucosaandsubmucosaofthelaminapropriamakethe
appendixhistologicallydistinctfromthececum[5].Thesecellscreatealymphoidpulpthataidsimmunologic
functionbyincreasinglymphoidproductssuchasIgAandoperatingaspartofthegutassociatedlymphoid
tissuesystem[3].Lymphoidhyperplasiacancauseobstructionoftheappendixandleadtoappendicitis.The
lymphoidtissueundergoesatrophywithage[6].
EPIDEMIOLOGYAppendicitisoccursmostfrequentlyinthesecondandthirddecadesoflife.Theincidence
isapproximately233/100,000populationandishighestinthe10to19yearoldagegroup[7].Itisalsohigher
amongmen(maletofemaleratioof1.4:1),whohavealifetimeincidenceof8.6percentcomparedwith6.7
percentforwomen[7].
PATHOGENESISThenaturalhistoryofappendicitisissimilartothatofotherinflammatoryprocesses
involvinghollowvisceralorgans.Initialinflammationoftheappendicealwallisfollowedbylocalizedischemia,
perforation,andthedevelopmentofacontainedabscessorgeneralizedperitonitis.
Appendicealobstructionhasbeenproposedastheprimarycauseofappendicitis[3,811].Obstructionis
frequentlyimplicatedbutnotalwaysidentified.Astudyofpatientswithappendicitisshowedthattherewas
elevatedintraluminalpressureinonlyonethirdofthepatientswithnonperforatedappendicitis[12].
Appendicealobstructionmaybecausedbyfecaliths(hardfecalmasses),calculi,lymphoidhyperplasia,
infectiousprocesses,andbenignormalignanttumors.However,somepatientswithafecalithhavea
histologicallynormalappendixandthemajorityofpatientswithappendicitisdonothaveafecalith[13,14].
Whenobstructionoftheappendixisthecauseofappendicitis,theobstructionleadstoanincreaseinluminal
andintramuralpressure,resultinginthrombosisandocclusionofthesmallvesselsintheappendicealwall,and
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stasisoflymphaticflow.Astheappendixbecomesengorged,thevisceralafferentnervefibersenteringthe
spinalcordatT8T10arestimulated,leadingtovaguecentralorperiumbilicalabdominalpain[8].Welllocalized
painoccurslaterinthecoursewheninflammationinvolvestheadjacentparietalperitoneum.
Themechanismofluminalobstructionvariesdependinguponthepatient'sage.Intheyoung,lymphoid
follicularhyperplasiaduetoinfectionisthoughttobethemaincause.Inolderpatients,luminalobstructionis
morelikelytobecausedbyfibrosis,fecaliths,orneoplasia(carcinoid,adenocarcinoma,ormucocele).In
endemicareas,parasitescancauseobstructioninanyagegroup.(See"Canceroftheappendixand
pseudomyxomaperitonei".)
Onceobstructed,thelumenbecomesfilledwithmucusanddistends,increasingluminalandintramural
pressure.Thisresultsinthrombosisandocclusionofthesmallvessels,andstasisoflymphaticflow.As
lymphaticandvascularcompromiseprogress,thewalloftheappendixbecomesischemicandthennecrotic.
Bacterialovergrowthoccurswithinthediseasedappendix.Aerobicorganismspredominateearlyinthecourse,
whilemixedinfectionismorecommoninlateappendicitis[15].Commonorganismsinvolvedingangrenous
andperforatedappendicitisincludeEscherichiacoli,Peptostreptococcus,Bacteroidesfragilis,and
Pseudomonasspecies[16].Intraluminalbacteriasubsequentlyinvadetheappendicealwallandfurther
propagateaneutrophilicexudate.Theinfluxofneutrophilscausesafibropurulentreactionontheserosal
surface,irritatingthesurroundingparietalperitoneum[6].Thisresultsinstimulationofsomaticnerves,causing
painatthesiteofperitonealirritation[5].
Duringthefirst24hoursaftersymptomsdevelop,approximately90percentofpatientsdevelopinflammation
andperhapsnecrosisoftheappendix,butnotperforation.Thetypeofluminalobstructionmaybeapredictorof
perforationofanacutelyinflamedappendix.Fecalithsweresixtimesmorecommonthantruecalculiinthe
appendix,butcalculiweremoreoftenassociatedwithperforatedappendicitisorperiappendicealabscess(45
percent)thanwerefecaliths(19percent).Thisispresumablyduetotherigidityoftruecalculiascomparedwith
thesofter,morecrushablefecaliths[13].
Oncesignificantinflammationandnecrosisoccur,theappendixisatriskofperforation,whichleadsto
localizedabscessformationordiffuseperitonitis.Thetimecoursetoperforationisvariable.Onestudyshowed
that20percentofpatientsdevelopedperforationlessthan24hoursaftertheonsetofsymptoms[17].Sixty
fivepercentofpatientsinwhomtheappendixperforatedhadsymptomsforlongerthan48hours.
CLINICALFEATURES
Clinicalmanifestations
HistoryAbdominalpainisthemostcommonsymptom,andisreportedinnearlyallconfirmedcasesof
appendicitis[18,19].Theclinicalpresentationofacuteappendicitisisdescribedasaconstellationofthe
followingclassicsymptoms:
Rightlowerquadrant(rightanterioriliacfossa)abdominalpain
Anorexia
Nauseaandvomiting
Intheclassicpresentation,thepatientdescribestheonsetofabdominalpainasthefirstsymptom.Thepainis
typicallyperiumbilicalinnaturewithsubsequentmigrationtotherightlowerquadrantastheinflammation
progresses[18].Althoughconsideredaclassicsymptom,migratorypainoccursonlyin50to60percentof
patientswithappendicitis[8,20].Nauseaandvomiting,iftheyoccur,usuallyfollowtheonsetofpain.Fever
relatedsymptomsgenerallyoccurlaterinthecourseofillness.
Inmanypatients,initialfeaturesareatypicalornonspecific,andcaninclude:
Indigestion
Flatulence
Bowelirregularity
Diarrhea
Generalizedmalaise
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Becausetheearlysymptomsofappendicitisareoftensubtle,patientsandcliniciansmayminimizetheir
importance.Thesymptomsofappendicitisvarydependinguponthelocationofthetipoftheappendix(figure1)
(see'Anatomy'above).Forexample,aninflamedanteriorappendixproducesmarked,localizedpainintheright
lowerquadrant,whilearetrocecalappendixmaycauseadullabdominalache[21].Thelocationofthepain
mayalsobeatypicalinpatientswhohavethetipoftheappendixlocatedinthepelvis,whichcancause
tendernessbelowMcBurney'spoint.Suchpatientsmaycomplainofurinaryfrequencyanddysuriaorrectal
symptoms,suchastenesmusanddiarrhea.
PhysicalexaminationTheearlysignsofappendicitisareoftensubtle.Lowgradefeverreaching
101.0F(38.3C)maybepresent.Thephysicalexaminationmaybeunrevealingintheveryearlystagesof
appendicitissincethevisceralorgansarenotinnervatedwithsomaticpainfibers.
However,astheinflammationprogresses,involvementoftheoverlyingparietalperitoneumcauseslocalized
tendernessintherightlowerquadrantandcanbedetectedontheabdominalexamination.Rectalexamination,
althoughoftenadvocated,hasnotbeenshowntoprovideadditionaldiagnosticinformationincasesof
appendicitis[22].Inwomen,rightadnexalareatendernessmaybepresentonpelvicexamination,and
differentiatingbetweentendernessofpelvicoriginversusthatofappendicitismaybechallenging.Highgrade
fever(>101.0F/38.3C)occursasinflammationprogresses.(See"Causesofabdominalpaininadults".)
Patientswitharetrocecalappendixmaynotexhibitmarkedlocalizedtendernessintherightlowerquadrant
sincetheappendixdoesnotcomeintocontactwiththeanteriorparietalperitoneum(figure1)[21].Therectal
and/orpelvicexaminationismorelikelytoelicitpositivesignsthantheabdominalexamination.Tenderness
maybemoreprominentonpelvicexamination,andmaybemistakenforadnexaltenderness.
Severalfindingsonphysicalexaminationhavebeendescribedtofacilitatediagnosis,butthesefindingspre
dateddefinitiveimagingforappendicitis,andthewidevariationintheirsensitivityandspecificitysuggeststhat
theybeusedwithcautiontobroaden,ornarrow,adifferentialdiagnosis.Therearenophysicalfindings,taken
aloneorinconcert,thatdefinitivelyconfirmadiagnosisofappendicitis.
Commonlydescribedphysicalsignsinclude:
McBurney'spointtendernessisdescribedasmaximaltendernessat1.5to2inchesfromtheanterior
superioriliacspine(ASIS)onastraightlinefromtheASIStotheumbilicus[23](sensitivity50to94
percentspecificity75to86percent[2426]).
Rovsing'ssignreferstopainintherightlowerquadrantwithpalpationoftheleftlowerquadrant.Thissign
isalsocalledindirecttendernessandisindicativeofrightsidedlocalperitonealirritation[27](sensitivity
22to68percentspecificity58to96percent[25,2830]).
Thepsoassignisassociatedwitharetrocecalappendix.Thisismanifestedbyrightlowerquadrantpain
withpassiverighthipextension.Theinflamedappendixmaylieagainsttherightpsoasmuscle,causing
thepatienttoshortenthemusclebydrawinguptherightknee.Passiveextensionoftheiliopsoasmuscle
withhipextensioncausesrightlowerquadrantpain(sensitivity13to42percentspecificity79to97
percent[28,31,32]).
Theobturatorsignisassociatedwithapelvicappendix.Thistestisbasedontheprinciplethatthe
inflamedappendixmaylayagainsttherightobturatorinternusmuscle.Whentheclinicianflexesthe
patient'srighthipandkneefollowedbyinternalrotationoftherighthip,thiselicitsrightlowerquadrant
pain,(sensitivity8percentspecificity94percent[31]).Thesensitivityislowenoughthatexperienced
cliniciansnolongerperformthisassessment.
LaboratoryfindingsAmildleukocytosis(whitebloodcellcount>10,000cells/microL)ispresentinmost
patientswithacuteappendicitis[33].Approximately80percentofpatientshavealeukocytosisandaleftshift
(increaseintotalWBCcount,bands[immatureneutrophils],andneutrophils)inthedifferential[3436].The
sensitivityandspecificityofanelevatedwhitebloodcell(WBC)countinacuteappendicitisis80percentand
55percentrespectively.
AcuteappendicitisisunlikelywhentheWBCcountisnormal,exceptintheveryearlycourseoftheillness[36
38].Incomparison,meanWBCcountsarehigherinpatientswithagangrenous(necrotic)orperforated
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appendix[39]:
Acute14,5007,300cells/microL
Gangrenous17,1003,900cells/microL
Perforated17,9002,100cells/microL(see'Perforatedappendix'below)
Mildelevationsinserumbilirubin(totalbilirubin>1.0mg/dL)havebeennotedtobeamarkerforappendiceal
perforationwithasensitivityof70percentandaspecificityof86percent[40].Thiscomparesfavorablywitha
sensitivityandspecificityofanelevatedWBCof80percentand55percentrespectively.
Imagingstudies
ComputedtomographyfindingsThefollowingfindingssuggestacuteappendicitisonstandard
abdominalcomputedtomography(CT)scanningwithcontrastincluding(image1andimage2)[4143]:
Enlargedappendicealdiameter>6mmwithanoccludedlumen
Appendicealwallthickening(>2mm)
Periappendicealfatstranding
Appendicealwallenhancement
Appendicolith(seeninapproximately25percentofpatients)
UltrasoundfindingsThemostaccurateultrasoundfindingforacuteappendicitisisanappendiceal
diameterof>6mm(image3andimage4)[8,44,45].
PlainradiographfindingsPlainradiographsareusuallynothelpfulforestablishingthediagnosisof
appendicitis(image5).However,thefollowingradiographicfindingshavebeenassociatedwithacute
appendicitis:
Rightlowerquadrantappendicolith
Localizedrightlowerquadrantileus
Lossofthepsoasshadow
Freeair(occasionally)
Deformityofcecaloutline
Rightlowerquadrantsofttissuedensity
MagneticresonanceimagingMagneticresonanceimaging(MRI)canassistwiththeevaluationof
acuteabdominalandpelvicpainduringpregnancy(image6)[46,47].Anormalappendixisvisualizedasa
tubularstructurelessthanorequalto6mmindiameterandfilledwithairand/ororalcontrastmaterial[48].An
enlargedfluidfilledappendix(>7mmindiameter)isconsideredanabnormalfinding,whileanappendixwitha
diameterof6to7mmisconsideredaninconclusivefinding[48].(See"Approachtoabdominalpainandthe
acuteabdomeninpregnantandpostpartumwomen"and"Acuteappendicitisinpregnancy".)
DIFFERENTIALDIAGNOSISAvarietyofinflammatoryandinfectiousconditionsintherightlower
quadrantcanmimicthesignsandsymptomsofacuteappendicitis.(See"Causesofabdominalpaininadults".)
PerforatedappendixDuringthefirst24hoursaftertheonsetofabdominalpainandassociatedsymptoms,
approximately90percentofpatientsdevelopinflammationandperhapsnecrosisoftheappendix,butnot
perforation.Oncesignificantinflammationandnecrosisoccur,theappendixisatriskforperforation,which
leadstolocalizedabscessformationordiffuseperitonitis.Thetimecoursetoperforationisvariable.Onestudy
showedthat20percentofpatientsdevelopedperforationlessthan24hoursaftertheonsetofsymptoms[17].
Sixtyfivepercentofpatientsinwhomtheappendixperforatedhadsymptomsforlongerthan48hours.
Aperforatedappendixmustbeconsideredinapatientwhosetemperatureexceeds103.0F(39.4C),theWBC
countisgreaterthan15,000cells/microL,andimagingstudiesrevealafluidcollectionintherightlower
quadrant.(See'Pathogenesis'aboveand'Laboratoryfindings'aboveand"Acuteappendicitisinadults:
Diagnosticevaluation",sectionon'Imaging'and'Imagingstudies'above.)
CecaldiverticulitisCecaldiverticulitisusuallyoccursinyoungadultsandpresentswithsignsand
symptomsthatcanbevirtuallyidenticaltothoseofacuteappendicitis.Rightsideddiverticulitisoccursinonly
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1.5percentofpatientsinWesterncountries,butismorecommoninAsianpopulations(accountingforasmany
as75percentofcasesofdiverticulitis).Patientswithrightsideddiverticulitistendtobeyoungerthanthose
withleftsideddiseaseandoftenaremisdiagnosedwithacuteappendicitis.Computedtomographic(CT)
scanningoftheabdomenwithIVandoralcontrastisthediagnostictestofchoiceinpatientssuspectedof
havingacutediverticulitis.(See"Clinicalmanifestationsanddiagnosisofacutediverticulitisinadults"and
"Nonoperativemanagementofacuteuncomplicateddiverticulitis",sectionon'Rightsided(cecal)diverticulitis'.)
Meckel'sdiverticulitisMeckel'sdiverticulitispresentsinafashionsimilartoacuteappendicitis.AMeckel's
diverticulumisacongenitalremnantoftheomphalomesentericductandislocatedonthesmallintestinetwo
feetfromtheileocecalvalve[49,50].Meckel'sdiverticulitisshouldbeincludedinthedifferentialdiagnosis,as
thesmallbowelmaymigrateintotherightlowerquadrantandmimicthesymptomsofappendicitis.Ifan
inflamedappendixisnotfoundonabdominalexplorationforacuteappendicitis,thesurgeonshouldsearchfor
aninflamedMeckel'sdiverticulum.(See"Meckelsdiverticulum",sectionon'Clinicalpresentations'.)
AcuteileitisAcuteileitis,duemostcommonlytoanacuteselflimitedbacterialinfection(Yersinia,
Campylobacter,Salmonella,andothers),shouldbeconsideredwhenacutediarrheaisaprominentsymptom.
Otherclinicalmanifestationsofacuteyersiniosisincludeabdominalpain,fever,nauseaand/orvomiting.
Yersiniosiscannotbereadilydistinguishedclinicallyfromothercausesofacutediarrheathatpresentwith
thesesymptoms.However,localizationofabdominalpaintotherightlowerquadrantalongwithacutediarrhea
maybeadiagnosticclueforyersiniosis.(See"ClinicalmanifestationsanddiagnosisofYersiniainfections",
sectionon'Acuteyersiniosis'.)
Acuteyersiniosispresentingwithrightlowerabdominalpain,fever,vomiting,leukocytosis,andunderstated
diarrheamaybeconfusedwithacuteappendicitis.Atsurgery,findingsincludevisibleinflammationaroundthe
appendixandterminalileumandinflammationofthemesentericlymphnodestheappendixitselfisgenerally
normal.Yersiniacanbeculturedfromtheappendixandinvolvedlymphnodes.(See"Clinicalmanifestations
anddiagnosisofYersiniainfections",sectionon'Pseudoappendicitis'.)
Crohn'sdiseaseCrohn'sdiseasecanpresentwithsymptomssimilartoappendicitis,particularlywhen
localizedtothedistalileum.Fatigue,prolongeddiarrheawithabdominalpain,weightloss,andfever,withor
withoutgrossbleeding,arethehallmarksofCrohn'sdisease.AnacuteexacerbationofCrohnsdiseasecan
mimicacuteappendicitisandmaybeindistinguishablebyclinicalevaluationandimaging.
Crohn'sdiseaseshouldbesuspectedinpatientswhohavepersistentpainaftersurgery,especiallyifthe
appendixishistologicallynormal.(See"Clinicalmanifestations,diagnosisandprognosisofCrohndiseasein
adults".)
GynecologicandobstetricalconditionsThefollowinggynecologicdiseasesmaypresentwithsymptoms
and/orclinicalfindingsthatareincludedinthedifferentialofacuteappendicitis:
TuboovarianabscessAtuboovarianabscess(TOA)isaninflammatorymassinvolvingthefallopian
tube,ovary,and,occasionally,otheradjacentpelvicorgans(eg,bowel,bladder).Theseabscessesarefound
mostcommonlyinreproductiveagewomenandtypicallyresultfromuppergenitaltractinfection.Tuboovarian
abscessisusuallyacomplicationofpelvicinflammatorydisease.Theclassicpresentationincludesacute
lowerabdominalpain,fever,chills,andvaginaldischarge.However,feverisnotpresentinallpatients,some
patientsreportonlylowgradenocturnalfeversorchills,andnotallwomenpresentinanacutefashion.Clinical
historyandCTimagingcanhelpdifferentiateTOAfromacuteappendicitis(picture1).(See"Epidemiology,
clinicalmanifestations,anddiagnosisoftuboovarianabscess",sectionon'Clinicalpresentation'.)
PelvicinflammatorydiseaseLowerabdominalpainisthecardinalpresentingsymptominwomenwith
pelvicinflammatorydisease(PID),althoughthecharacterofthepainmaybequitesubtle.Therecentonsetof
painthatworsensduringcoitusorwithjarringmovementmaybetheonlypresentingsymptomofPIDthe
onsetofpainduringorshortlyaftermensesisparticularlysuggestive.Onphysicalexamination,onlyabout
onehalfofpatientswithPIDhavefever.Abdominalexaminationrevealsdiffusetendernessgreatestinthe
lowerquadrants,whichmayormaynotbesymmetrical.Reboundtendernessanddecreasedbowelsoundsare
common.Onpelvicexamination,thefindingofapurulentendocervicaldischargeand/oracutecervicalmotion
andadnexaltendernesswithbimanualexaminationisstronglysuggestiveofPID.ClinicalhistoryandCT
imagingcanhelpdifferentiatePIDfromacuteappendicitis(See"Pelvicinflammatorydisease:Clinical
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manifestationsanddiagnosis".)
RupturedovariancystRuptureofanovariancystisacommonoccurrenceinwomenofreproductive
ageandmaybeassociatedwiththesuddenonsetofunilaterallowerabdominalpain.Therightlowerquadrant
ismostcommonlyaffected,possiblybecausetherectosigmoidcolonprotectstheleftovaryfromtheeffectsof
abdominaltrauma.Thepainoftenbeginsduringstrenuousphysicalactivity,suchasexerciseorsexual
intercourse,andmaybeaccompaniedbylightvaginalbleedingduetoadropinsecretionofovarianhormones
andsubsequentendometrialsloughing.Bloodfromtherupturesitemayseepintotheovary,whichcancause
painfromstretchingoftheovariancortex,oritmayflowintotheabdomen,whichhasanirritanteffectonthe
peritoneum.Serousormucinousfluidreleaseduponcystruptureisnotveryirritatingthepatientmayremain
asymptomaticdespiteaccumulationofalargevolumeofintraperitonealfluid.Ontheotherhand,spillageof
sebaceousmaterialuponruptureofadermoidcystcausesamarkedgranulomatousreactionandchemical
peritonitis,whichisusuallyquitepainful.IntraabdominalhemorrhagemaybeassociatedwithCullen'ssign(ie,
periumbilicalecchymoses).ClinicalhistoryandCTimagingcanhelpdifferentiatearupturedovariancystfrom
acuteappendicitis(image7andimage8).(See"Evaluationandmanagementofrupturedovariancyst".)
MittelschmerzMittelschmerzreferstomidcyclepaininanovulatorywomancausedbynormalfollicular
enlargementjustpriortoovulationortonormalfollicularbleedingatovulation.Thepainistypicallymildand
unilateralitoccursmidwaybetweenmenstrualperiodsandlastsforafewhourstoacoupleofdays.Fluidor
bloodisreleasedfromtherupturedeggfollicleandcancauseirritationoftheliningoftheabdominalwall.(See
"Physiologyofthenormalmenstrualcycle".)
OvarianandfallopiantubetorsionOvariantorsionreferstothetwistingoftheovaryonits
ligamentoussupports,oftenresultinginimpedanceofitsbloodsupply(picture2).Isolatedfallopiantubetorsion
isuncommon(picture3).Expedientdiagnosisisimportanttopreserveovarianfunctionandpreventadverse
sequelae.However,thediagnosiscanbechallengingbecausethesymptomsarerelativelynonspecific.
Themostcommonsymptomofovariantorsionissuddenonsetlowerabdominalpain,oftenassociatedwith
wavesofnauseaandvomiting.Fever,althoughanuncommonfindinginovariantorsion,maybeamarkerof
necrosis,particularlyinthesettingofanincreasedwhitebloodcellcount.ClinicalhistoryandCTimagingcan
helpdifferentiatethediagnosisfromacuteappendicitis(picture4).(See"Ovarianandfallopiantubetorsion".)
EndometriosisEndometriosisisdefinedasthepresenceofendometrialglandsandstromaat
extrauterinesites.Theseectopicendometrialimplantsareusuallylocatedinthepelvis,butcanoccurnearly
anywhereinthebody(picture5).
Commonsymptomsofendometriosisincludepelvicpain(whichisusuallychronicandoftenmoresevere
duringmensesoratovulation),dysmenorrhea,deepdyspareunia,cyclicalbowelorbladdersymptoms,
abnormalmenstrualbleeding,andinfertility.Thereareoftennoabnormalfindingsonphysicalexamination
whenfindingsarepresent,themostcommonistendernessuponpalpationoftheposteriorfornix.Ultrasoundis
mostlyusefulfordiagnosingovarianendometriomasitlacksadequateresolutionforvisualizingadhesionsand
superficialperitoneal/ovarianimplants,whicharemorecommonthanendometriomas.(See"Endometriosis:
Pathogenesis,clinicalfeatures,anddiagnosis".)
OvarianhyperstimulationsyndromeOvarianhyperstimulationsyndrome(OHSS)isaniatrogenic
complicationofovulationinductiontherapy,andmaybeaccompaniedbyormistakenforcystrupture.Clinical
findingsincludebloating,nausea,vomiting,diarrhea,lethargy,shortnessofbreath,andrapidweightgain.
Severeovarianhyperstimulationsyndromeischaracterizedbylargeovariancysts,ascites,and,insome
patients,pleuraland/orpericardialeffusion,electrolyteimbalance(hyponatremia,hyperkalemia),hypovolemia,
andhypovolemicshock.Markedhemoconcentration,increasedbloodviscosity,andthromboembolic
phenomena,includingdisseminatedintravascularcoagulation,occurinthemostseverecases.(See
"Pathogenesis,clinicalmanifestations,anddiagnosisofovarianhyperstimulationsyndrome".)
EctopicpregnancyEctopicpregnancyhasclinicalsymptomsandsonographicfeaturessimilartothose
ofarupturedovariancyst.Inwomenwithacutepelvicpainorabnormalvaginalbleeding,apositivepregnancy
teststronglysuggeststhepresenceofanectopicpregnancyifanintrauterinepregnancycannotbevisualized
sonographically.Ifanintrauterinepregnancyisvisualized,thenpelvicpainandintraperitonealfluidcouldbedue
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toarupturedovariancyst(eg,corpusluteumcyst,thecaluteincyst)orheterotopicpregnancy.(See"Ectopic
pregnancy:Clinicalmanifestationsanddiagnosis",sectionon'Heterotopicpregnancy'.)
AcuteendometritisAcuteendometritisoccursafteranobstetricaldeliveryor,rarely,afteraninvasive
uterineprocedure.Thediagnosisislargelybaseduponthepresenceoffever,gradualonsetofuterine
tenderness,fouluterinedischarge,andleukocytosisinanatrisksetting.(See"Postpartumendometritis"and
"Endometritisunrelatedtopregnancy".)
Urologicconditions
RenalcolicPainisthemostcommonsymptomandvariesfromamildandbarelynoticeableacheto
discomfortthatissointensethatitrequiresparenteralanalgesics.Thepaintypicallywaxesandwanesin
severity,anddevelopsinwavesorparoxysmsthatarerelatedtomovementofthestoneintheureterand
associatedureteralspasm.Paroxysmsofseverepainusuallylast20to60minutes.Painisthoughttooccur
primarilyfromurinaryobstructionwithdistentionoftherenalcapsule.(See"Diagnosisandacutemanagement
ofsuspectednephrolithiasisinadults"and"Acutemanagementofnephrolithiasisinchildren".)
TesticulartorsionTesticulartorsionisaurologicemergencythatismorecommoninneonatesand
postpubertalboys,althoughitcanoccuratanyage.Testiculartorsionresultsfrominadequatefixationofthe
testistothetunicavaginalis.Iffixationofthelowerpoleofthetestistothetunicavaginalisisinsufficiently
broadbasedorabsent,thetestismaytorse(twist)onthespermaticcord,potentiallyproducingischemiafrom
reducedarterialinflowandvenousoutflowobstruction.(See"Causesofscrotalpaininchildrenand
adolescents",sectionon'Testiculartorsion'and"Evaluationoftheacutescrotuminadults",sectionon
'Testiculartorsion'.)
EpididymitisEpididymitisoccursmorefrequentlyamonglateadolescents,butalsooccursinyounger
boyswhodenysexualactivityandisthemostcommoncauseofscrotalpaininadultsintheoutpatientsetting.
Severalfactorsmaypredisposepostpubertalboystodevelopsubacuteepididymitis,includingsexualactivity,
heavyphysicalexertion,anddirecttrauma(eg,bicycleormotorcycleriding).Bacterialepididymitisin
prepubertalboysisassociatedwithstructuralanomaliesoftheurinarytract.Inacuteinfectiousepididymitis,
palpationrevealsindurationandswellingoftheinvolvedepididymiswithexquisitetenderness.Moreadvanced
casesoftenpresentwithtesticularswellingandpain(epididymoorchitis)withscrotalwallerythemaanda
reactivehydrocele.(See"Causesofscrotalpaininchildrenandadolescents",sectionon'Epididymitis'and
"Evaluationoftheacutescrotuminadults",sectionon'Epididymitis'.)
TorsionoftheappendixtestisorappendixepididymisTheappendixtestisisasmallvestigial
structureontheanterosuperioraspectofthetestis(anembryologicremnantoftheMllerianductsystem).The
appendixepididymisisavestigialremnantoftheWolffianductthatislocatedattheheadoftheepididymis.
Thepedunculatedshapeoftheseappendagespredisposesthemtotorsion,whichcanproducescrotalpainthat
rangesfrommildtosevere.Mostcasesoftorsionoftheappendixtestisoccurbetweentheagesof7and14
years,andrarelyoccurinadults.(See"Causesofscrotalpaininchildrenandadolescents",sectionon'Torsion
oftheappendixtestisorappendixepididymis'and"Evaluationoftheacutescrotuminadults",sectionon
'Torsionoftheappendixtestis'.)
TREATMENTThemanagementofacuteappendicitisinchildrenandadultsisdiscussedindetail
separately.(See"Acuteappendicitisinchildren:Management"and"Managementofacuteappendicitisin
adults".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasics
andBeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
16/05/2016
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Appendicitisinadults(TheBasics)").
SUMMARYANDRECOMMENDATIONSAppendicitisisoneofthemostcommoncausesoftheacute
abdomenandoneofthemostfrequentindicationsforanemergentabdominalsurgicalprocedureworldwide.
Thetipoftheappendixcanbefoundinaretrocecalorpelviclocation,aswellasmedial,lateral,anterior,
orposteriortothececum.Anatomicvariabilitycancomplicatethediagnosis,asclinicalpresentationwill
reflecttheanatomicpositionoftheappendix.(See'Anatomy'above.)
Appendicealobstructionplaysaroleinthepathogenesisofappendicitis,butitisnotrequiredforthe
developmentofappendicitis.(See'Pathogenesis'above.)
Theclassicsymptomsofappendicitisincluderightlowerquadrantabdominalpain,anorexia,fever,
nausea,andvomiting.Theabdominalpainisinitiallyperiumbilicalinnaturewithsubsequentmigrationto
therightlowerquadrantastheinflammationprogresses(see'Clinicalmanifestations'above).Patients
withappendicitiscanalsopresentwithatypicalornonspecificsymptoms,suchasindigestion,flatulence,
bowelirregularity,andgeneralizedmalaiseandnotallpatientswillhavemigratoryabdominalpain.
Thedifferentialdiagnosisofrightlowerquadrantabdominalpainincludesinflammatorydiseaseprocesses
(eg,Crohnsdisease,rupturedcyst),infectiousdiseases(eg,acuteileitis,tuboovarianabscess),and
obstetricalconditions(eg,ectopicpregnancy).(See'Differentialdiagnosis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.WilliamsGR.PresidentialAddress:ahistoryofappendicitis.Withanecdotesillustratingitsimportance.
AnnSurg1983197:495.
2.Fitz,RH.Perforatinginflammationofthevermiformappendixwithspecialreferencetoitsearlydiagnosis
andtreatment.AmJMedSci188692:321.
3.Jaffe,BM,Berger,DH.TheAppendix.In:SchwartzPrinciplesofSurgery,8thed,Schwartz,SI,
Brunicardi,CF(Ed),McGrawHillHealthPub.Division,NewYork2005.
4.BuschardK,KjaeldgaardA.Investigationandanalysisoftheposition,fixation,lengthandembryologyof
thevermiformappendix.ActaChirScand1973139:293.
5.Mulholland,MW,Lillemoe,KD,Doherty,GM,etal.Greenfield'sSurgery,4thed,LippincottWilliams&
Wilkins,Philadelphia,PA2005.
6.Kumar,V,Abbas,AK,Fausto,N.RobbinsandCotran:PathologicBasisofDisease,7thed,Saunders
Elsevier,Philadelphia,PA2007.
7.AddissDG,ShafferN,FowlerBS,TauxeRV.Theepidemiologyofappendicitisandappendectomyinthe
UnitedStates.AmJEpidemiol1990132:910.
8.BirnbaumBA,WilsonSR.Appendicitisatthemillennium.Radiology2000215:337.
9.BurkittDP.Theaetiologyofappendicitis.BrJSurg197158:695.
10.ButlerC.Surgicalpathologyofacuteappendicitis.HumPathol198112:870.
11.MirandaR,JohnstonAD,O'LearyJP.Incidentalappendectomy:frequencyofpathologicabnormalities.
AmSurg198046:355.
12.ArnbjrnssonE,BengmarkS.Obstructionoftheappendixlumeninrelationtopathogenesisofacute
appendicitis.ActaChirScand1983149:789.
13.NiteckiS,KarmeliR,SarrMG.Appendicealcalculiandfecalithsasindicationsforappendectomy.Surg
GynecolObstet1990171:185.
14.JonesBA,DemetriadesD,SegalI,BurkittDP.Theprevalenceofappendicealfecalithsinpatientswith
andwithoutappendicitis.AcomparativestudyfromCanadaandSouthAfrica.AnnSurg1985202:80.
15.LauWY,TeohChanCH,FanST,etal.Thebacteriologyandsepticcomplicationofpatientswith
appendicitis.AnnSurg1984200:576.
16.BennionRS,BaronEJ,ThompsonJEJr,etal.Thebacteriologyofgangrenousandperforated
16/05/2016
appendicitisrevisited.AnnSurg1990211:165.
17.TempleCL,HuchcroftSA,TempleWJ.Thenaturalhistoryofappendicitisinadults.Aprospectivestudy.
AnnSurg1995221:278.
18.LeeSL,WalshAJ,HoHS.Computedtomographyandultrasonographydonotimproveandmaydelay
thediagnosisandtreatmentofacuteappendicitis.ArchSurg2001136:556.
19.RaoPM,RheaJT,NovellineRA,etal.HelicalCTtechniqueforthediagnosisofappendicitis:
prospectiveevaluationofafocusedappendixCTexamination.Radiology1997202:139.
20.ChungCH,NgCP,LaiKK.Delaysbypatients,emergencyphysicians,andsurgeonsinthe
managementofacuteappendicitis:retrospectivestudy.HongKongMedJ20006:254.
21.GuidrySP,PooleGV.Theanatomyofappendicitis.AmSurg199460:68.
22.TakadaT,NishiwakiH,YamamotoY,etal.TheRoleofDigitalRectalExaminationforDiagnosisof
AcuteAppendicitis:ASystematicReviewandMetaAnalysis.PLoSOne201510:e0136996.
23.McBurney,C.Experiencewithearlyoperativeinterferenceincasesofdiseaseofthevermiform
appendix.NYMedJ188950:676.
24.GolledgeJ,TomsAP,FranklinIJ,etal.Assessmentofperitonisminappendicitis.AnnRCollSurgEngl
199678:11.
25.AnderssonRE,HuganderAP,GhaziSH,etal.Diagnosticvalueofdiseasehistory,clinicalpresentation,
andinflammatoryparametersofappendicitis.WorldJSurg199923:133.
26.LaneR,GrabhamJ.Ausefulsignforthediagnosisofperitonealirritationintherightiliacfossa.AnnR
CollSurgEngl199779:128.
27.Rovsing,NT.IndirektesHervorrufendestypischenSchmerzesanMcBurney'sPunkt.EinBeitragzur
diagnostikderAppendicitisundTyphlitis.ZentralblattfrChirurgie,Leipzig,190734:1257.
28.IzbickiJR,KnoefelWT,WilkerDK,etal.Accuratediagnosisofacuteappendicitis:aretrospectiveand
prospectiveanalysisof686patients.EurJSurg1992158:227.
29.AlshehriMY,IbrahimA,AbuaishaN,etal.Valueofreboundtendernessinacuteappendicitis.EastAfr
MedJ199572:504.
30.JahnH,MathiesenFK,NeckelmannK,etal.Comparisonofclinicaljudgmentanddiagnostic
ultrasonographyinthediagnosisofacuteappendicitis:experiencewithascoreaideddiagnosis.EurJ
Surg1997163:433.
31.BerryJJr,MaltRA.Appendicitisnearitscentenary.AnnSurg1984200:567.
32.JohnH,NeffU,KelemenM.Appendicitisdiagnosistoday:clinicalandultrasonicdeductions.WorldJ
Surg199317:243.
33.Silen,W.Cope'sEarlyDiagnosisoftheAcuteAbdomen,19thedition,OxfordUniversityPress1996.
p.70.
34.ColemanC,ThompsonJEJr,BennionRS,SchmitPJ.Whitebloodcellcountisapoorpredictorof
severityofdiseaseinthediagnosisofappendicitis.AmSurg199864:983.
35.TehraniHY,PetrosJG,KumarRR,ChuQ.Markersofsevereappendicitis.AmSurg199965:453.
36.ThompsonMM,UnderwoodMJ,DookeranKA,etal.RoleofsequentialleucocytecountsandCreactive
proteinmeasurementsinacuteappendicitis.BrJSurg199279:822.
37.GrnroosJM,GrnroosP.LeucocytecountandCreactiveproteininthediagnosisofacuteappendicitis.
BrJSurg199986:501.
38.BrJSurg199986:501.
39.GurayaSY,AlTuwaijriTA,KhairyGA,MurshidKR.Validityofleukocytecounttopredicttheseverityof
acuteappendicitis.SaudiMedJ200526:1945.
40.SandM,BecharaFG,HollandLetzT,etal.Diagnosticvalueofhyperbilirubinemiaasapredictivefactor
forappendicealperforationinacuteappendicitis.AmJSurg2009198:193.
41.RaoPM,RheaJT,NovellineRA.SensitivityandspecificityoftheindividualCTsignsofappendicitis:
experiencewith200helicalappendicealCTexaminations.JComputAssistTomogr199721:686.
42.WhitleyS,SookurP,McLeanA,PowerN.TheappendixonCT.ClinRadiol200964:190.
43.ChoiD,ParkH,LeeYR,etal.Themostusefulfindingsfordiagnosingacuteappendicitisoncontrast
enhancedhelicalCT.ActaRadiol200344:574.
44.KesslerN,CytevalC,GallixB,etal.Appendicitis:evaluationofsensitivity,specificity,andpredictive
valuesofUS,DopplerUS,andlaboratoryfindings.Radiology2004230:472.
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45.JeffreyRBJr,LaingFC,TownsendRR.Acuteappendicitis:sonographiccriteriabasedon250cases.
Radiology1988167:327.
46.SpallutoLB,WoodfieldCA,DeBenedectisCM,LazarusE.MRimagingevaluationofabdominalpain
duringpregnancy:appendicitisandothernonobstetriccauses.Radiographics201232:317.
47.OtoA,ErnstRD,GhulmiyyahLM,etal.MRimaginginthetriageofpregnantpatientswithacute
abdominalandpelvicpain.AbdomImaging200934:243.
48.PedrosaI,LevineD,EyvazzadehAD,etal.MRimagingevaluationofacuteappendicitisinpregnancy.
Radiology2006238:891.
49.LeeTH,KimJO,KimJJ,etal.AcaseofintussusceptedMeckel'sdiverticulum.WorldJGastroenterol
200915:5109.
50.BanliO,KarakoyunR,AltunH.IleoilealintussusceptionduetoinvertedMeckel'sdiverticulum.Acta
ChirBelg2009109:516.
Topic1386Version24.0
http://www.uptodate.com/contents/acuteappendicitisinadultsclinicalmanifestationsanddifferentialdiagnosis?topicKey=SURG%2F1386&elapsedTim 10/26
16/05/2016
GRAPHICS
Variationsinthepositionoftheappendix
Graphic64911Version2.0
16/05/2016
Bloodsupplytothecolonandrectum
ThebloodsupplytothecolonoriginatesfromtheSMAandtheIMA.TheSMA
arisesapproximately1cmbelowtheceliacarteryandrunsinferiorlytowardthe
cecum,terminatingastheileocolicartery.TheSMAgivesrisetotheinferior
pancreaticoduodenalartery,severaljejunalandilealbranches,themiddlecolic
artery,andtherightcolicartery.Asageneralrule,themiddlecolicarteryarises
fromtheproximalSMAandsuppliestheproximaltomidtransversecolon.
However,itoccasionallyprovidesthepredominantbloodflowtothesplenic
flexure.Therightcolicarteryariseseitherfromacommontrunkwith,orjust
below,themiddlecolicartery,andsuppliesbloodtothemiddistalascending
colon.Theileocolicarterysuppliesthedistalileum,cecum,andproximal
ascendingcolon.
TheIMAarisesapproximately6to7cmbelowtheSMA.TheIMAgivesrisetothe
leftcolicarteryandsigmoidarteriescontinuingasthesuperiorrectal
(hemorrhoidal)artery.Itislargelyresponsibleforbloodsupplyfromthedistal
transversecolontotherectum.
SMA:superiormesentericarteryIMA:inferiormesentericartery.
16/05/2016
CTscannormalappendix
CTscandepictsanormalappendix.Thefigureontheleftshowsanappendiceallumen
containingairandwallthicknessof3mm(arrow).Thefigureontherightshowsthetipof
thenormalappendix(arrowhead)thatmeasures6mmandnoassociatedinduration.
CT:computedtomography.
16/05/2016
CTscanacuteappendicitis
TheCTscanwasobtainedusingoralandintravenouscontrastfromapatientwhopresented
withrightlowerquadrantabdominalpain.Thesefiguresshowaninflammedappendixthat
measures21mmindiameterandcontainsanappendicolithandfluidthatislikelypurulent.
(A)Showsanappendicolithintheappendixusinganarrow.
(B)Showstheappendicolith,anoverlayoforangetoshowfluidinsidetheappendix,anda
yellowarrowindicatesfreefluid.
(C)Showstheenlargedappendixandfluidwithoutanoverlay.
(D)Showsacoloredoverlay:redcircledepictstheenhancingappendicealwallorange
depictstheintraappendicealfluidyellowdepictsthefreefluid.
CT:computedtomography.
16/05/2016
Normalappendixbyultrasoundimaging
Thegrayscaleultrasound(A,andmagnifiedinB)andDopplerimage(C)oftheappendixare
projectedinthetransverseplane.ImagesAandBshowanormalappendixmeasuringalmost
6mminmaximumtransversedimension(arrow).Theappendixwascompressibleandno
hyperemiawasdemonstrated(arrow)ontheDopplerimage(C).Thesefindingsareconsistent
withanormalappendixbyultrasound.
16/05/2016
Acuteappendicitisultrasound
Thepatientisa19yearoldfemalewhopresentedtotheemergencydepartmentwithright
lowerquadrantpain.Thegrayscaleultrasoundoftheappendixisprojectedinthe
longitudinal(A)andtransverseplanes(B).Anoncompressibleappendixmeasuresalmost20
mmindiameter,consistentwithadiagnosisofacuteappendicitis.Theechogenicmucosal
andsubmucosalportionsofthewallhavebecomediscontinuous(arrows)suggesting
disruptionasaresultofsloughing.Luminalair(arrowheads)resultsinposteriorshadowing.
16/05/2016
Appendicolithonabdominalfilms
Thisplainfilmoftheabdomenrevealsa1.2cmcalcificdensity,an
appendicolith.Thepatientpresentedwithrightlowerquadrantpainand
wasdiagnosedwithacuteappendicitis.
16/05/2016
Magneticresonanceimageofappendicitisin
pregnancy
T2weightedmagneticresonanceimageofawomanwithappendicitis
at9weeksofgestation.Theappendixwasfluidfilledandmeasured7
mm(arrow).Thegestationalsac(gs)isseenlowerinthepelvis.
CourtesyofDeborahLevine,MD.
16/05/2016
Tuboovarianabscess
Grossintraoperativephotographofalefttuboovarianabscessina
patientwithpelvicinflammatorydisease.
CourtesyofMitchelHoffman,MD.
16/05/2016
Rupturedovariancyst
Computedtomography.Arrowsindicatefreebloodwithinperitoneal
cavitysurroundingliverandspleen.
CourtesyofWilliamJMann,Jr,MD.
16/05/2016
Adnexalmass
Image
Computedtomography.Arrowindicatespoorlydefinedadnexalmass,whichat
explorationwasrupturedcorpusluteumcystandclot.
CourtesyofWilliamJMann,Jr,MD.
16/05/2016
Ovarianandtubaltorsiondemonstratingmarked
vascularengorgementaswellasincreasedsize
anddistension
Anatomywasrestoredandbothstructuresweresalvageddespitenon
viableappearance.
Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6th
ed,EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,
Philadelphia2012.Copyright2012LippincottWilliams&Wilkins.
www.lww.com.
16/05/2016
Tubaltorsiondemonstratingseveredistensionofthe
distaltube
Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6thed,
EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,
www.lww.com.
16/05/2016
Enlargedleftovaryfoundtorseduponlaparotomy
demonstratingadark,duskyappearance
secondarytovenouslymphaticcongestioninthe
settingofcontinuedarterialperfusion
Reproducedwithpermissionfrom:PediatricandAdolescentGynecology,6th
ed,EmansSJ,LauferMR,GoldsteinDP(Eds),LippincottWilliams&Wilkins,
www.lww.com.
16/05/2016
Peritonealendometriosis
Theperitoneuminthiswomanwithendometriosisisstuddedwith
reddish,irregularlyshapedimplants.
Reprintedwithpermission.Copyright1990SyntexLaboratories,Inc.Allrights
reserved.
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ContributorDisclosures
RonaldFMartin,MDNothingtodisclose.MartinWeiser,MDNothingtodisclose.WenliangChen,MD,
PhDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconformto
UpToDatestandardsofevidence.
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