Differential Diagnosis

The following conditions may at times be confounded with appendicitis, namely, biliary, renal, and intestinal colic. The following points will serve as a guide in making a correct diagnosis. In biliary colic the pains are referred by the patient to the right abdominal cavity, radiating to the back and up to the shoulders. Palpation shows a painful area situated immediately below the right margin of the ribs; occasionally jaundice is present. In kidney colic (right side) the pain is felt by the patient in the right lumbar region, radiating toward the bladder. There is generally a frequent desire for micturition and slight burning in the urethra. The urine may show the presence of mucus, sometimes of blood and pus cells. In intestinal colic the pain may be referred to the right iliac region, but, as a rule, it is relieved very soon after the passage of flatus. In contradistinction to these three conditions the pain in appendicitis is referred to the right iliac region, where it remains localized, does not disappear upon passage of flatus, does not radiate to the shoulder and but very rarely to the bladder, while there is also great tenderness and pain upon pressure at McBurney's point.

No jaundice is present and the urine is normal.

In women the differential diagnosis between appendicitis and a right-sided salpingitis is not always easily made. A thorough examination through the vagina, however, will in most instances enable us to decide as to the true condition. If the appendix is situated in the small pelvis and has given rise to the formation of an abscess in this locality the decision of the question whether the abscess is due to appendicitis or to oophoritis is extremely difficult and sometimes even impossible. Typhoid fever in exceptional cases may simulate an appendicitis; the presence or absence of Widal's reaction will serve to differentiate the former.

Prognosis

Catarrhal appendicitis affords in most instances a favorable prognosis as regards to life. With reference to complete recover}', however, the outlook is by no means bright, for the liability to recurrence of the disease is very great. Inasmuch as an apparently mild form of appendicitis may all of a sudden change its character and assume alarming features, the prognosis should always be made with a certain reserve, even in this class.

The purulent form of appendicitis must be regarded as a very serious disease and gives quite an unfavorable prognosis unless timely surgical intervention is adopted. The intensity of the symptoms in purulent appendicitis is by no means a correct measure of the gravity of the disease. Experience shows that cases with violent symptoms, very high fever, and intense pains, etc., occasionally recover within a few days, the pus rupturing into the intestine, while apparently mild cases after a few days of sickness suddenly develop symptoms of a general septic peritonitis with a fatal issue. Diffuse peritonitis is liable to occur between the second and fourth days of sickness, but even later the patient is subjected to numerous risks. Grave complications may suddenly develop even in a patient who is apparently progressing nicely and already convalescent. Thus purulent appendicitis may give rise to pyopneumothorax, empyema, or purulent pericarditis, and these complications may result in a fatal issue.

The prognosis of perforating appendicitis is decidedly less favorable than that of a simple empyema of the appendix, as in the former septicaemia is liable to occur.

After having described the numerous dangers present in the severe form of appendicitis it is consoling to say that spontaneous recoveries are, notwithstanding this, in the majority. With regard to the frequency of spontaneous recoveries Nothnagel gives the following statistics: Among 130 hospital patients he observed 85 complete recoveries, 4 deaths without operation, 30 partial recoveries, and 11 cures after operation. The large number of cases reported by Sahli is also very important in this connection. This author reports the results in 7,213 cases of appendicitis; 473 cases were operated upon, while 6,740 received only medical treatment. Among the latter 6,194 recovered (91.2 per cent) while 591 (8.8 per cent) died. Sahli further states that of the 4,593 cases which had not been operated upon and in which inquiries had been made with regard to recurrence of appendicitis, 3,635 were cured without any recurrence.

Nothnagel says that circumscribed appendicitis is curable in the large majority of cases, and that about eighty per cent recover under simple medical treatment. Among the rest there are still some that can be cured by means of operative procedures. Careful watching of the patient and timely surgical intervention in proper cases may reduce the number of deaths from appendicitis to perhaps five per cent or three per cent. It is, however, impossible entirely to avoid fatal issues, even with the greatest and strictest watchfulness. Aside from accidental complications and from rare cases in which a correct diagnosis is hardly to be made, there remain instances in which the peritoneum is diffusely affected quite early without presenting any symptoms. These are the cases which make the prognosis unfavorable and they form the greatest contingent of deaths among patients with appendicitis. The acute septic form with perforation of the appendix is the most dangerous, while the progressive suppurative form is comparatively favorable.