Intended for healthcare professionals

Practice Easily Missed?


BMJ 2011; 343 doi: (Published 06 October 2011) Cite this as: BMJ 2011;343:d5976
  1. Sian R R Lewis, locum general practitioner1,
  2. Peter J Mahony, general practitioner2,
  3. John Simpson, associate professor in gastrointestinal surgery3
  1. 1Nottingham, UK
  2. 2Belvoir Health Group, The Surgery, Nottingham, UK
  3. 3Department of General Surgery, University Hospital/Queens Medical Centre, Nottingham NG7 2UH, UK
  1. Correspondence to: J Simpson j.simpson{at}
  • Accepted 29 August 2011

Acute appendicitis is the most common abdominal condition requiring emergency surgery. It results from inflammation of the vermiform appendix, which is a tubular structure attached to the base of the caecum.

Case scenario

A 50 year old man presented with a 24 hour history of generalised abdominal pain that had become localised in the right loin. He had no urinary symptoms but was feverish (37.8°C). His urine was positive for blood and protein, and a provisional diagnosis of renal colic was made. He was referred to hospital, where computed tomography of the kidneys, ureters, and bladder did not demonstrate any evidence of urinary calculi but did confirm the presence of an inflamed retrocaecal appendix. He underwent an open appendicectomy and made an uneventful recovery.

How common is appendicitis?

  • Appendicitis is the most common abdominal emergency and accounts for more than 40 000 hospital admissions in England every year (approximately 1 per 1500 population)1

  • Appendicitis is most common between the ages of 10 and 20 years, but no age group is exempt

  • There is a male to female ratio of 1.4:1; overall lifetime risk is 8.6% for males and 6.7% for females in the United States2

  • Since the 1940s the incidence of hospital admission for acute appendicitis has been falling, but the reason for this decline is not clear3

Why is appendicitis missed?

The classical presentation of appendicitis appears in only approximately 50% of patients.4 Appendicitis can affect all age groups, and presentation may be influenced by the patient’s age and the anatomical position of the appendix. An accurate history may not be possible from the very young or from older people presenting with confusion.

Pregnancy seems to protect against appendicitis,5 but it is the most common non-obstetric emergency requiring surgery in pregnancy. Presentations in pregnant women may be atypical (due to anatomical displacement of the appendix …

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