Recurrent and chronic appendicitis: Diagnostic challenges and clinical insights

Abstract

Chronic and acute recurrent appendicitis are often underrecognized in clinical practice, particularly in patients presenting with persistent or recurrent right lower quadrant abdominal pain. It is essential to obtain a detailed and comprehensive history from the patient, as careful questioning often reveals a history of prior attacks. Diagnosing recurrent and chronic appendicitis remains challenging, necessitating thorough history-taking, awareness of varied clinical presentations, and physical examination integrating specific maneuvers. Maintaining a high index of clinical suspicion is essential for recognizing these atypical presentations. Confirming a high pretest probability prior to surgical intervention is crucial to avoid unnecessary procedures.

Key Words: Appendicitis; Chronic; Recurrent; Rovsing; Sign

Core Tip: Diagnosing recurrent and chronic appendicitis poses significant clinical challenges. It requires a clear understanding of pathophysiological mechanisms, precise case definitions, and detailed patient history and physical examination. Employing these approaches, supplemented by imaging studies, enhances diagnostic accuracy. Surgeons should avoid operating without a definitive diagnosis to prevent unnecessary interventions.

TO THE EDITOR

We read with interest the article by Huang et al[1] titled “Chronic abdominal pain caused by foreign bodies in the appendix: A case report”. We concur with the authors that diagnosing chronic appendicitis can be challenging, as it is often misunderstood and poorly defined clinically. This correspondence aims to refine the definitions of recurrent and chronic appendicitis, elucidate their underlying pathophysiology, and highlight bedside maneuvers that may aid in their diagnosis.

Our paper emphasizes the importance of understanding the pathophysiological processes involved, which helps clarify the types of reflexes - viscerosensory, visceromotor, somatosensory, and somatomotor - activated by these maneuvers. We presented examples of several signs observed in patients with chronic appendicitis. Additionally, there are other signs, including those described by Gregory, Altschüler, Bassler, Reder, and Aaron, which we intend to address in a future publication. All of these maneuvers share a common pathway, activating viscerosensory and visceromotor reflexes.

Defining recurrent and chronic appendicitis

Chronic and acute recurrent appendicitis are often underrecognized in clinical practice, particularly in patients presenting with persistent or recurrent right lower quadrant abdominal pain. It is essential to obtain a detailed and comprehensive history from the patient, as careful questioning often reveals a history of prior attacks. This suggests that acute recurrent appendicitis may be more common than previously recognized. We use the term “persistent” to emphasize that there are no specific time constraints on the duration of symptoms.

Physicians typically assess for appendiceal pain by superficially palpating the right lower quadrant, especially at McBurney point. McBurney point represents the most common location for tenderness on the anterior abdominal wall by which the T11 and T12 nerves segments are reflexively irritated by peritoneal inflammation and does not correspond to the anatomical location of the appendix. However, in cases of chronic appendicitis, tenderness is usually absent. During an acute episode of recurrent appendicitis, abdominal wall pain may occur due to peritoneal inflammation.

The authors presented a patient with recurrent episodes of right lower quadrant abdominal pain but did not detail the frequency, duration, or intervals between episodes. Although described as “mild”, the pain was significant enough to prompt medical consultation. Currently, “chronic appendicitis” and “acute recurrent appendicitis” lack formal diagnostic criteria. Diagnosis depends on consistent signs, symptoms, and physical findings indicative of appendiceal disease, characteristic histopathological features, and symptom resolution following appendectomy. Chronic appendicitis is perhaps better classified as a pathological entity rather than purely clinical, as no definitive duration criterion exists. Gross examination reveals that a chronically inflamed appendix appears firmer and more rigid compared to a normal appendix. Histopathological features include eosinophilic infiltration, scattered or clustered lymphocytes, plasma cells, large mononuclear cells, and fibrosis of the appendiceal wall[2,3].

In chronic cases, eliciting tenderness during physical examination often requires deep rather than superficial palpation, as the source of pain is in the appendix rather than the abdominal peritoneum. This technique involves using the flexor surface of the fingers with the hand positioned at a slight angle. Either a single-handed or dual-handed method may be employed. Palpation of the right lower quadrant should proceed gently and slowly. To date, we are unaware of any literature indicating a risk of appendiceal rupture associated with deep palpation in cases of chronic or acute recurrent appendicitis. Limited data indicates these complications are infrequent or considered low risk. To classify appendicitis as “recurrent”, the patient must experience symptom-free intervals indicating complete clinical recovery between episodes. Although extremely rare, foreign bodies such as pins, toothpicks, and animal or fish bones have been previously documented in cases of chronic appendicitis[4-7], aligning with the rarity noted by Huang et al[1].

Conceptual definition

Herein we propose a conceptual framework for acute recurrent and chronic appendicitis. There are currently no established diagnostic criteria for chronic appendicitis. Based on current literature[8-10], acute recurrent appendicitis may be defined by the following criteria: (1) Recurrent episodes of sudden onset of acute abdominal pain primarily located in the epigastric, periumbilical, hypogastric, or right lower quadrant; (2) Symptom-free interval occurs between acute episodes; (3) Associated symptoms during acute episodes may include nausea, vomiting, and fever; (4) No prior history of appendectomy; (5) Histopathologic examination reveals, in some cases, acute inflammation superimposed on chronic inflammation; and (6) Symptomatic improvement following appendectomy.

Chronic appendicitis may be defined by the following criteria[10-12]: (1) Persistent symptoms of mild abdominal pain located in the epigastric, periumbilical, hypogastric, or right lower quadrant; (2) Associated symptoms are variable, vague, and non-specific, they may include fatigue, malaise, nausea, constipation, or diarrhea; (3) No prior history of appendectomy; (4) Histopathologic examination confirms chronic inflammation; and (5) There is symptomatic improvement following appendectomy.

Pathophysiology of acute recurrent and chronic appendicitis

Pain location in appendicitis depends on whether inflammation is confined to the appendix or involves the parietal peritoneum. In early recurrent episodes, visceral afferent nerves and Pacinian corpuscles within the appendix respond to distention and stretch[13]. These pain fibers travel with splanchnic sympathetic nerves to the dorsal root ganglion through the superior mesenteric, gastric, and hepatic plexuses, initially manifesting as deep-seated, poorly localized pain in the midline epigastric or periumbilical regions involving the T8-T10 dermatomes[13,14].

Additionally, abrupt and severe distention may trigger a “spill-over” effect, directly stimulating spinal efferent motor intercostal nerves within the dorsal root ganglion, resulting in localized pain and muscular spasms within the right T10-T11 dermatomes, even in the absence of parietal peritoneal inflammation[13]. This represents a viscerosensory-visceromotor segmental reflex[13,14]. When appendiceal rupture occurs, the ensuing inflammation extends to the parietal peritoneum, activating somatosensory and somatomotor segmental reflexes via intercostal nerves traveling to the dorsal root ganglion and cerebral cortex[13]. This activation results in pain, muscle spasm, and abdominal guarding localized to the T10-T12 dermatomes[13,14].

Signs to support the diagnosis of chronic appendicitis

Thirty-two visceral nerve reflex signs associated with acute and chronic appendicitis have been identified[14]. Understanding these viscerosensory signs allows clinicians to correlate symptoms with underlying inflammation. Rovsing sign, described by Niels Thorkild Rovsing (1862 to 1927), involves applying pressure to the left iliac fossa and moving superiorly toward the splenic flexure, eliciting pain in the right iliac fossa due to retrograde tension on the appendix through a competent ileocecal valve[15]. Banani et al[16] in 2014 proposed a modified maneuver: Applying downward and medial pressure in the left lower quadrant with the right hand for 10-20 seconds, concurrently pressing downward at McBurney’s point with the left hand, provoking pain in the right lower quadrant. While both maneuvers are sensitive, neither is specific; thus, a positive test assists in ruling in appendicitis but cannot definitively rule it out.

Several additional signs, including those described by Berthomier[17], Michelson[18], and Aaron[19], have been historically associated with chronic appendicitis. Berthomier[17] in 1906 and Michelson[18] in 1911 described eliciting pain by palpating McBurney’s point in the left lateral decubitus position, a pain absent in the supine position due to improved direct palpation access. The significance of this sign is that placing the patient in the left lateral decubitus position shifts non-retroperitoneal structures to the left, thus improving access for direct palpation of the fixed appendiceal structure. Aaron[19] in 1913 noted that sustained fingertip pressure over McBurney’s point induced referred pain in regions such as the epigastrium, left hypochondrium, and umbilicus, consistent with known viscerosensory pathways.

Conclusion

Diagnosing recurrent and chronic appendicitis remains challenging, necessitating thorough history-taking, awareness of varied clinical presentations, and physical examination integrating specific maneuvers. Maintaining a high index of clinical suspicion is essential for recognizing these atypical presentations. Confirming a high pretest probability prior to surgical intervention is crucial to avoid unnecessary procedures.

ACKNOWLEDGEMENTS

We thank the reviewers for their constructive comments.