Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
The main symptom of appendicitis is abdominal pain. The pain is at first
diffuse and poorly localized, that is, not confined to one spot. (Poorly
localized pain is typical whenever a problem is confined to the
small intestine or colon, including
the appendix.) The pain is so difficult to pinpoint that when asked to point to
the area of the pain, most people indicate the location of the pain with a
circular motion of their hand around the central part of
As appendiceal inflammation increases, it extends through the appendix to its
outer covering and then to the lining of the abdomen,
a thin membrane called the
peritoneum. Once the peritoneum
becomes inflamed, the pain changes and then can be localized clearly to one
small area. Generally, this area is between the front of the right hip bone and
the belly button. The exact point is named after
Dr. Charles McBurney--McBurney's point. If the appendix ruptures and infection
spreads throughout the abdomen, the pain becomes diffuse again as the entire
lining of the abdomen becomes inflamed.
Nausea and vomiting also occur in appendicitis and may be due to intestinal
How is appendicitis diagnosed?
The diagnosis begins with a thorough history and physical
examination. Patients often have an elevated temperature, and there usually will
be moderate to severe tenderness in the right lower abdomen when the doctor
pushes there. If inflammation has spread to the peritoneum, there is frequently
tenderness. This means that when the doctor pushes on the abdomen and then
quickly releases his hand, the pain becomes suddenly but transiently worse.
White Blood Cell Count
The white blood cell count in the blood
usually becomes elevated with infection. In early appendicitis, before infection
sets in, it can be normal, but most often there is at least a mild elevation
even early. Unfortunately, appendicitis is not the only condition that causes
elevated white blood cell counts. Almost any infection or inflammation can cause
this count to be abnormally high. Therefore, an elevated white blood cell count
alone cannot be used as a sign of appendicitis.
Urinalysis is a microscopic examination of the
urine that detects red blood
cells, white blood cells and bacteria in the urine. Urinalysis usually is
abnormal when there is inflammation or stones in
the kidneys or bladder which
sometimes can be confused with appendicitis. Therefore, an abnormal urinalysis
suggests that there is a kidney or bladder
problem while a normal urinalysis is
more characteristic of appendicitis.
An abdominal x-ray may detect the fecalith (the hardened and calcified,
pea-sized piece of stool that blocks the appendiceal opening) that may be the
cause of appendicitis. This is especially true in children.
An ultrasound is a painless procedure that uses sound
waves to identify organs within the body. Ultrasound can identify an enlarged
appendix or an abscess. Nevertheless, during appendicitis, the appendix can be
seen in only 50% of patients. Therefore, not seeing the appendix during an
ultrasound does not exclude appendicitis. Ultrasound also is helpful in women
because it can exclude the presence of conditions involving the ovaries,
fallopian tubes and uterus
that can mimic appendicitis.
A barium enema is an x-ray test where liquid barium is inserted into the
colon from the anus to fill
the colon. This test can, at times, show an impression on the colon in the area
of the appendix where the inflammation from the adjacent inflammation impinges
on the colon. Barium enema also can exclude other intestinal problems that mimic
appendicitis, for example Crohn's disease.
who are not pregnant, a CT Scan of the area of the appendix is
useful in diagnosing appendicitis and peri-appendiceal abscesses as well as in
excluding other diseases inside the abdomen and pelvis that can mimic
Laparoscopy is a surgical procedure wherein a small fiberoptic tube with a
camera is inserted into the abdomen through a small puncture made on the
abdominal wall. Laparoscopy allows a direct view of the appendix as well as
other abdominal and pelvic organs.
If appendicitis is found, the inflamed
appendix can be removed at the same time. The disadvantage of laparoscopy
compared to ultrasound and CT scanning is that it requires
a general anesthetic.
There is no one test that will diagnose appendicitis
with certainty. Therefore, the approach to suspected appendicitis may include a
period of observation, tests as previously discussed, or surgery.