World Journal of Surgery

, Volume 31, Issue 1, pp 86–92 | Cite as

The Natural History and Traditional Management of Appendicitis Revisited: Spontaneous Resolution and Predominance of Prehospital Perforations Imply That a Correct Diagnosis is More Important Than an Early Diagnosis

  • Roland E. AnderssonEmail author



The principle of early exploration on wide indications in order to prevent perforation has been the guiding star for the management of patients with suspected appendicitis for over 100 years, dating back to a time when appendicitis was a significant cause of mortality. Since then there has been a dramatic decrease in mortality due to appendicitis. Emerging evidence calls for a new understanding of the natural history of untreated appendicitis. This motivates a reappraisal of the fundamental principles for the management of patients with suspected appendicitis.


Analysis of epidemiologic and clinical studies that elucidate the natural history of appendicitis, i.e. the possibility of spontaneous resolution or the risk of progression to perforation, the determinants of the proportion of perforations and mortality, and the consequence of in-hospital delay.


The results presented in a number of studies suggest that spontaneous resolution of appendicitis is common, that perforation can seldom be prevented, that the risk of perforation has been exaggerated and that in-hospital delay is safe. An alternative understanding of the inverse relationship between the proportion of negative explorations and perforation and the increasing proportion of perforation with length of time is presented, mainly explaining these findings by selection due to spontaneous resolution.


Evidence suggests that spontaneous resolution of untreated, non-perforated appendicitis is common and that perforation can rarely be prevented and is associated with a lower increase in mortality than was previously thought. This motivates a shift in focus from the prevention of perforation to the early detection and treatment of advanced appendicitis. In order to minimize mortality, morbidity and costs avoidance of negative appendectomies is more important then preventing perforation. In patients with an equivocal diagnosis where advanced appendicitis is deemed less likely a correct diagnosis is more important than a rapid diagnosis. These patients can safely be managed by active observation with an improved diagnostic work-up under observation, which has consistently shown a low proportion of negative appendectomies without an increase in the proportion of perforations or morbidity. A high proportion of perforations can be explained by selection due to undiagnosed resolving appendicitis. The proportion of perforation is therefore a questionable measure of the quality of the management of patients with suspected appendicitis and should be used with caution.


Appendicitis Excess Mortality Standardize Mortality Ratio Spontaneous Resolution Perforated Appendicitis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA 2001;286:1748–1753PubMedCrossRefGoogle Scholar
  2. 2.
    McDonald GP, Pendarvis DP, Wilmoth R, Daley BJ. Influence of preoperative computed tomography on patients undergoing appendectomy. Am Surg 2001;67:1017–1021PubMedGoogle Scholar
  3. 3.
    Howie JGR. Too few appendectomies? Lancet 1964;I:1240–1242CrossRefGoogle Scholar
  4. 4.
    Andersson R, Hugander A, Thulin A, Nystrom PO, Olaison G. Indications for operation in suspected appendicitis and incidence of perforation. BMJ 1994;308:107–110PubMedGoogle Scholar
  5. 5.
    Decadt B, Sussman L, Lewis MP, Secker A, Cohen L, Rogers C et al. Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain. Br J Surg 1999;86:1383–1386PubMedCrossRefGoogle Scholar
  6. 6.
    Barber MD, McLaren J, Rainey JB. Recurrent appendicitis. Br J Surg 1997;84:110–112PubMedCrossRefGoogle Scholar
  7. 7.
    Heller MB, Skolnick ML. Ultrasound documentation of spontaneously resolving appendicitis. Am J Emerg Med 1993;11:51–53PubMedCrossRefGoogle Scholar
  8. 8.
    Migraine S, Atri M, Bret PM, Lough JO, Hinchey JE. Spontaneously resolving acute appendicitis: clinical and sonographic documentation. Radiology 1997;205:55–58PubMedGoogle Scholar
  9. 9.
    Cobben LP, de Van Otterloo AM, Puylaert JB. Spontaneously resolving appendicitis: frequency and natural history in 60 patients. Radiology 2000;215:349–352PubMedGoogle Scholar
  10. 10.
    Kirshenbaum M, Mishra V, Kuo D, Kaplan G. Resolving appendicitis: role of CT. Abdom Imaging. 2003;28:276–279PubMedCrossRefGoogle Scholar
  11. 11.
    Ciani S, Chuaqui B. Histological features of resolving acute, non-complicated phlegmonous appendicitis. Pathol Res Pract 2000;196:89–93PubMedGoogle Scholar
  12. 12.
    Stengel A. Appendicitis. In: Modern medicine, vol V. Diseases of the alimentary tract. Osler W, McCrae T (eds). Lea & Febiger. Philadelphia, 1908Google Scholar
  13. 13.
    De Dombal FT. Diagnosis of acute appendicitis. Churchill Livingstone, Edinburgh, 1991, p 109Google Scholar
  14. 14.
    Velanovich V, Satava R. Balancing the normal appendectomy rate with the perforated appendicitis rate. Am Surg 1992;58:264–269PubMedGoogle Scholar
  15. 15.
    Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg 1992;158:37–41PubMedGoogle Scholar
  16. 16.
    Coran AG, Wheeler HB. Early perforation in appendicitis after age 60. JAMA 1966;197:745–748PubMedCrossRefGoogle Scholar
  17. 17.
    Redmond JM, Smith GW, Wilasrusmee C, Kittur DS. A new perspective in appendicitis: calculation of half time (T(½)) for perforation. Am Surg 2002;68:593–597PubMedGoogle Scholar
  18. 18.
    Kraemer M, Franke C, Ohmann C, Yang Q. Acute appendicitis in late adulthood: incidence, presentation, and outcome. Results of a prospective multicenter acute abdominal pain study and a review of the literature. Langenbecks Arch Surg 2000;385:470–481PubMedCrossRefGoogle Scholar
  19. 19.
    Pieper R, Forsell P, Kager L. Perforating appendicitis. A nine-year survey of treatment and results. Acta Chir Scand Suppl 1986;530:51–57PubMedGoogle Scholar
  20. 20.
    Luckmann R. Incidence and case fatality rates for acute appendicitis in California. A population-based study of the effects of age. Am J Epidemiol 1989;129:905–918PubMedGoogle Scholar
  21. 21.
    Hale DA, Jaques DP, Molloy M, Pearl RH, Schutt DC, d’Avis JC. Appendectomy. Improving care through quality improvement. Arch Surg 1997;132:153–157PubMedGoogle Scholar
  22. 22.
    Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995;221:278–281PubMedCrossRefGoogle Scholar
  23. 23.
    Maroju NK, Smile SR, Sistla SC, Narasimhan R, Sahai A. Delay in surgery for acute appendicitis. ANZ J Surg 2004;74:773–776PubMedCrossRefGoogle Scholar
  24. 24.
    Yardeni D, Hirschl RB, Drongowski RA, Teitelbaum DH, Geiger JD, Coran AG. Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night? J Pediatr Surg 2004;39:464–469PubMedCrossRefGoogle Scholar
  25. 25.
    Williams N, Bello M. Perforation rate relates to delayed presentation in childhood acute appendicitis. J R Coll Surg Edinb 1998;43:101–102PubMedGoogle Scholar
  26. 26.
    Colson M, Skinner KA, Dunnungton G. High negative appendectomy rates are no longer acceptable. Am J Surg 1997;174:723–726PubMedCrossRefGoogle Scholar
  27. 27.
    Koepsell TD, Inui TS, Farewell VT. Factors affecting perforation in acute appendicitis. Surg Gynecol Obstet 1981;153:508–510PubMedGoogle Scholar
  28. 28.
    Eldar S, Nash E, Sabo E, Matter I, Kunin J, Mogilner JG et al. Delay of surgery in acute appendicitis. Am J Surg 1997;173:194–198PubMedCrossRefGoogle Scholar
  29. 29.
    Pittman-Waller VA, Myers JG, Stewart RM, Dent DL, Page CP, Gray GA et al. Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies. Am Surg 2000;66:548–554PubMedGoogle Scholar
  30. 30.
    Williams N, Bello M. Perforation rate relates to delayed presentation in childhood acute appendicitis. J R Coll Surg Edinb 1998;43:101–102PubMedGoogle Scholar
  31. 31.
    Walker SJ, West CR, Colmer MR. Acute appendicitis: does removal of a normal appendix matter, what is the value of diagnostic accuracy and is surgical delay important? Ann R Coll Surg Engl 1995;77:358–363PubMedGoogle Scholar
  32. 32.
    Howie JG. Death from appendicitis and appendicectomy. An epidemiological survey. Lancet 1966; 2:1334–1337PubMedCrossRefGoogle Scholar
  33. 33.
    Blomqvist PG, Andersson RE, Granath F, Lambe MP, Ekbom AR. Mortality after appendectomy in Sweden, 1987–1996. Ann Surg 2001;233:455–460PubMedCrossRefGoogle Scholar
  34. 34.
    Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002;137:799–804PubMedCrossRefGoogle Scholar
  35. 35.
    Graff L, Radford MJ, Werne C. Probability of appendicitis before and after observation. Ann Emerg Med 1991;20(5):503–507PubMedCrossRefGoogle Scholar
  36. 36.
    Andersson RE, Hugander A, Ravn H, Offenbartl K, Ghazi SH, Nystrom PO et al. Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 2000;24(4):479–485PubMedCrossRefGoogle Scholar
  37. 37.
    Neutra RR. Appendicitis: decreasing normal removals without increasing perforations. Med Care 1978;16(11):956–961PubMedCrossRefGoogle Scholar
  38. 38.
    Jones PF. Suspected acute appendicitis: trends in management over 30 years. Br J Surg 2001;88(12):1570–1577PubMedCrossRefGoogle Scholar
  39. 39.
    White JJ, Santillana M, Haller JA Jr. Intensive in-hospital observation: a safe way to decrease unnecessary appendectomy. Am Surg 1975;41(12):793–798PubMedGoogle Scholar
  40. 40.
    Jones PF. Active observation in management of acute abdominal pain in childhood. Br Med J 1976;2(6035):551–553PubMedCrossRefGoogle Scholar
  41. 41.
    Antoine M, Askenasi R, Ansay J, Van de Stadt J. Appendicite aiguë: bénèfice d’une attitude attentiste. Acta Chir Belg 1984;84(4):203–206PubMedGoogle Scholar
  42. 42.
    Nauta RJ, Magnant C. Observation versus operation for abdominal pain in the right lower quadrant. Roles of the clinical examination and the leukocyte count. Am J Surg 1986;151(6):746–748PubMedCrossRefGoogle Scholar
  43. 43.
    Thomson HJ, Jones PF. Active observation in acute abdominal pain. Am J Surg 1986;152(5):522–525PubMedCrossRefGoogle Scholar
  44. 44.
    Dolgin SE, Beck AR, Tartter PI. The risk of perforation when children with possible appendicitis are observed in the hospital. Surg Gynecol Obstet 1992;175(4):320–324PubMedGoogle Scholar
  45. 45.
    Senbanjo RO. Management of patients with equivocal signs of appendicitis. J R Coll Surg Edinb 1997;42(2):85–88PubMedGoogle Scholar
  46. 46.
    Bachoo P, Mahomed AA, Ninan GK, Youngson GG. Acute appendicitis: the continuing role for active observation. Pediatr Surg Int 2001;17(2–3):125–128PubMedCrossRefGoogle Scholar
  47. 47.
    Kirby CP, Sparnon AL. Active observation of children with possible appendicitis does not increase morbidity. ANZ J Surg 2001;71(7):412–413PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2006

Authors and Affiliations

  1. 1.Department of SurgeryCounty Hospital RyhovJönköpingSweden

Personalised recommendations