More than 100 years have passed since Reginald Fitz, Professor of pathology at Harvard University, Boston., coined the term ‘appendicitis’ and went on to stress ‘the vital importance of early recognition of perforated appendicitis’, the best management of patients believes to have acute appendicitis is still subject of keen debate.1 Acute appendicitis is the most common surgical condition of abdomen. Approximately 6 percent of population has risk of suffering from acute appendicitis in their lifetime, with the pick incidence occurring between age of 10 and 30 years, therefore much effort has been directed toward early diagnosis and intervention.2 Today, more than a century later, acute appendicitis, one of the most frequent reasons for emergency abdominal operation can still be a diagnostic problem.3-7 Delay in diagnosis and surgery of acute appendicitis is associated with a more advanced stage of disease and a higher morbidity.8-10

Although the overall mortality rate associated with acute appendicitis has now fallen to about one in six hundred, 11 this tradition has prevailed in many centers, which report negative appendicectomy rate of 20-25 percent.12 The negative lapratomy rate is significantly higher in young women (up to 45 percent) because of the prevalence of pelvic inflammatory disease and other common obstetrical and gynecological disorders.13-16

Incidence studies have shown a considerable decline in appendicectomy rates over the past decades.14 Whereas in the 1960s it was considered good surgical practice to operate on almost any patient with right lower abdominal pain, surgical attitudes have changed towards a more selective approach. This change was probably encouraged by continuing reports of high negative lapratomy rates, 15 showing that many patients underwent unnecessary operations.

The clinical history and physical examination are most important in establishing a diagnosis of acute appendicitis. Abdominal pain is the most common symptoms of appendicitis.17 Anorexia, nausea and vomiting are symptoms that are commonly associated with acute appendicitis. Physical examination shows the sign of local and rebound tenderness, muscles guarding, rigidity, cutaneous hyperesthesia and tenderness on rectal examination. However, barely 50% of patients have a classical history of presentation due to variation in the pathphysiological development of the disease as well as due to wide range of position of organ.18-20

Suppurative appendicitis has traditionally been considered a later stage of appendicitis, in which bacteria and inflammatory fluids accumulated in the lumen of the appendix enter the wall of structure and subsequently cause intense pain when the inflamed membrane rubs against the parietal peritoneum lining the abdominal cavity. Accordingly, for many years incidence of suppurative appendicitis was utilized as a measure of medical care since, according to this view, delays in diagnosis or treatment increase the likelihood of suppuration. Recent research, however, indicates that acute appendicitis and suppurative appendicitis may develop through discrete processes. For instance, one intriguing study found that the incidence of acute appendicitis is greatest among teenagers, but that incidence of suppurative appendicitis does not vary by age. Also, according to some researchers, acute appendicitis is more frequently linked to mucosal ulceration than suppurative appendicitis, which is more often caused by obstruction of the appendix.21

Various diagnostic modalities have been devised to aid the diagnosis of acute appendicitis. Laboratory investigations such as total and differential white blood count are a basic diagnostic procedure in clinical medicine which aid in decision making especially in thoughtful cases. Leucocytosis is usually present in patients with acute bacterial infections often accompanied by Polymorphonuclear predominance.22 Multi variety analysis showed that serial C - reactive protein (CRP) measurement can improve the accuracy of diagnosing acute appendicitis. 23

Scoring systems assisted diagnosis have proved useful.24,25,26 Ultrasonography and computed tomography scans are helpful in evaluating patients with suspected appendicitis. Abdominal ultrasonography has a sensitivity of 85 to 90 percent and specificity of 92 to 96 percent. 27

Computed Tomography scanning improve the diagnostic accuracy to the extent of 96-97%.Laprascopy is useful in young women in reproductive age group because gynecological condition may mimic acute appendicitis.28 X-ray film of abdomen is frequently done investigation but has an overall accuracy of only 8 percent, although they can be of significant benefit in ruling out other abdominal pathology.15, 29

Barium enema has the accuracy of 50 to 84 percent30, 31 but it is time consuming, unpleasant and uncomfortable to the patient, needs preparation, dangerous and might cause perforation. Laparoscopic appendectomy (LA) is rapidly becoming an alternative to open appendectomy for the treatment of appendicitis in children.
Acute appendicitis is among the five leading causes of litigation against emergency physicians and accounts for 5 percent of the total dollars lost by insurers of emergency physicians32. In context of Nepal, so far Emergency care is provided by General practitioners and in zonal as well as in district hospitals they are responsible for performing appendicectomy. General practitioners and emergency physicians face a difficult problem when patient presents with a right iliac fossa pain with equivocal signs. The decision to admit or discharge these patients is not always straightforward.33