<b>Macroscopic Normal Appendix in Patients Presented with Features Suggestive of Acute Appendicitis</b>

Background: Acute appendicitis is one of the most common causes of abdominal pain requiring surgical intervention. However, a subset of patients presents with classical symptoms suggestive of appendicitis, but intraoperative findings reveal a macroscopically normal appendix. This study aimed to evaluate the clinical, radiological, and histopathological characteristics of such cases. Methods: This prospective study included 100 patients who presented with clinical features suggestive of acute appendicitis and underwent appendectomy. Only those with macroscopically normal appendices were included. Clinical symptoms, physical signs, laboratory and radiological findings, intraoperative observations, and histopathological results were collected and analyzed. Results: Out of 100 patients 65 were females and 35 males. All of them reported right iliac fossa pain. Nausea was present in 80%, fever in 67%, and vomiting in 49%. Tenderness in the right side of the abdomen was noted in 97 patients (69 females, 28 males), while 3 patients (2 females, 1 male) presented with flank pain, anorexia, elevated white blood cell count, and negative β-hCG. Per rectal examination in these 3 patients revealed tenderness. Clinical examination showed RIF tenderness in 56% and rebound tenderness in 41%. Fever was documented in 53%. White blood cell count was elevated in 45% of patients. Ultrasound, performed in female patients only (40 cases), was non-diagnostic in all. Intraoperatively, all appendices were macroscopically normal. Thirteen females were found to have ruptured ovarian follicles. Histopathological examination revealed true appendicitis in 19 patients (13 males and 6 females), including 6 with normal white blood cell counts. Conclusion: A macroscopically normal appendix may still harbor histological evidence of inflammation. Clinical judgment should be supported by histopathology, especially in female patients, where gynecological conditions may mimic appendicitis. Improved diagnostic tools and imaging protocols are essential to reduce negative appendectomy rates.