ACUTE APPENDICITIS Symptoms Clinical Features Diagnosis Treatment

ACUTE APPENDICITIS

Acute appendicitis is acute inflammation of the appendix.

• Acute appendicitis usually occurs in 2^nd and 3^rd de­cades in males and females equally.
• Perforation is common in infancy and elderly.
• appendicitis has been recognized as one of the most common causes of the acute abdomen worldwide,Classic presentations, which occur about 60% of the time, include abdominal pain (initially diffuse, gradually localizing to the right lower quadrant), loss of appetite, nausea, fever, and an elevated white blood cell count
• Acute inflammation of the vermiform appendix, 1st described by Reginald Fitz in 1886
• Most common cause of the acute surgical abdomen

ACUTE APPENDICITIS Symptoms Clinical Features Diagnosis Treatment

Etiology of APPENDICITIS

• · Luminal obstruction, ulceration of mucosa, in­fection with Yersinia, fecoliths, enlarged lymphoid follicles, worms, tumors, may cause obstruction and appendicitis.
• · Ganwene and perforation may occur.
• Other foreign bodies
• Intestinal worms (ascarids)
• Strictures, fibrosis
• · Sometimes terminal ileum, cecum and omentum may adhe;re together and form a lump or abscess.
• · Appendicitis may also occur in Crohn’s disease.
• Fecaliths (most common)
• Lymphoid tissue hyperplasia (in children)
• Inspissated barium
• Vegetable, fruit seeds
• Neoplasms

APPENDICITIS Pathophysiology

• Acute obstruction raises intraluminal pressure, leading to ischemia.
• initial event to incite appendicitis is thought to be obstruction of the appendiceal lumen
• Bacteria invade the appendiceal wall at sites of ulceration, producing inflammation.
• Necrosis of appendiceal wall results in perforation with fecal contamination of the peritoneum.

History for APPENDICITIS

• Q: Is there constipation and inability to pass gas?
  • A: These are considered traditional cardinal signs for irritation associated with peritoneal or abdominal mesentery.
• Q: Is there nausea or vomiting?
  • A: Many surgeons feel that vomiting is the cardinal symptom associated with appendicitis.
• Q: Is there fever?
  • A: Low-grade fever is common in appendicitis; higher fever can indicate an abscess or other infectious disease.
• Q: Does the pain move, or is there point tenderness associated in the right lower quadrant (RLQ)?
  • A: Typically, there is poorly localized, cramplike mid-abdominal pain that migrates to the RLQ.
• Q: Other classic features?
  • A: Rectal tenderness, nausea, anorexia; patient prefers to lie still; rarely, secretory diarrhea, more common in infants <2 years of age; change in bowel habits, especially diarrhea; guarding (i.e., voluntary contraction of the abdominal muscle); appendicitis may be presenting with unusual features.
  • Toddlers are not able to explain the time of onset and localization of pain.

Physical Exam for APPENDICITIS

• Fever; temp >100.4°F (can be absent)
• Tachycardia
• Right lower quadrant (RLQ) tenderness
• Maximal tenderness at McBurney’s point
• Voluntary and involuntary guarding
• Cutaneous hyperesthesia at T10–12
• Rovsing sign: RLQ pain with palpation of LLQ
• Psoas sign: Pain with right thigh extension (retrocecal appendix)
• Obturator sign: Pain with internal rotation of flexed right thigh (pelvic appendix)
• Local and suprapubic pain on rectal exam (pelvic appendix)
• Pelvic and rectal exams necessary to explore other pathology (PID, prostatitis, etc.)

APPENDICITIS Symptoms Clinical features

• · Abdominal pain, usually in periumbilical or epi­gastric region.
• · Cramps, colics, lasting 4 to 6 hours.
• · Pain is aggravated by motion or cough, and is
• usually present in right lower quadrant later
• · Anorexia, nausea, vomiting.
• · Diarrhea.
• · Urinary frequency.
• · Tenderness in mid-abdomen and right lower
• quadrant.
• · Flexion of right hip due to local peritonitis.
• · Positive psoas or obturator sign.
• · Fever 99-100^oF.
• · Tachycardia.
• · Rigidity and tenderness in diffuse peritonitis.
• · A mass may develop if there is perforation, in 3 days.
• · Mass is palpable in carcinoma of cecum.

APPENDICITIS Diagnosis

• The differential diagnosis of this presentation includes flares of inflammatory bowel disease, mesenteric adenitis, pelvic inflammation, and many other illnesses.
• Diagnosis is simple when pain eventually localizes to the right lower quadrant,
• with rebound tenderness and rigidity over the right rectus muscle or McBurney’s point.

Risk Factors in APPENDICITIS

• Infestation by Enterobius vermicularis or Ascaris lumbricoides
• Recent viral infection
• Adolescent males
• Familial tendency
• Intra-abdominal tumors

Lab diagnosis

• Urinanalysis to exclude urinary tract pathology
• CBC; elevated WBC count with left shift
• CRP; acute phase reactant, increased within 12 hours of onset of infection
• • Leucocytosis 10,000 to 18,000 per mm³
• · Anaemia and blood in stools

Imaging X-ray, CT,–

• · X-ray, CT, Ultrasound may show obstruction, cal­culus, mass, cysts, abscess etc.
• Abdominal x-ray:
• Air-fluid levels suggesting small bowel obstruction
• Indistinct psoas margins
• Often normal
• 8–10% show calcified fecalith
• Cecal wall thickening
• Pneumoperitoneum (rare)

APPENDICITIS Treatment

• Avoid enema.
• Operative treatment, usually laparoscopic sur­gery.
• If there is palpable mass after 3 days, operation
• is not done. .
• Conservative treatment is antibiotics, fluids. Appendectomy is done 3 months later

Medication

First Line

• Uncomplicated acute appendicitis: 1 perioperative dose of broad-spectrum antibiotic
• Cefoxitin (Mefoxin); cefotetan (Cefotan)
• Gangrenous or perforating appendicitis:
• Broadened antibiotic coverage for aerobic and anaerobic enteric pathogens
• Fluoroquinolone and metronidazole typical
• Adjust dosage and choice of antibiotic based on intraoperative cultures
• Continue antibiotics for 7 days postoperatively or until patient becomes afebrile

Second Line

• Ampicillin-sulbactam (Unasyn)
• Ticarcillin-clavulanate (Timentin)
• Piperacillin-tazobactam (Zosyn)
• Surgery (appendectomy) is still the standard of care. However, nonoperative management with antibiotics has been studied as an alternative.

Complications of APPENDICITIS

• · Perforation; subphrenic, pelvic, intraabdominal abscess.