ACUTE APPENDICITIS Symptoms Clinical Features Diagnosis Treatment

Article Contents ::

Acute appendicitis is acute inflammation of the appendix.

Acute appendicitis usually occurs in 2^nd and 3^r^d 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

· 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

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.

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.)

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.

· 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)

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

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.