ACUTE APPENDICITIS Symptoms Clinical Features Diagnosis Treatment


Acute appendicitis is acute inflammation of the appendix.

  • Acute appendicitis usually occurs in 2nd and 3rd 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


  • · 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.


  • 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 99-100oF.
  • · 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.


  • 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)


  • 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.
Complications of APPENDICITIS
  • · Perforation; subphrenic, pelvic, intraabdominal abscess.


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