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___________________ACUTE APPENDICITIS_______________________
nd rd
Lifetime risk: M>F, with the highest incidence in the 2 or 3 decades
{lecture} not common 5 years and below; there are only few cases of
appendicitis in the elderly (appendix in the elderly already atrophied)
{lecture} most common acute surgical disease in the abdomen,
frequent in pubertal age
C. NATURAL HISTORY
Circumstantial evidence suggests that not all patients with
appendicitis will progress to perforation and that resolution may be
a common event
D. CLINICAL PRESENTATION
The inflammatory process in the appendix presents as pain, which
initially is of a diffuse visceral type and later becomes more
localized as the peritoneal lining gets irritated
SYMPTOMS_______________________________________________
Appendicitis usually starts with periumbilical (visceral) and diffuse
pain that eventually localizes to the right lower quadrant (somatic)
RLQ pain is one of the most sensitive signs of appendicitis, but pain
in atypical locations will sometimes be the initial presentation
Appendicitis is also associated with GI symptoms like Nausea,
vomiting, and anorexia. GI symptoms that develop before the onset
of pain suggests a different etiology such as gastroenteritis
Many patients complain of a sensation of obstipation prior to the
onset of pain and feel that defecation will relieve their abdominal
pain. Diarrhea may occur in association with perforation, especially
children
{Lecture} Location of somatic pain depends on the location of the
appendix (TIP OF THE APPENDIX)
o RETROCECAL –Flank or back pain
o PELVIC – suprapubic pain
o RETROILEAL – testicular pain
SIGNS____________________________________________________
Physical findings are determined by the presence of peritoneal
irritation and are influenced by whether the organ has already
ruptured when the patient is first examined. Patients with
appendicitis usually move slowly and prefer to lie supine due to the
peritoneal irritation.
On Abdominal Paplation, there is tenderness with a maximum or
near McBurney’s Point (pic below)
On deep Palpation, one can often feel a muscular resistance
(guarding) in the right illac fossa, which may be more evident when
compared to the left side.
LABORATORY FINDINGS_____________________________________
Appendicitis is associated with an inflammatory response that is
strongly related to the severity of the disease. Laboratory
examinations are therefore an important part of the diagnosis.
MILD LEUKOCYTOSIS is often present in patients with acute
uncomplicated appendicitis. Predominance of PMN
o 10,000 – 18,000 cells
o >18,000 cells suggests perforation
INCREASED CRP is a strong indicator of appendicitis especially for
complicated appendicitis ULTRASONOGRAPHY
FALSE + FALSE -
- - - - - - - - - - - - - - - - - - {NOTES FROM LECTURE}- - - - - - - - - - - - - - - - - -
Presence of peri-appendicitis Appendicitis confined to
Anal Verge -> Anal Canal is 2-4 cm
from surrounding inflammation appendiceal tip
CUTANEOUS HYPERESTHESIA (T10-T12 Spinal Nerves)
Dilated fallopian tube mistaken Retrocecal location
RUPTURE OF APPENDICITIS from inflamed appendix
-Occurs distal to the point of obstruction Inspissated stool mimics Markedly enlarged appendix
-Anti-mesenteric border appendicolith mistaken for small bowel
-SUSPECTED IF Obese patients, overlying fat Perforated appendix showing
- Temp >39 C obscures compressibility of compressibility
- WBC >18k appendix
- Localized tenderness if rupture is contained
- Generalized peritonitis if rupture is not contained
PHLEGMON
- Ill defined mass of matted loops of bowel and abscesses
- “when your ruptured appendix is enveloped by your omentum”
- TX: IV Antibiotics, Percutaneous drainage, Interval appendectomy,
surgery
- OMENTUM (avoids spreading of infection)
INTUSSUCEPTION
Patients are usually less than 2 years old
Bloody mucoid stool after abdominal pain
Sausage shaped mass
Treatment
o Segmental Resection if with peritonitis
o Reduction by barium enema if with no signs of
E. DIFFERENTIAL DIAGNOSIS peritonitis
o SAFEST: Explore Lap and Reduction
The differential diagnosis of acute appendicitis is essentially the
diagnosis of acute abdomen.
GYNECOLOGIC DISORDER
The most common findings in the case of an erroneous
PID
preoperative diagnosis of appendicitis are in descending order of
RUPTURED GRAAFIAN FOLLICLE
frequency
TWISTED OVARIAN CYST or TUMOR
1. Acute Mesenteric Adenitis
ENDOMETRIOSIS
2. No organic pathologic condition
ECTOPIC PREGNANCY
3. Acute pelvic inflammatory disease
o Bilateral inguinal pain
DISEASES OF THE MALE
4. Twisted ovarian cyst
TORSION OF THE TESTES
o Easily diagnosed by UTZ
o Severe inguinal pain
5. Ruptured graafian follicle
o Violaceous color of scrotum
6. Acute gastroenteritis
ACUTE EPIDIDYMITIS
o Ask and see companions if they also bear the
o Inflammation of the epididymis
symptoms; then ask what food taken
o Counterpart of PID
The diagnosis of acute appendicitis depends on four major factors:
1. the anatomic location of the inflamed appendix;
URETERAL STONE
2. the STAGE of the process (uncomplicated or complicated)
May simulate retrocecal appendicitis
3. patients AGE
4. and the patients GENDER Pain is reffered to the labia majora, scrotum or penis
Hematuria
1. ACUTE MESENTERIC ADENITIS Fever may be present
inflammation of the mesenteric lymph node Leukocytosis
is the disease most often confused with acute appendicitis in Increased RBC, cast in urine
CHILDREN DX by UTZ or Pyelography or CT sonogram
Recent or Present URTI
Diffuse abdominal pain with occasional voluntary guarding URINARY TRACT INFECTION
(-) boardlike rigidity May present as hypogastric or flank pain
(+) Lymphocytosis Fever may be present
Self-limited Increased urine in WBC
Close observation
APPENDICITIS IN PREGNANCY
Surgery if complications set in st
More frequent in 1 2 trimester but can occur anytime
st
6. ACUTE GASTROENTERITIS 1 trimester – teratogenic effects of MEDs –
VIRAL or BACTERIAL developmental/congenital defects
Viral Causes Location of appendix may change as the uterus enlarges
o Watery diarrhea, nausea, vomiting, crampy abdominal pain Surgery during pregnancy
o Absent Tenderness o RISK OF PREMATURE LABOR 10-15%
o Laboratory exams are usually low Perforation is associated with 20% risk of fetal and maternal
SALMONELLA GASTROENTERITIS death
o Intense abdominal pain, chills and fever UTZ may be utilized if diagnosis is doubtful
o Tenderness present
o Prostration, maculopapular rash, leucopenia PEDIATRIC APPENDICITIS
o Canned goods!!! –source Voluntary guarding is sometimes present, but true rigidity is rare
Acute Mesenteric adenitis is most often confused with
appendicitis in children
___________________OPEN APPENDECTOMY_____________________
Typically performed with a patient under general anesthesis, the
patient is placed in supine position. The entire abdomen should be
prepped and draped in case larger incision is needed.
For NONPERFORATED APPENDICITIS, a Right Lower Quadrant Incision
rd
at McBurney’s Point (1/3 of the distance from the ASIS to the
umbilicus) is Commonly Used
A McBURNEY (OBLIQUE) or ROCKY DAVIS (Transverse) RLQ muscle
splitting incision is made.