Acute appendicitis

acute appendicitis
reports of perityphlitis (caecal region) - late 1500s Fitz presented a paper to AAP 1886 described it as a clinical entity McBurney described the point of maximum tenderness in the RIF A perforated appendix found in an Egyptian mummy, however, indicates that the disease has been around since ancient times

Aetiology-obstruction
faecolith stricture carcinoma of the caecum Intestinal parasites mucosal inflammation and lymphoid hyperplasia., possibly viral

Acute RIF pain

This can result from a number of conditions Is it appendicitis or not?

 Even the most experienced surgeons may remove normal appendixes (10-20% appendicectomies a normal appendix is removed ) or "sit on" those that have perforated

 Delayed diagnosis and treatment ( occurs in young and elderly patients ) is associated with an increased rate of morbidity and mortality ( >5 % ) Mortality in nonperforated appendicitis is < 1 %.

Causes of right iliac fossa pain

Appendicitis Non-specific abdominal pain Meckels diverticulitis Cholecystitis Typhoid fever Mesenteric lymphadenitis Ectopic pregnancy Urinary tract infection Renal colic Pneumonia (basilar)

diagnosis RIF pain (n50)

Appendix related Number % 20 40 operated % 16 80

no diagnosis
gynaecological UT GI total

17
6 4 3 50

34
12 8 6 100

3
2 1 1 23

18
33 25 33 46

Diagnosis
Appendicitis is essentially a clinical diagnosis

Age

Pain Anorexia Nausea Vomiting Pain migration

Classic presentation sequence (vague periumbilical pain to anorexia/nausea/ unsustained vomiting to migration of pain to right lower quadrant to low-grade fever) 50% only

Acute appendicitis
Initially , poorly localised vague abdominal pain-visceral pain Colicky in obstruction or distension. The pain is not felt in the organ. But in the skin of same embryonic segment (periumbilical pain) .It is called referred pain.

Acute appendicitis
parietal peritoneum overlying skin has the same somatic innervation. So when the parietal peritoneum becomes involved, the pain is felt in the RIF (<24 hours) and intensifies Then the pain is sharp aggravated by movements and coughing

Gynecological conditions
RIF pain in females. ask about the LRMP The lack of amenorrhoea doesn't exclude a diagnosis of ectopic pregnancy.

Acute appendicitis
Coated tongue Foetor oris Mild pyrexia up to 38oC Slight tachycardia Tenderness rebound tenderness Cough sign guarding Rovsings sign Psoas stretch sign Obturator test Rectal and vaginal examinations

Psoas sign
pain on extension of right thigh (retroperitoneal retrocecal appendix)

The obturator sign.

Pain on passive internal rotation of the flexed thigh.

The location of the appendix varies-so the clinical presentation also

hidden from the anterior peritoneum, the usual symptoms and signs of acute appendicitis may not be present.

Retrocaecal appendicitis
RIF tenderness & guarding Often Absent

Right loin tenderness

Psoas spasm &stretch sign

May be +
+

Post ileal
Pain is poorly localised Vomiting can be more persistent Diarrhoea is more frequent

pelvic
Diarrhoea Increased frequency and microscopic haematuria McBurneys point tenderness absent Psoas stretch sign Obturator test Rectal and vaginal examinations

Investigations
No single investigation will accurately diagnose appendicitis Often required to exclude other causes

 Moderate neutrophil leucocytosis 90% 15,000 >75% UFR-normal not always Urine culture Pregnancy test

Plain radiographs US Laparoscopy CT

Percentage with symptoms

Migr anore N/vo pain xia Appe 86.7 (n=15) NSAP 29.5 (n=17) Gynae 33.3 (n=6) 87.5 52.9 66.7 94 70.6 83.3 RBT 68.7 52.9 33.3 pyreia leuk 62.5 35.3 00 PMN 45.4 81.8 (n=11) 23.1 53.9 (n=13) 00 66.6 (n=3)

UT (n=4) GI (n=3)

50.0
60.7

50.0
66.7

75.0
100

50.0
33.3

25.0
100

50.0
00 (n=2)

00
00

Alvarado score
symptoms Migrating pain anorexia Nausea/vomiting score 1 1 1

Signs

Tender RIF
RBT pyrexia

2
1 1 2 1

Lab findings

leukocytosis PMN

Distribution of Alvarado scores by diagnosis

score 4
No of 1 Pt

5
9

6
9

7
6

8
4

9
2

10
1

Appe

6(3) 2(0) 1(0)

2(2)
4(0) 1(1) 2(0) -

3(3)
1(0) 1(0) 1(0)

3(3)
1(0) -

2(2)

1(1)

NSAP 1(0) Gyna UT GI

Treatment
Appendicectomy Perioperative broad spectrum antibiotics (e.g. cefuroxime and metronidazole) should be used in all because they reduce postoperative wound infection and intra abdominal abscesses Diet within 24-48 hours Antibiotics for 5 days for perforated appendices

postoperative complications
Wound infection <5%-20% Intra abdominal abscesses ( pelvic subphrenic) Faecal fistula

Appendix mass
Delay in presentation Tender RIF mass Overlying muscle rigidity Conservative management if the patient is well and stable

management
Conservative management
Nil by mouth Antibiotics Close observation

If increasing peritonitis
Systemically unwell -surgery Mass can be clearly defined over next few days when Rigidity settles

Mass resolves

Increase in size if abscess formation

Appendicular abscess
RIF / pelvis
Swinging pyrexia Tachycardia Very Tender Mass Tenderness on DRE /vaginal examination

Polymorpho nuclear leukocytosis US Aspiration under US/CT Open procedure

Interval appendicectomy
Some do elective appendicectomy to eliminate the possibility of further attacks controversial because the recurrence rate varies 10-35%