ACUTE APPENDICITIS

YIN Detao MD
Department of General Surgery, the
First Affiliated Hospital of
ZhengZhou University
 一， Essentials of Diagnosis
• Abdominal pain;
• Anorexia, nausea and vomiting;
• Localized abdominal tenderness;
• low-grade fever;
• Leukocytosis.
 二， General considerations
• In approximately 70% of acutely inflamed
appendices, obstruction of the proximal
lumen by fibrous bands, tumors, parasites,
or foreign bodies can be demonstrated.
• Introaluminal obstruction is not found in
one-third of specimens, however, and
external compression by bands has been
postulated to explain these cases.
• It has also been suggested that acute
appendicitis may begin with mucosal
ulceration, perhaps viral, followed by
secondary bacterial invasion.
• As appendicitis progresses, the blood
supply is impaired by bacterial infection in
the wall and distention of the lumen by
pus; gangrene and perforation occur at
about 24 hours, although the timing is
highly variable.
• Gangrene implies microscopic perforation
and bacterial peritonitis.
 三， Clinical findings
• Acute appendicitis has protean
manifestations.
• It may simulate almost any other acute
abdominal illness and in turn may be
mimicked by a variety of conditions.
• Progression of symptoms and signs is the
rule-in contrast to the fluctuating course of
some other diseases.
 1, symptoms and signs:
• Typically, the illness begins with vague
abdominal discomfort followed by slight
nausea, anorexia, and indigestion.
• The pain is persistent and continuous but
not severe, with occasional mild epigastric
cramps.
• There may be an episode of vomiting, and
within several hours the pain shifts to the
right lower quadrant, becoming localized
and causing discomfort on moving,
walking, or coughing.
• The patient has a sense of being
constipated and may feel the need for a
cathartic or an enema.
• Examination at this time will show cough
tenderness localized to the right lower quadrant.
• There will be well-localized tenderness to one
finger palpation and possibly very slight
muscular rigidity.
• Rebound tenderness is classically referred to the
same area.
• Rectal and pelvic examinations are likely to be
negative.
• The temperature is only slightly elevated
(37.8℃) in the absence of perforation.
 2, Laboratory finding:
• The average leukocyte count is 15,000/μl,
and 90% of patients have counts over 10,
000/μl. In three-fourths of patients, the
differential white count shows more than
75% neutrophils.
• The urine is usually normal, but a few
leukocytes and erythrocytes and
occasionally even gross hematuria may be
noted, particularly in retrocecal or pelvic
appendicitis.
 3, X-ray finding:
• Abdominal X-rays may be of value in
detecting other causes of abdominal pain,
since plain films seldom contribute to the
diagnosis of acute appendicitis.
• Localized air-fluid levels, localized ileus, or
increased soft tissue density in the right
lower quadrant is present in 50% of
patients with early acute appendicitis.
• Positive radiologic signs become more
frequent as appendicitis progresses.
 四， Differential diagnosis
• The diagnosis of acute appendicitis is
particularly difficult in the very young and
in the elderly. These are the groups where
diagnosis is most often delayed and
perforation most common.
• Infants manifest only lethargy, irritability, and
anorexia in the early stages, but vomiting,
fever, and pain are apparent as the disease
progresses.
• Classic symptoms may not be elicited in aged
patients, and the diagnosis is often not
considered by the examining physician.
• The course of appendicitis is more virulent in
the elderly, and suppurative complications
occur earlier.
 五， Complications
• The complications of acute appendicitis
include perforation, peritonitis, abscess,
and pylephlebitis.
 1, Perforation:
• Perforation is accompanied by more
severe pain and higher fever than in slight
appendicitis.
• It is unusual for the acutely inflamed
appendix to perforate within the first 12
hours.
• The appendicitis has progressed to
perforation by the time of appendectomy
in about 50% of patients under age 10 or
over age 50.
• Nearly all deaths occur in the latter group.
 2, Peritonitis:
• Localized peritonitis results from
microscopic perforation of a gangrenous
appendix, while spreading or generalized
peritonitis usually implies gross perforation
into the free peritoneal cavity.
• Increasing tenderness and rigidity,
abdominal distention, and adynamic ileus
are obvious in patients with peritonitis.
• High fever and severe toxicity mark
progression of this catatrophic illness in
untreated patients.
 3, Appendiceal abscess:
• Localized perforation of appendix leads to
formation of an appendiceal abscess that
is protected from the free peritoneal cavity
by omentum or loops of small bowel.
 4, Pylephlebitis:
• Pylephlebitis is suppurative
thrombophlebitis of the portal venous
system.
• Chills, high fever, low-grade jaundice, and,
later, hepatic abscesses are the hallmarks
of this grave condition.
• The appearance of shaking chills in a
patient with acute appendicitis demands
vigorous antibiotic therapy to prevent the
development of pylephlebitis.
 六， Treatment
• With few exceptions, the treatment of
appendicitis is surgical.
• The use of prophylactic antibiotics
decreases the incidence of septic
complications in both perforated and
nonperforated appendicitis.
 七， Prognosis
• Although a death rate of zero is
theoretically attainable in acute
appendicitis, deaths still occur, some of
which are avoidable.
• The death rate in simple acute
appendicitis is approximately 0.1% and
has not changed significantly since 1930.