Acute Appendicitis

APPENDIX

Not essential for life

Immunologic organ
secretes IgA Length <1 cm to >30 cm usually 6 to 9 cm

Location of the Tip of the Appendix

retrocecal pelvic subcecal preileal right pericolic

INCIDENCE
most frequently seen in patients in their 2nd 4th decades of life mean age of 31.3 years median age of 22 years. slight male:female predominance (1.2 to 1.3:1)

Etiology Obstruction of the lumen

Fecaliths Lymphoid hyperplasia

Less common etiology

Hypertrophy of lymphoid tissue Inspissated barium Tumors Vegetables and fruit seeds Intestinal parasites

Occlusion of the lumen Closed Loop Obstruction Distension Vascular Congestion Serosal inflammation

Sequence of events

Gangrene
Perforation

Pathology Sequence of events

1. Closed loop obstruction caused by proximal 2. Distension result of continued secretion by
obstruction
mucosa nerve endings of visceral afferent nerves are stimulated vague, dull, diffuse pain in the

Occlusion of the lumen

midabdomen crampy pain peristalsis

3. Vascular congestion venous pressure is exceeded as a result of continued distension due to mucosal secretion and rapid multiplication of bacteria
Nausea and vomiting

4. Serosal inflammation parietal peritoneum

right lower quadrant pain

5. Gangrene - Vascular supply compromised arteriolar pressure exceeded 6.

Perforation -

antimesenteric border

Bacteriology
Escherischia coli, Bacteroides fragilis

Antibiotics = 24 to 48 hours, nonperforated 7 to 10 days, perforated

Shift of IV antibiotics to Oral 1. WBC is NORMAL

2. Afebrile for 24 hours

SYMPTOMS
Abdominal Pain

diffuse initially centered in the lower epigastrium or umbilical area, mod. Severe and steady with intermittent cramping 4 to 6 hours

ANOREXIA Vomiting 75% of patients

Right Lower quadrant pain

neural stimulation and ileus

Sequence of SYMPTOMS

ANOREXIA

Abdominal Pain initially at the epigastrium then localizes to the right lower quadrant

Vomiting

Clinical SIGNS
(anatomic position of the inflammed area and ruptured or not)

Uncomplicated Appendicitis
Vital signs are minimally changed
Lie supine with right thigh flexed Slow movement with caution

Clinical SIGNS Right Lower quadrant Physical Signs diminished bowel sounds

Muscle Guarding

Maximal tenderness at McBurneys Point Direct rebound tenderness Rovsings Sign Cutaneous hyperesthesia (T10,T11,T12)

resistance to palpation is dependent on severity Voluntary initially then becomes involuntary

McBurneys Point

Signs to elicit
1. Pointing Sign/direct tenderness 2. Rovsings Sign

3. Psoas Sign
4. Obturator Sign Cough sign

Diagnosis
Laboratory
1. CBC

Acute, Uncomplicated
10,000 to 18,000 WBC with predominance of PMNs >18,000 WBC = Perforated Appendix? 2. Urinalysis 3. Imaging Studies

Imaging Studies
Plain Film of Abdomen rarely helpful Barium enema Ultrasound Graded Compression Sonography

+ noncompressible appendix 6 mm or
greater in the A-P direction

+ appendicolith
CT-Scan

+thickened appendiceal wall with

periappendiceal fluid

Acute Mesenteric Adenitis Gynecologic Disorders Pelvic Inflammatory Disease Ruptured Graafian Follicle Twisted Ovarian Cyst Ruptured Ectopic Pregnancy Acute Gastroenteritis Meckel's Diverticulitis Crohn's Enteritis Colonic Lesions

Differential Diagnosis

Medical Treatment
Adequate hydration should be ensured Electrolyte abnormalities should be corrected Pre-existing cardiac, pulmonary, and renal conditions should be addressed Most surgeons routinely administer antibiotics to all patients with suspected appendicitis. simple acute appendicitis - antibiotic coverage within 24hrs perforated or gangrenous appendicitis -antibiotics are continued until the patient is afebrile and has a normal WBC single-agent therapy with cefoxitin, cefotetan, or ticarcillin-clavulanic acid

Surgical Management
1. Open Apendectomy a. Rocky Davis (Transverse skin Incision) b. McBurney Skin Incision (Oblique skin incision) 2. Laparoscopic

Perforated Appendicitis
Must receive fluid resuscitation

IV antibiotics
Operated by open method or laparoscopic approach Antibiotics for 7 to 10 days or until afebrile with normal wbc

Post-operative Complications

Infection - most common complication after surgery

2 common sites of infection 1. Subcutaneous wound 2. Abdominal cavity

- Infection rate for uncomplicated appendicitis < 1 % - Incidence of intra abdominal abscess < 1 %

Bowel Obstruction

- Incidence is 1% to 1.3% - Most usually presents within the 1st 6 months