Acute Appendicitis

Chp. 78

Stephen Cluff D.O.

6/14/07
Acute Appendicitis
Begins as a Lumen obstruction
mucosal secretion increases pressure
overcomes perfusion pressure
obstructs venous/lymphatic drainage
epithelial breakdown
invasion by bowel flora
eventual arterial stasis and necrosis
spillage of infected contents into peritoneum
Pain Presentation
Visceral afferents enter at 10th thoracic vertebra
Poorly localized pain to periumbilical area
Inflammation continuessomatic pain fibers
become involved and localize pain to RLQ

26% of appendices are retrocecal(gravid)

that may mean RUQ or FLANK pain
Males can have testicular pain
Micturary pain possible
History
#1 symptom.Abdominal Pain

Anorexia, nausea, vomitting

RLQ pain81% sensitive, 53%specific

Migration is 82% specific

Vomiting occurs in only half of AA

Pain before vomiting100% sensitive

Physical Exam
McBurneys Point tenderness
Rovsing sign (prlqwpllq)

Guarding .74/.57
Rebound .63/.69
Rigidity .27/.83
Psoas sign .16/.95 (llr,el)
Obturator sign (frh/kwir)

Temp > 39 C are uncommon before rupture

Labs
CBCelevated WBC
sens. 70-90%, spec. very low
PPV 92 NPV 50

UA not helpful, except to exclude urinary

pathology
Imaging
Plain radiographsabnormal in 24 - 95%
appendiceal fecolith, appendiceal gas,
localized paralytic ileus, blurred right psoas,
free air
Graded compression US 95/89use?

CT is test of choice
96% sensitive, 94% accuracy, NPV 95
Changes management in women, not men
Special Cases
Very young present insidiously
Elderly misdiagnosis rates 50%
30% mortality for over 70 y/o
Most common extrauterine surgical emergency in
pregnancy
AIDs patients susceptible to complications
higher perforation rate, delayed presentation,
no white count common
Treatment
Appendectomy

NPO, IV fluids, pre-op antibiotics

Cover anaerobes, enterococci, Gr. Neg. intestinal

flora
monotherapy Zosyn 3.375 G IV Unasyn
3.00 G IV
Narcotic analgesic
Disposition
Classic presentationprompt surgery

Suspicious but not diagnosticCT and

observation with serial exams q 4-6

Abdominal pain with AA remote possibility

observe with serial examsif unchanged, d/c with
Dx of nonspecific abdominal pain

High risk special populationslow index of

suspicion for imaging and surg consult
QUIZ
1. Visceral fibers of the appendix enter at the _____________ vertebrae
a. 4th thoracic b. 6th thoracic
c. 10th thoracic d. 3rd Lumbar

2. 50% of appendices are retrocecal.

T F

3. Imaging of choice for suspected acute appendicitis.

a. Contrast CT b. Graded compression Ultrasound
c. non-contrast CT d. Plain abdominal XR

4. Pain before vomiting is 100% sensitive for acute appendicitis .

T F