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Acute appendicitis

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pathophysology, diagnosis, differential diagnoses and treatment of acute appendicitis

pathophysology, diagnosis, differential diagnoses and treatment of acute appendicitis

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  • 1. Acute Appendicitis Al-Momtan Ahmed T. C2 Supervised by: Dr. Ghazi Qasaymeh
  • 2. Epidemiology
    • The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.
    • Despite newer imaging techniques, acute appendicitis can be very difficult to diagnose.
  • 3. Pathophysiology
    • Acute appendicitis is thought to begin with obstruction of the lumen
    • Obstruction can result from food matter, adhesions, or lymphoid hyperplasia
    • Mucosal secretions continue to increase intraluminal pressure
  • 4. Pathophysiology
    • Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed.
    • With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.
  • 5. Pathophysiology
    • Increased pressure also leads to arterial stasis and tissue infarction
    • End result is perforation and spillage of infected appendiceal contents into the peritoneum
  • 6. Pathophysiology
    • Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10 th thoracic vertebral level.
    • This pain is generally vague and poorly localized.
    • Pain is typically felt in the periumbilical or epigastric area.
  • 7. Pathophysiology
    • As inflammation continues, the serosa and adjacent structures become inflamed
    • This triggers somatic pain fibers, innervating the peritoneal structures.
    • Typically causing pain in the RLQ
  • 8. Pathophysiology
    • The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.
  • 9. Pathophysiology
    • Exceptions exist in the classic presentation due to anatomic variability of the appendix
    • Appendix can be retrocecal causing the pain to localize to the right flank
    • In pregnancy, the appendix ca be shifted and patients can present with RUQ pain
  • 10. Pathophysiology
    • In some males, retroileal appendicitis can irritate the ureter and cause testicular pain.
    • Pelvic appendix may irritate the bladder or rectum causing suprapubic pain, pain with urination, or feeling the need to defecate
    • Multiple anatomic variations explain the difficulty in diagnosing appendicitis
  • 11. History
    • Primary symptom: abdominal pain
    • ½ to 2/3 of patients have the classical presentation
    • Pain beginning in epigastrium or periumbilical area that is vague and hard to localize
  • 12. History
    • Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting
    • As the illness progresses RLQ localization typically occurs
    • RLQ pain was 81 % sensitive and 53% specific for diagnosis
  • 13. History
    • Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific
    • Anorexia is the most common of associated symptoms
    • Vomiting is more variable, occuring in about ½ of patients
  • 14. Physical Exam
    • Findings depend on duration of illness prior to exam.
    • Early on patients may not have localized tenderness
    • With progression there is tenderness to deep palpation over McBurney’s point
  • 15. Physical Exam
    • McBurney’s Point: just below the middle of a line connecting the umbilicus and the ASIS
    • Rovsing’s: pain in RLQ with palpation to LLQ
    • Rectal exam: pain can be most pronounced if the patient has pelvic appendix
  • 16. Physical Exam
    • Additional components that may be helpful in diagnosis: rebound tenderness, voluntary guarding, muscular rigidity, tenderness on rectal
  • 17. Physical Exam
    • Psoas sign: place patient in L lateral decubitus and extend R leg at the hip. If there is pain with this movement, then the sign is positive.
    • Obturator sign: passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positive
  • 18. Physical Exam
    • Fever: another late finding.
    • At the onset of pain fever is usually not found.
    • Temperatures >39 C are uncommon in first 24 h, but not uncommon after rupture
  • 19. Diagnosis
    • Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain who has not had an appendectomy
  • 20. Diagnosis
    • Women of child bearing age need a pelvic exam and a pregnancy test.
    • Additional studies: CBC, UA, imaging studies
  • 21. Diagnosis
    • CBC: the WBC is of limited value.
    • Sensitivity of an elevated WBC is 70-90%, but specificity is very low.
    • But, +predictive value of high WBC is 92% and –predictive value is 50%
    • CRP and ESR have been studied with mixed results
  • 22. Diagnosis
    • UA: abnormal UA results are found in 19-40%
    • Abnormalities include: pyuria, hematuria, bacteruria
    • Presence of >20 wbc per field should increase consideration of Urinary tract pathology
  • 23. Diagnosis
    • Imaging studies: include X-rays, US, CT
    • Xrays of abd are abnormal in 24-95%
    • Abnormal findings include: fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free air
    • Abdominal xrays have limited use b/c the findings are seen in multiple other processes
  • 24. Diagnosis
    • Graded Compression US: reported sensitivity 94.7% and specificity 88.9%
    • Basis of this technique is that normal bowel and appendix can be compressed whereas an inflamed appendix can not be compressed
    • DX: noncompressible >6mm appendix, appendicolith, periappendiceal abscess
  • 25. Diagnosis
    • Limitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameter
  • 26. Diagnosis
    • CT: best choice based on availability and alternative diagnoses.
    • In one study, CT had greater sensitivity, accuracy, -predictive value
    • Even if appendix is not visualized, diagnose can be made with localized fat stranding in RLQ.
  • 27. Diagnosis
    • CT appears to change management decisions and decreases unnecessary appendectomies in women, but it is not as useful for changing management in men.
  • 28. Differential Diagnoses
    • Mesenteric lymphadenitis (children,higher fever than in appendicitis, + Hx of sore throat)
    • Ectopic pregnancy!! (pregnancy test, anaemia, hypotesion)
    • Torsion of ovarian cyst.(no fever, tender mobile mass in the right suprapubic region or on vaginal examination)
    • Ureteric colic (radiating to the glans penis or labia majora in females)
    • Testicular torsion
    • Meckel’s diverticulitis
  • 29. Alvardo Score
  • 30. Special Populations
    • Very young, very old, pregnant, and HIV patients present atypically and often have delayed diagnosis
    • High index of suspicion is needed in the these groups to get an accurate diagnosis
  • 31. Treatment
    • Appendectomy is the standard of care
    • Patients should be NPO, given IVF, and preoperative antibiotics
    • Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation
  • 32. Treatment
    • There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage
    • One sample monotherapy regimen is Zosyn (piperacillin+ tazobactam) 3.375g or Unasyn (ampicillin and Salbactam) 3g
    • Also, short acting narcotics should be used for pain management
  • 33.  
  • 34. Disposition
    • Abdominal pain patients can be put in 4 groups
    • Group 1: classic presentation for Acute appendicitis- prompt surgical intervention
    • Group 2: suspicious, but not diagnosed appendicitis- benefit from imaging and 4-6h observation with surgical consult if serial exam changes or imaging studies confirm
  • 35. Disposition
    • Group 3: remote possibility of appendicitis- observe in ED for serial exams; if no change and course remains benign patient can D/C with dx of nonspecific abd pain
    • Patients are given instructions to return if worsening of symptoms, and they should be seen by PCP in 12-24 h
    • Also advised to avoid strong analgesia
  • 36. Disposition
    • Group 4: high risk population(including elderly, pediatric, pregnant and immunocomprimised)- require high index of suspicion and low threshold for imaging and surgical consultation