Acute appendicitis


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pathophysology, diagnosis, differential diagnoses and treatment of acute appendicitis

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Acute appendicitis

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