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Acute appendicitis
Acute appendicitis is defined as inflammation of the vermiform appendix, categorized as uncomplicated or complicated based on the presence of additional issues such as perforation or fecalith. Common causes include obstruction due to lymphoid hyperplasia in younger patients and fecaliths in adults, leading to symptoms like abdominal pain, nausea, and fever. Treatment typically involves supportive care and antibiotics, with appendectomy being the standard surgical intervention for non-perforated cases.
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Acute appendicitis
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- 2. DEFINITIONS Appendicitis: acute inflammationof the vermiform appendix Uncomplicated appendicitis: appendicitis with no evidence of an appendiceal fecalith, an appendiceal tumor, or complications, such as perforation, gangrene, abscess, or mass Complicated appendicitis: appendicitis associated with perforation, gangrene, abscess, an inflammatory mass, an appendiceal fecalith, or an appendiceal tumor
- 3. ETIOLOGY Caused by obstructionof the appendiceal lumen due to: Lymphoid tissue hyperplasia; (60% of cases): most common cause in children and young adults Fecalith; and fecal stasis (35% of cases): most common cause in adult Neoplasm; (uncommon): more likely in patients > 50 years of age Parasitic infestation (uncommon): e.g., Enterobius vermicularis, Ascaris lumbricoides, and species of the Taenia and Schistosoma genera
- 4. PATHOPHYSIOLOGY 1. Obstructed proximalappendiceal lumen (closed-loop obstruction), resulting in: Stasis of mucosal secretions → bacterial multiplication and local inflammation → transmural spread of infection → clinical features of appendicitis Increased intraluminal pressure → obstruction of veins → edema of the appendiceal walls → obstruction of capillaries → ischemia → gangrenous appendicitis with/without perforation 2. Inflammation can spread to serosa, leading to peritonitis
- 5. CLINICAL PRESENTATION Symptoms Abdominalpain: initial periumbilical pain with migration to the right lower quadrant (RLQ) Anorexia Nausea Vomiting Diarrhea Constipation Indigestion
- 6. CLINICAL PRESENTATION Physical exam Low grade Fever McBurney point tenderness Tenderness at the junction of the lateral third and medial two-thirds of a line drawn from the right anterior superior iliac spine to the umbilicus This point corresponds to the location of the base of the appendix. Rovsing sign: pain in the RLQ with palpation of the left lower quadrant (LLQ) Psoas sign: associated with retrocecal appendix RLQ pain with passive right hip extension Obturator sign: RLQ pain with right hip flexion followed by internal rotation
- 7. OTHER CLINICAL SIGNS Hyperesthesia within Sherren triangle: formed by the anterior superior iliac spine, umbilicus, and symphysis pubis Lanz point tenderness: at the junction of the right third and left two-thirds of a line connecting both the anterior superior iliac spines Pain in the Pouch of Douglas: pain elicited by palpating the recto uterine pouch on rectal examination Baldwin sign: pain in the flank when flexing the right hip (suggests an inflamed retrocecal appendix)
- 8. INVESTIGATIONS CBC: mildleukocytosis with left shift; normal WBC count does not rule out acute appendicitis CRP: elevated (> 10 mg/L) Creatinine: maybe elevated Serum electrolyte abnormalities may be present in patients with severe vomiting; and diarrhea Tests to rule out differential diagnoses Urine/serum β-hCG test; : perform in all women of reproductive age to rule out pregnancy (including ectopic pregnancy) ACUTE APPENDICITIS IS CLINICAL DIAGNOSIS
- 9. Radiological Investigation CTabdomen with IV contrast: preferred initial imaging modality in adults (except for pregnant women) MRI abdomen without IV contrast: pregnant patients with inconclusive ultrasound findings Abdominal ultrasound: Preferred initial imaging modality in children or pregnant patients As an alternative to CT scan if CT findings are inconclusive Abdominal ultrasound is more reliable for confirming acute appendicitis than ruling it out.
- 10. DIFFERENTIAL DIAGNOSIS Ectopicpregnancy Renal colic Psoas abscess Epiploid appendagitis Constipation Irritable Bowel syndrome
- 11. DIAGNOSTIC CRITERIA –ALVARDO SCORING
- 12. TREATMENT Supportive care Bowelrest - Nil by mouth (NPO) Intravenous fluids: Ringer Lactate and Normal saline Electrolyte repletion as needed IV analgesics: Ketorolac 30mg (Toradol) OR Tramadol 100mg (Tramol) IV antiemetics as needed: Metoclopramide Or Dimenhydrinate Antipyretic therapy: IV Paracetamol 1g/100ml x TDS/BD IV antibiotic therapy: Ceftriaxone 1g x BD, + Metronidazole 500mg/100ml x TDS
- 13. SURGICAL TREATEMNT Non-perforated appendicitis Appendectomy (laparoscopic or open) should be performed within 12 hours of diagnosis laparoscopic approach is more common and popular Perforated appendicitis with hemodynamic instability, sepsis, free perforation, or peritonitis emergency appendectomy: irrigation and drainage of peritoneal cavity, colon resection if needed Stable perforated appendicitis initial nonoperative management: IV antibiotics, percutaneous drainage of abscess if present Rescue appendectomy for patients who do not respond to antibiotics
- 14. COMPLICATIONS Appendiceal abscess Perforation Sepsis Peritonitis Hemodynamic instability Death
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