4. PATHOPHYSIOLOGY OF APPENDICITIS
Inflammation of appendix due to obstruction of lumen, such are, CAUSES,
a)fecolith *common cause- in those with low fibre diet, 30-40% has perforated
appendix
b) hyperplasia of lymphoid tissue within lumen near base.Organism such as
yersenia, salmonella and shigella causing lymphoid reaction and hyperplasia.
same goes to parasitic infestation entamoeba, strongloides,
enterobius,schistosoma,ascariasis, viral infection such as mumps, coxsackie
virus B, CMV, adenovirus can cause lumen obstruction by causing hyperplasia of
lymphoid tissue
c) in children with cystic fibrosis,abnormal production of mucous causing
enlargement of appendix
d) appendix in neonate is rare, thus cystic fibrosis and hirschprung's disease
need to be excluded
5. • Appendiceal lumen get obstructed, mucous accumulation lead to
proliferation of bacteria. A s intramural pressure increase, there is
impaired venous and lymphatic drainage and result in edema.
worsening of edema, arterial blood flow, result in tissue hypoxia>
necrosis and perforation
• this progression its time based, children have a very low prception
regarding the symptoms thus present late to US. This is the reason why,
appendicitis more common in children compare to adult.
• perforation is 82% in children <5years, and 100% in children <1year
• lack of access to health care, is a major cause of perforation in view of
delayed in starting antibiotic
6. CF AND PHYSICAL EXAMINATION
• vague abominal pain mainly over umbilical- due to visceral pain and its a
midgut pain referred to umbilicus
• slowly pain progress to RIF in view of irritation abdominal layer (parietal
layer)- migrating pain. thus any movement of perironeum lead to
exacerbation of pain
. due to that, patient will not want to move/jump
• a/e: nausea, vomiting, diarrhea, fever, tachycardia
• tenderness over right lower quadrant. analgesia will reduce the pain
symptoms however, will not eliminate the tenderness
• localized tenderness depend on the degree of peritoneal irritation. Thus,in
obesity, retrocecal appendix, appendix walled off by omentum , mesentry or
small bowel may not associated with local tenderness
7. INVESTIGATION AND INTERPRETATION
• leukocytosis, due to release of imflammatory cell, left shift of counts
• high crp> 3
• ufeme: possible of red and white cell seen in view ofirritation of appendix to the bladder n ureter
• Imaging : can prevent negative appendicectomy(incidence 10-20 %) and detect early of
appendicitis
• axr: 10-20% can see fecolith, obliteration of psoas muscle, exclude othe disease
• us: fluid filled appendix, non-compressible appendix, diameter of appendix >6mm/0.6cm,
appendicolith, periappendiceal or pericecal fluid, increase periappendiceal echogenicity due to
inflammation, appendicular mass, aperistalstic of bowel. u/s senstivity: 85%, specifity:90%.
however, it is operator dependent
• ct: appendix diameter >6mm, appendiceal wall thickness>1cmm, periappendiceal fat stranding,
appendiceal wall enhancement. sensitivity and specifity -95%
8. • cons with ct
- required contrast
-required sedation
-increase radition exposure which increase life time risk of
malignancy(developing tissue its more radiation
9. AVACADO SCORE, PAPER BASED
• ALVARADO SCORE: 5-6: POSSIBLE, 7-8: PROBABLE, > 9 VERY
PROBABLE
M:MIGRATORY PAIN: 1
A:ANOREXIA: 1
N:NAUSEA AND VOMITING: 1
T: TENDERNESS: 2
R: REBOUND TENDERNESS: 1
E: ELEVATED TEMPERATURE: 1
L: LEUCOCYTOSIS: 2
S: SHIFT OF THE LEFT OF NEUTROPHIL: 1
12. UNCOMPLICATED APPENDICITIS (acute,
suppurative, gangrenous)
• antibiotic, cause cure rate of 44-85%
• sbsequently plan for interval elective appendicectomy or wait for
recurrence acute appendicitis(rate 8-14%). recurrence usually occur
within 1st 3years, n majority within 1 to 6months
• if parents opted not for operation then we will wait and watch
