A presentation on appendicitis by Dr. Basil Tumaini, MD Done at Kilema Hospital in Moshi District Council

1. Appendicitis
Dr. Basil B. Tumaini, MD
Kilema hospital
Moshi District Council

2. Outline
Rationale for choosing the topic
Clinical vignette
Introduction & Epidemiology
Pathophysiology & natural history
Clinical features
Diagnosis and differential diagnoses
Management
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3. Rationale for choosing this
topic
Not in STG
Common in our setup
Tendency to mismanage/ delay
management
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4. Clinical Vignette
An otherwise healthy 22-year-old woman comes to
the emergency department with
acute abdominal pain of 18 hours’ duration in the
right lower quadrant. On physical
examination, she is afebrile, with tenderness on
deep palpation in the right lower
quadrant, and has no peritoneal signs. Pelvic
examination reveals tenderness in the
right adnexa without a mass.
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5. Introduction
Appendicitis is an acute
inflammation of the appendix.
It is a common abdominal surgical
emergency.
Diagnosis is made on the basis of
history, examination.
Specific investigations may be
needed in equivocal cases.
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6. Epidemiology
The incidence of acute appendicitis is
around 7% of the population in the US and
in Europe
In Asia and Africa, the incidence is
probably lower because of the dietary
habits
High incidence of appendicitis is believed
to be related to poor fiber intake
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7. Epidemiology ...ctd
Persons of any age may be affected
Highest incidence occurring during the
second and third decades of life
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8. Pathophysiology
Obstruction of the lumen is the
primary cause of appendicitis.
Obstruction may often be secondary
to impacted faecolith or hyperplasia
of the submucosal lymphoid
follicles, which is associated with
respiratory disease, infectious
mononucleosis, and gastroenteritis .
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9. 13 October 2015 Dr. Basil, KH/15/01 9

10. Bacteriology
Aerobes
E. coli
Klebsiella Species
Pseudomonas
aeroginosa
Staphylococcal
Species
Enterococcus
Anaerobes
Bacteroides fragilis
Fusobacterium
Species
Peptostreptococcus
Clostridium Species
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11. Natural History
Early appendicitis
Suppurative appendicitis
Gangrenous appendicitis
Perforated appendicitis
Appendicular mass or abscess
Rare types of appendicitis
(Spontaneously resolving appendicitis, Recurrent
appendicitis, Chronic appendicitis)
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12. Gangrenous appendix
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13. Inflammed Appendix
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14. Clinical Features
Migratory Pain (50%)
Anorexia (75%)
Nausea (75%)
vomiting
low-grade fever (15%)
Tenderness and rebound tenderness
(96%)
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15. Alvarado Score
Parameter Findings Points
Symptoms Migration of pain 1
Anorexia 1
Nausea and vomiting 1
Signs Tenderness in the right
lower quadrant
2
Rebound tenderness 1
Elevation of temperature
≥ 37.3°C
1
Laboratory Leucocytosis (WBC count
> 10k /µL)
2
Shift to the left
(neutrophils > 75% of
differential)
1
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16. Interpretation
A score of 9 or 10 indicates very
probable acute appendicitis.
A score of 7 or 8 indicates probable acute
appendicitis.
A score of 5 or 6 indicates compatible
with acute appendicitis.
A score ≤4 indicates that acute
appendicitis is unlikely.
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17. Application
If score is 5 or 6: observe
If score is ≥7: appendectomy
indicated
If score ≤ 4 evaluate for other causes
of abdominal pain
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18. Diagnosis
Medical history (lack of appetite, abdominal
pain, nausea, vomiting, diarrhoea or constipation, fever)
Clinical examination (fever, tenderness at
McBurney's point , Rovsing sign, Cope’s psoas test,
Cope’s obturator test)
Investigations
– Laboratory: FBP, Urinalysis, UPT
– Radiology: USS, CT scan, MRI
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19. Diagnosis ...ctd
The diagnosis of appendicitis is clinical and
essentially is based on history and clinical
examination findings
The classic form of appendicitis may be
promptly diagnosed and treated
In atypical presentations, it remains a
clinical challenge. In such cases, lab and
imaging may be useful in establishing a
correct diagnosis.
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20. Diagnosis ...ctd
Statistics report that 1 of 5 cases of
appendicitis is misdiagnosed
A normal appendix is found in 15-40% of
patients who have an emergency
appendectomy
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21. Case definition
Acute appendicitis should be suspected in
anyone with epigastric, periumbilical,
right flank, or right sided abd pain who
has not had an appendectomy
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22. Physical Exam 1
McBurney’s Point: just below the
middle of a line connecting the umbilicus
and the ASIS
Rovsing’s sign: pain in RLQ with
palpation to LLQ
DRE: pain can be most pronounced if the
patient has pelvic appendix
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23. Physical Exam 2
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
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24. Imaging 1
For equivocal presentations
To detect complications
CT equal results as ultrasound*
Has not lowered rates of false
pos/neg
Diagnosing perforation
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25. Imaging 2
Graded Compression USS: 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
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26. Imaging 3
Limitations of US: retrocecal appendix
may not be visualized, perforations may be
missed due to return to normal diameter
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27. Imaging 4
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,
diagnosis can be made with localized fat
stranding in RLQ.
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28. USS
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29. USS
Appendicitis
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30. Differential diagnosis
Perforated peptic ulcer, UTI &
urolithiasis, PID & tubo ovarian mass,
endometriosis, ovarian cyst, torsion,
acute cholecystitis, mesenteric adenitis
Crohn’s disease, Meckel’s
diverticulitis, ileal or caecal
perforation, Ca colon, abdominal TB,
gastroenteritis, omental torsion and
HIV
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32. Appendiceal Rupture
Overall rate 26%
Higher rates in Children <5: 45%
Elderly >65: 51%
Perforation difficult to diagnose
Increases with length of symptoms
Suspicion: T ≥ 39 °C
WBC >18,000/µL
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33. Management
Emergency surgery
Conservative management
Interval appendectomy
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34. Take home message
Although many antibiotics to control
infections are available, appendicitis
remains a surgical disease
In fact, appendectomy is the only rational
therapy for acute appendicitis
It avoids clinical deterioration and may
avoid chronic or recurrent appendicitis
Although difficult, prompt recognition and immediate
treatment of the disease prevents complications
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35. Management …ctd
Appendectomy is the standard of care
Patients should be NPO, given IVF,
preoperative antibiotics and analgesic
Antibiotics are most effective when given
preoperatively and they decrease post-op
infections and abscess formation
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36. Surgery
Appendectomy must be performed
early to prevent uncontained perforation
and generalized or diffuse peritonitis.
Incision and drainage is indicted in
patients with an abscess.
The patient should receive IV antibiotics
within 2 hours of procedure (such as
cefoxitin and metronidazole).
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37. Appendectomy
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38. Conservative Management
This is indicated in patients who are
seen late and are improving, and
those with an appendicular mass.
In these patients bed rest, IV fluids,
antibiotics and analgesics are
administered with close monitoring
for progression of disease
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39. Interval appendectomy
Performed at 8 weeks.
The risk of recurrence without
surgery is 5-40%.
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40. Thanks for Listening & Bye
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