Appendix

1. ACUTE APPENDICITIS

3.  HOPI :15 yr old boy present with graduall
onset lower right abd pain 4 days before
admission moderate to sever for 5 min
duration every 1to2 hr stabing in nature no
radiation aggrevate by movement relive by
sleep associated with low grade fever no
sweating no rigor .and also with nausea and
vomiting and decrease appitite but no FBM
.he came to outclinic and was examined and
send for investigations in form of CBC GUE
US

4.  GENERAL EXAMINATION
 Young Age male siting on the chair look ill
{in pain}pale not dysenic no cynosis no
jaundice no lymphoadenopathy no palmer
erythema no clubbing no temer no
sweating no edema

5.  ABDOMMENAL EXAMINATION
 Inspection flat abdomen no skin color change
inverted umblicus no scar no dilated vein no skin
lesion no visible pulsation or skin lesion no
hearnia
 Palpation there is tenderness in right iliac fossa
and rebound tendreness {-ve}rovsing sign
obturator sign psoas sign no mass
 By deep palpation no organomegaly
 Percussion normal tympanitic sound no
transmited thrill or shifting dullness
 Ascultation {+ve} bowel sound no

6.  DDX
 Appendicitis
 Urolithiasis
 Gall bladder disease
 Intestinal obstruction
 Pancreatitis

7.  Appendicitis occurs in >250,000 people per
year in the United States alone. Appendicitis
occurs in people of any age, but is most
common in later childhood through young
adulthood. The presentation of appendicitis in
young children
and the elderly is often atypical. There is no
race or gender predilection. Diagnosis in
female patients can be more difficult, although
males are more likely to have a perforated
appendix.

8.  Pathogenesis
 The appendix is a long diverticulum extending
from the cecum. Appendicitis results when the
long lumen is occluded.Proliferation of lymphoid
tissue, associated with viral infections,
 Epstein-Barr virus, upper respiratory infection, or
 gastroenteritis, is the most common cause of
obstruction and appendicitis in young adults.
Other causes of occlusion include tumors, foreign
bodies, fecaliths, parasites, and complications of
 Crohn’s disease.

9.  Symptoms and Signs
 History is the most important component of
diagnosis.
 Missed diagnosis of appendicitis can have
severe sequelae.
 The presence of the following historical
indicators should
 be elicited: abdominal pain, usually RLQ pain
often preceded by periumbilical pain (~100%
of patients); anorexia(~100%); nausea
(90%), with vomiting (75%); progression of
abdominal pain from periumbilical to RLQ
(50%); and classic progression from vague
abdominal pain to anorexia,nausea, vomiting,
RLQ pain, and low-grade fever (50%).

10.  Physical Examination
 Careful abdominal examination with inspection,
palpation,
 and percussion often identifies the cause of
abdominal pain.Peritoneal signs, including rigidity,
rebound tenderness,and guarding, and a low-grade
fever [38°C (100.4°F)], are characteristic findings.
Rebound tenderness and sharp pain on palpation of
the McBurney point is usually elicited 2 inches from
the anterior superior iliac spine on a line drawn from
this process through the umbilicus. However, the size
of the appendix and the location of pain with
palpation may vary,so pain may occur at a remote
distance from the classic McBurney point.
 Pelvic examination should be performed in all women
 who present with RLQ pain to rule out gynecologic
causes.
 Thorough respiratory and genitourinary examination
is
 often helpful. Rectal examination is useful when the
diagnosis remains unclear.

11.  There is debate about the use of analgesics
during the
 evaluation of possible appendicitis. Traditional
practice suggested that the use of pain
medication may mask important signs or
symptoms. Studies showed mixed results,
although more recent one have shown that the
use of opiate medications
 alleviate pain without compromising, and
possibly
 enhancing, the examination. Recent studies have
shown increased pain relief on treatment when
nonsteroidal antiinflammatory pain medication is
used. This contrasts with results of prior studies.
Additional studies suggest that informed consent
is compromised by not using adequate pain
medication. Observational units and sequential
examines can be helpful.

12.  Laboratory Findings
 Many laboratory studies are performed
routinely on patients with abdominal pain.
Few, if any, are truly helpful and can be
misleading. Studies suggest the WBC count is
seldom helpful diagnostically, although if the
WBC count is <7000/mm3,appendicitis is
unlikely. A WBC count of >19,000/mm3 is
associated with an 80% probability of
appendicitis. Thepresence of neutrophilia
makes the diagnosis of appendicitis more
likely but is not diagnostic.

13.  with neutrophilia generally is accompanied by
increased C-reactive protein levels. The
presence of all three is not diagnostic, but
the absence of all three rules out
appendicitis.
 Routine use of a chemistry examination is
helpful to determine the level of dehydration.
Urinalysis commonly shows leukocytosis and
increased red blood cells and thus may be
misleading. All women of childbearing age
should have a pregnancy test. Urine markers
of acute pediatric appendicitis may help
improve diagnostic accuracy in children.

14.  Imaging Studies
 Imaging studies can delay treatment, increase cost, and
 increase radiation exposure. When the diagnosis is clear
 from the history and physical (H&P), rapid surgical consult
 should be obtained prior to imaging studies. Studies are
 helpful in less clear cases and may decrease rate of
removal of normal appendices. Current rate of negative
pathology is ~3%. CT scan is the single best test for
diagnosing appendicitis.
 It is cost-efficient and fast, and provides low radiation
 exposure when specific protocols are used. Complete
 adominal radiographs can be misleading, are not diagnostic
 in most cases, and cost about the same as CT scan

15.  . CT scan
 can be done without contrast yet without loss of accuracy.
 Use of oral contrast is difficult and unnecessary in cases
 of suspected appendicitis. Ultrasound is less invasive than
 CT, is cost-efficient, and can be useful in situations when
 CT scan is not possible. Findings are considered “normal”
 only if a normal appendix is seen. An appendix located
 retroperitoneally or in the pelvis can be difficult to
visualize.
 Ultrasound may be useful for gynecologic abnormalities
and in evaluation of pregnant patients. It also is a good
choice for children because of lack of contrast and patient
compliance.
 Focused spiral CT without contrast can be performed
 in less than an hour and is very sensitive and specific for
 appendicitis. Use of contrast may be helpful in certain
cases,especially in patients who are thin or older, and those
with unclear etiology

16.  Treatment
 Treatment consists of surgical removal of inflamed appendix
 via laparotomy or laparoscopy. Laparotomy is faster,
 simpler, and less expensive, and has a lower rate of
complications.
 Laparoscopy allows visualization of other possible
 causes of pain. Recent advances in surgical technology have
 shown other benefits of laparoscopic procedures: faster
 recovery, shorter hospital stay, and decreased postoperative
 pain. Choice of surgical options should be done on an individual
 basis and based on surgical experience and opinion at
 time of surgery. A few small studies suggest that treatment
 with antibiotics and observation can result in temporary
 resolution of symptoms but generally result in high reoccurrence
 rates. This may be an option for medically unstable
 patients or where surgery is not readily available.

17. SUMMARY

18.  What are the pt’s symptoms?
 The severity, quality, location, and
radiation of the pain can make the
diagnosis.
 Usually periumbilical or midepigastric pain
presents first (visceral pain).
 The abdominal pain then radiates and
localizes to the RLQ (parietal pain).

19.  Are there any associated symptoms?
 Commonly associated symptoms include:
 - Fever - Nausea
 - Vomiting - Anorexia
 Less common symptoms may include:
 - Diarrhea - Hematemesis
 - Hematochezia - Melena
 In appendicitis, pain typically presents before
vomiting, the reverse being true in
 acute gastroenteritis.

20.  What makes the pain better or
worse?
 The pain is usually worsened with
movement such as walking.
 The pt may find that bending the knees
toward the chest alleviates the pain.
 Intermittent resolution of pain may
indicate a perforated appendix.

21.  It is unlikely that the pt has
appendicitis if there is a desire to eat.
 Check vital signs
 Low-grade temperature is commonly
present.
 High-grade temperature and tachycardia
may indicate perforation

22.  Perform a physical exam
 Abdomen:
 Auscultate for bowel sounds.
 Look for signs of rebound or guarding, which
may indicate peritoneal irritation.
 McBurney’s point: Maximum tenderness to
palpation at about one-third away from the
anterosuperior iliac spine to the umbilicus
 Rovsing’s sign: Palpation in the LLQ elicits pain in
the RLQ.
 Obturator sign: Pain with internal rotation of a
flexed hip and knee
 Psoas sign: Pain with full extension of hip and
knee or lifting the thigh against pressure
 Rectal and pelvic exams should be performed.

23.  Consider the following labs:
 CBC to determine if WBCs are elevated
 β-hCG to rule out pregnancy
 LFTs to rule out hepatobiliary disease
 GUE may have mild pyuria or hematuria
 Amylase, usually to determine if cause is
pancreatitis; however, remember that it can be
mildly elevated with vomiting, as seen in
gastroenteritis.
 Consider imaging if clinical picture is vague
 Abdominal radiographs: Sometimes a fecalith or
sentinel loop of dilated bowel is
 seen next to the appendix.
 Abdominal ultrasound or spiral CT scan to
visualize the appendix

24.  Acute Appendicitis: Remember,
appendicitis is clinical diagnosis.
 Causes:
 Fecalith usually in adults
 Lymphoid hyperplasia usually in children
 Differential Diagnosis
 - Yersinia enterocolitica infection - Mesenteric
lymphadenitis
 - Cecal diverticulitis - Meckel’s diverticulum
 - Intussusception - Acute gastroenteritis
 - Mittelschmerz - Tubal ovarian cyst

25.  Admit pt to the hospital
 Keep pt NPO before surgery.
 Administer IV fluids.
 Start pain management.
 Begin IV antibiotic therapy.
 Obtain surgical consult

30. THANK YOU