Summary about appendicitis including Hx, examinations, ddx & Tx

1. Acute appendicitis
is the acute inflammation of the appendix
Uncomplicated app. (no perforation, gangrene, abscess, or mass)
Complicated app. (app. with perforation, gangrene, abscess, an inflammatory mass)
Definition
Etiology
Caused by obstruction of the appendiceal lumen due to:
• Lymphoid tissue hyperplasia (60% of cases)
Most common cause in children and young adults
• Appendiceal fecalith and fecal stasis (35% of cases)
Most common cause in adults
• Neoplasm (uncommon)
More likely in patients > 50 years of age
• Parasitic infestation
Pathophysiology
1- Obstructed appendiceal lumen:
• Stasis of mucosal secretions → bacterial multiplication and local inflammation → clinical
features of appendicitis
• Inc. intraluminal press. → obstruction of veins → edema → obstruction of capillaries →
ischemia → gangrenous appendicitis with/without perforation
2- Inflammation can spread to serosa, leading to peritonitis
Clinical features
A- Signs and Symptoms
1- Migrating abdominal pain
• Initial diffuse periumbilical pain (visceral peritoneum)
• Localizes to the RLQ ∼ 12–24 h parietal peritoneum
2- Nausea
3- Anorexia
4- Vomiting
5- Low-grade fever
6- Diarrhea or Constipation
B- Clinical Signs
1- McBurney point tenderness
RLQ tenderness, RLQ guarding and/or rigidity, Rebound tenderness (Blumberg sign)
2- Rovsing sign
3- Psoas sign
4- Obturator sign
-
-
.
-
L
-
L
y
-
-
-
-
L S
-
-
-
Y
-S S
S
-
-
-
- .
- R
u -
-
-S S
-
&

2. Alvarado score (MANTRELS)
Alvarado score (MANTRELS) [26]
Characteristics Score
Symptoms
Migration of pain to RLQ 1
Anorexia 1
Nausea and/or vomiting 1
Physical examination
Tenderness in RLQ 2
Rebound pain 1
Elevated temperature > 37.3°C (99.1°F) 1
Laboratory parameters
Leukocytosis (> 10,000/mm3) 2
Shift to the left (≥ 75% neutrophils) 1
Likelihood of appendicitis
• ≤ 4: Low [16]
• 5–6: Moderate
• ≥ 7: High [16]
Diagnostics
1- History
• Migrating Abdominal Pain
• Vomiting and/or Nausea
• Anorexia
2- Physical Examination
• Tenderness
• Rebound Tenderness
• +ve Rovsing Sign , Psoas Sign, obturator Sign
• Fever
3- Laboratory studies
• CBC —> Elevated WBC > 10k (Neutrophils > 75%)
• Elevated CRP
• Urine / serum B-hCG Test
4- Imaging
• Abdominal U / S (Distended appendix (diameter > 6 mm)) + Target sign
• Abdominal CT-scan with IV contrast
• MRI Without IV Contract (for pregnant if u/s don’t Dx), MRI + IV contrast for
patient contraindications CT scan (non-pregnancy)
5- laparoscopy
-
-
- -
⑨@π.
.
.
.
.
.
.
.
.
.

3. Treatment
1- Supportive Care
• Bowel Rest (NPO)
• IV Fluids + Analgesics
2- Antibiotic Therapy (coverage gram -ve and anaerobic organisms)
• cephalosporin
• Combination therapy (cephalosporin + metronidazole)
3- Operative management (Appendectomy within 24h of Dx)
• Relative contraindications
◦ Appendiceal mass
◦ Appendicular abscess >4cm
May be required if there are signs of septic shock or generalized peritonitis
May be required if can’t percutaneous drainage of the abscess
-
I
↑↑
-
I
-
-
1
⑤=
I
↳
---
↓