ACUTE APPENDICITIS

Nasal septal hematoma is a rare but potentially serious complication of nasal trauma.

The trauma allows blood to pass into both mucoperichondrial planes.

Because the septal cartilage has no blood supply of itself and receives all of its nutrients and oxygen from the perichondrium, untreated septal hematoma may lead to destruction of the septum resulting in a saddle nose deformity.

Immediate drainage is necessary.

Yersinia enterocolitica is the pathogen producing this clinical syndrome.

Yersinia is transmitted to patients via the oral route, via contaminated blood products, or by cutaneous inoculation.

Patients developing iron overload because of multiple transfusions (i.e., thalassemia patients) are at increased risk of Yersinia infections because some strains are unable to synthesize bacterial iron chelators called siderophores.

They can, however, use host-chelated iron stores or the drug deferoxamine (a siderophore produced by Streptomyces pilosus).

Yersinia is associated with reactive arthritis following an infection by an enteropathogenic organism.

Most patients who develop arthritis express HLA-B27.

Ans. is ‘b’ i.e., The specificity of temperature greater than 37.5°C as a marker for appendicitis is 42/70

o Suppose, there are 100 persons, then

Persons with the disease (appendicitis) —> 30 Persons without the disease  —> 70

o Assume that the screening criteria for the presence of appendicitis is temperature above 37.5°C

o First,

No. of persons with the disease

We know that the no. of persons with appendicitis are                   —> 30

No of patients with appendicitis and with temp > 37.5°c                  —>70%= 70×30/100 = 21

These patients are true positive

No. of patients with appendicitis but without temperature elevation –> 30-21 =9 These patient are false negative.

o Now

Total no of persons without the disease –> 70

No. of persons without the disease but with temperature elevated —> 40×70/ 100 = 28 These patient are false positive cases.

Persons without appendicitis who also do not have temperature elevation —> 70-28 = 42 These are true negative

Screening test                                        Patient with                                           Patient without

(fever) results                                         appendicitis                                          appendicitis

Fever present                                         21(True postive)                                  28 (False positive)

Fever not present                                  9 (false negative)                                 42 (true negative)

o Specificity = True negative/True negative + False positive = 42/42+28 = 42/70

o Sensitivity = True positive/True positive + False negative = 21/21+9 = 21/30

o Positive predictive value = True positive/(true+false) postive = 21/21+28 = 21/49

o Negative predictive value = True negative/(true+false) negative = 42/42+9 = 42/51

Ans. is ‘d’ i.e., Yersinia enterocolitica 

Ans. is a, b, c, and d ie Clinical examination, USG, CT scan and Blood counts 

As described in the above question, the diagnosis of appendicitis is primarily clinical, assisted by blood counts. Ultrasound and CT can be utilized to make the diagnosis in equivocal cases.

Lets also see the management of appendicitis:

Management of appendicitis:  [Ref Sabiston 18/e p1339; Schwartz 9/e p1084]

The treatment of appendicitis is appendectomy. (It can be done open or laparoscopically)

Prophylactic antibiotics are indicated preoperatively. Postoperative antibiotic coverage is of no use in simple (uncomplicated) acute appendicitis. If perforated or gangrenous appendicitis is found, antibiotics are continued until the patient is afebrile and has a normal white blood cell count.

Perforated Appendicitis (Maingot’s 11/e p603)

Rupture is suspected in the presence of fever with a temperature of >39°C (102°F) and a white blood cell count of >18,000 cells/mm3.

The management of perforation depends on the nature of the perforation.

If the perforation is free causing intraperitoneal dissemination of pus and fecal material, urgent laparotomy is done for appendectomy and irrigation and drainage of the peritoneal cavity.

If the perforation is contained it would result in an appediceal mass or abscess. This is managed as described under.

Appendiceal Abscess/ Mass

Patients who present late in the course of appendicitis with a palpable or radiographically documented mass (abscess or phlegmon) are treated with‑

conservative therapy and interval appendectomy 6 to 10 weeks later.

(conservative management includes intravenous antibiotics and fluids as well as bowel rest.)

– Patients with large abscesses, greater than 4 to 6 cm in size, and especially those patients with abscess and high fever, benefit from abscess drainage.

Patients who continue to have fever, persistent pain and leukocytosis or develop complications like bowel obstruction after several days of nonoperative treatment are likely to require immediate appendectomy during the same hospitalization, whereas those who improve promptly may be considered for interval appendectomy. Bailey lists Criteria for stopping conservative treatment and going for appendectomy

A rising pulse rate

–  increasing or spreading abdominal pain

–   increasing size of the mass

Ans is ‘a’ i.e. Early rupture of appendix

Perforation of appendix in acute appendicitis commonly leads to an abscess cavity walled off by the small bowel loops and the omentum, forming a phlegmon. Rarely the appendix may perforate freely into the peritoneal cavity and cause generalized peritonitis. This usually occurs in cases of early rupture of the appendix as inflammatory process did not get time to be localized by the omentum and bowel loops.

Usually the rupture of appendix is a late sequelae of appendicitis, usually occurring 48 to 72 hours from the onset of symptoms.

Ans. is ‘a’ i.e., Periumbilical pain 

Acute appendicitis begins as periumbilical pain, which is a visceral pain followed by anorexia and nausea; then, the pain shifts to the right lower quadrant due to peritoneal irritation.

Clinical features :

• The classical features of acute appendicitis begin with poorly localized colicky abdominal pain.
• This is due to midgut visceral discomfort in response to appendiceal inflammation and obstruction.
• The pain is frequently first noticed in the periumbilical region.

Symptoms of appendicitis

• Periumbilical colic
• Pain shifting to the right iliac fossa
• Anorexia
• Nausea 

Clinical signs in appendicitis

• Pyrexia
• Localized tenderness in the right iliac fossa
• Muscle guarding
• Rebound tenderness

Ans. D

• Appendicitis is clearly associated with bacterial proliferation within the appendix, a mixed growth of aerobic and anaerobic organisms is usual (no single organism is responsible).
• Obstruction of the appendix lumen either by a faecolith or a stricture.
• Obstruction of the appendiceal orifice by a tumor.
• Intestinal parasites, particularly Oxyuns vermicularis (pinworm), can proliferate in the appendix and occlude the lumen.

Ans. is ‘b’ i.e., Sterility 

1. Wound infection

• Wound infection is the most common postoperative complication, occurring in 5-10% of all patients. 
• This usually presents with pain and erythema of the wound on the fourth or fifth postoperative day, often soon after hospital discharge.

2. Intraabdominal abscess

• Approximately 87% of patients following appendectomy will develop a postoperative intra-abdominal abscess.

3. Ileus

• Ileus persisting for more than 4 or 5 days, particularly in the presence of a fever, is indicative of continuing intra-abdominal sepsis.

4. Respiratory

• In the absence of concurrent pulmonary disease, respiratory complications are rare following appendicectomy.

5. Venous thrombosis and embolism
6. Portal pyemia

• This is a rare but very serious complication of gangrenous appendicitis associated with high fever, rigors, and jaundice.

7. Fecal fistula

• Leakage from the appendicular stump occurs rarely but may follow if the encircling stitch has been put in too deeply or if the caecal wall was involved by edema or inflammation.

8. Adhesive intestinal obstruction

• This is the most common late complication of appendicectomy.

Ans. is ‘d’ i.e., Purgation 

Non-operative management-

• Treatment is bowel rest and intravenous antibiotics, often metronidazole and 3rd generation cephalosporin.

• Analgesics are given to relieve the pain.

Surgical management-

• The traditional treatment for acute appendicitis is appendicectomy.

Ans. is ‘C’  

• Aure-Rozanova’s sign: Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg’s).
• Bartomier-Michelson’s sign: Increased pain on palpation at the right iliac region as the person being examined lies on his or her left side compared to when he/she lies on the back.
• Dunphy’s sign: Increased pain in the right lower quadrant with coughing.
• Hamburger sign: The patient refuses to eat (anorexia is 80% specific for appendicitis)
• Kocher’s (Kosher’s) sign: From the person’s medical history, the start of pain in the umbilical region with a subsequent shift to the right iliac region.
• Massouh sign: Developed in and popular in southwest England, the examiner performs a firm swish with his or her index and middle finger across the abdomen from the xiphoid process to the left and the right iliac fossa. A positive Massouh sign is a grimace of the person being examined upon a right sided (and not left) sweep.
• Obturator sign: The person being evaluated lies on her or his back with the hip and knee both flexed at ninety degrees. The examiner holds the person’s ankle with one hand and knee with the other hand. The examiner rotates the hip by moving the person’s ankle away from his or her body while allowing the knee to move only inward. A positive test is pain with internal rotation of the hip.
• Psoas sign, also known as “Obraztsova’s sign”, is right lower-quadrant pain that is produced with either the passive extension of the right hip or by the active flexion of the person’s right hip while supine. The pain that is elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and causes pain.
• Rovsing’s sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon). The thought is there will be increased pressure around the appendix by pushing bowel contents and air toward the ileocaecal valve provoking right-sided abdominal pain.
• Sitkovskiy (Rosenstein)’s sign: Increased pain in the right iliac region as the person is being examined lies on his/her left side

Ans. C: Fever > 42-degree celsius

• The classical features of acute appendicitis begin with poorly localized colicky abdominal pain.
• Appendicitis usually starts with periumbilical and diffuse pain that eventually localizes to the right lower quadrant (sensitivity, 81%; specificity, 53%).
• Appendicitis is also associated with gastrointestinal symptoms like nausea, vomiting and anorexia.
• Diarrhea may occur in association with perforation, especially in children.
• The body temperature and pulse rate may be normal or slightly elevated.
• Patients with appendicitis usually move slowly and prefer to lie supine due to the peritoneal irritation.
• On abdominal palpation, there is the tenderness with a maximum at or near McBurney’s point.
• Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness (i.e., pain in the right lower quadrant when the left lower quadrant is palpated) are strong indicators of peritoneal irritation.
• Pain with an extension of the right leg (psoas sign) indicates a focus of irritation in the proximity of the right psoas muscle.
• Similarly, stretching of the obturator internus through internal rotation of a flexed thigh (obturator sign) suggests inflammation near the muscle.

Ans. b. Ultrasound

‘Abdominal ultrasound detects a dilated (<6 mm) tubular, aperistaltic structare which is not compressible and is
surrounded by fluid. Ultrasound has a sensitivity of 85%-90% and specificity of 95-100% diagnosing appenticitis.