Acute Appendicitis

Acute Appendicitis


ACUTE APPENDICITIS

  • Young males, low dietary fibre, family history, purgative abuse, faecolith
  • E.coli is the most common organism; enterococci rd most common
  • Oxyuris vermicularis (pinworm) can proliferate in the appendix and occlude the lumen
  • Appendicitis is less common after 30 years of age (as the lymphatic tissue in the submucosa decreases with age) 

Pseudoappendicitis

  • Appendicitis due to acute ileitis following Yersinia infection
  • Crohn’s disease 

Clinical features

  • Pain is the earliest feature, which is frequently first noticed at the periumbilical region
  • Soon the pain shifts to the RIF and changes in character
  • Murphy’s triad – pain, followed by vomiting and then fever
  • Pointing sign – the patient is asked to point where the pain started and where it moved
  • Rovsing’s sign – pressure in LIF causes pain in RIF
  • Psoas sign the inflamed appendix lies on the psoas muscle and the patient lies with the right hip flexed for pain relief
  • Cope’s Psoas test – hyperextension of hip causes pain in RIF in retrocaecal appendix
  • Obturator test flexion and internal rotation of hip causes pain in the hypogastrium in pelvic appendix
  • Mac Burney’s sign – guarding and maximum tenderness in the McBurney’s point
  • Blumberg (release) sign – rebound tenderness in right iliac fossa
  • Balswing’s test – in retrocaecal appendix, when legs are lifted off the bed with knee extended, patient complains pain while pressing over flanks
  • Hyperesthesia in Sherren’s triangle – lines joining ASIS, pubic symphysis and umbilicus
  • Pneumoperitoneum is not common in appendicular perforation
  • Pelvic appendix causes early diarrhea
  • Post Heal appendicitis is most difficult to diagnose
  • Appendicitis is the most common extra-uterine acute abdominal condition in pregnancy. Pain in the right lower quadrant is the cardinal feature in pregnancy 

Risk factors for perforation of appendix

  • Extremes of age
  • Immunosuppression
  • Diabetes mellitus
  • Fecolith obstruction
  • Pelvic appendix
  • Previous abdominal surgery 
  • Contrast-Enhanced CT (CECT) – investigation of choice specially in unclassical cases 

Sonographic criteria for appendicitis

  • Appendix of size > 6 mm (SABISTON > 7mm) AP diameter
  • Thick walled non continuous lumina! structure
  • Blind ending tubular structure
  • Noncompressible
  • Aperistaltic
  • Appendicolith
  • Interruption of submucosal continuity
  • Periappendicular fluid
  • Target appearance 

Surgery

  • Appendicectomy: Gridiron’s incision(McBurney’s incision) or Lanz crease incision
  • Appendicular mass is conservatively treated with Oschner Sherren’s regime
  • Majority of patients will not develop recurrence and it is no longer advisable to remove the appendix after an interval of 6-8 weeks
  • In children surgery is the only treatment of choice
Exam Question
 

Appendicitis is more common in men The risk of perforation is:

  • Less than 10 years old = 50%
  • 10-50 years old = 10%
  • Over 50 years old = 30%

Clinical features of appendicitis:

  • Central abdominal pain moving to right iliac fossa
  • Nausea, vomiting, anorexia
  • Low-grade pyrexia (37.2-37.7 degree celsius)
  • Localised tenderness in right iliac fossa
  • Right iliac fossa peritonism
  • Percussion tenderness is a kinder sign of peritonism than rebound
  • Rovsing’s sign = pain in right iliac fossa on palpation of the left iliac fossa
  • 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.
  • 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
Don’t Forget to Solve all the previous Year Question asked on Acute Appendicitis

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