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
Alvardo score
|
Symptoms |
Score |
Signs |
Score |
Laboratory |
Score |
|
Migratory RIF pain Anorexia Nausea and Vomiting |
1 1 1 |
RIF tenderness Rebound tenderness Elevated temperature |
2 1 1 |
Leucocytosis Shift to left |
2 1 |
- A score of 7 or more is strongly predictive of acute appendicitis
Risk factors for perforation of appendix
- Extremes of age
- Immunosuppression
- Diabetes mellitus
- Fecolith obstruction
- Pelvic appendix
- Previous abdominal surgery
v 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
- During an operation for presumed appendicitis, the patient appendix is found to be markedly thickened and feels rubbery to firm. The serosa is edematous and inflamed and the mesentery is thickened with fat growing about the bowel circumference. Most likely diagnosis is Ileal Crohn’s disesase.
- In a case of retrocecal appendicitis ,extension movement aggravates pain.
- A female who underwent laproscopic appendicectomy for acute appendicitis, on post op. day 2 bumped her nose on to a table. She developed difficulty in breathing and examination showed a swelling in the anterior part of the nasal septum. Next line of management is Incision and Drainage.
- Three hours after an uneventful appendectomy, a previously healthy (except for appendicitis) 78 year old man becomes disoriented and confused. He repeatedly asks the nurses where he is, and his speech pattern is disorganized and rambling. His temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 70/min, and respirations are 18/min. The patient is uncooperative, but shows no physical abnormalities. Mental status examination is not possible because of an altered level of consciousness. Laboratory studies show no abnormalities.Delirium is the most likely diagnosis.
- A 23-year-old man is admitted to the hospital through the emergency department with probable appendicitis. He has been having right lower quadrant abdominal pain for several days, which has been becoming increasingly worse. His temperature 39.2 C (102.6 F), blood pressure is 80/40 mm Hg, Pulse is 120/min, and Respiratory rate is 35/min. The abdomen is rigid with guarding. Multiple petechiae and purpura are present, and the patient is oozing blood from his oral mucosa. According to the patient’s wife, he has not had bleeding problems in the past. The fact the abdomen is rigid with guarding suggests Peritonitis.
ALVARADO SCORE in Appendicitis:
| Migratory right iliac fossa pain | 1 |
| Anorexia | 1 |
| Nausea/ vomiting | 1 |
| RLQ tenderness | 2 |
| Rebound tenderness | 1 |
| Elevated temperature | 1 |
| Leukocytosis | 2 |
| Left shift | 1 |
| Total | 10 |
- Ochsner-Sherren regimen is used in the management of Appendicular mass.
- Rovsing’s sign, Obturator sign and Psoas sign are seen in appendicitis..
- Appendicitis like syndrome is caused by : Yersinia enterocolitica ,Yersinia pseudotuberculosis , Pasteurella septica.
- Appendicitis is diagnosed by TLC & DLC and USG.
- When acute appendicitis is suspected, it can be confirmed by Clinical examination,USG and CT scan.
- Diffuse peritonitis in acute appendicitis is caused due to early rupture of Appendix.
- Earliest symptoms in acute appendicitis is pain.
- Acute Appendicitis is due to Faecoliths & Worms of ileo-caecal region.
- Early complications arising after appendicectomy for acute appendicitis are Ileus , Intestinal obstruction, Pulmonary complications.
- All are useful in acute appendicitis : Antibiotics ,Analgesics , IV Fluids.
- About McBurney’s incsion:Most suitable if the diagnosis of appendicitis is definite,If it is converted into a muscle cutting incision it is called Rutherford Morison’s incision,Inguinal hernia is a sequlae of the incision.
- Diffuse peritonitis following appendicitis is usually seen -when appendicular perforation occurs early (within 24 hours).
- Aaron’s Sign is seen in Acute Appendicitis.
- The term “Left sided appendicitis” as popularly called is nothing but Diverticulitis.
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.
- Investigation of choice for acute appendicitis in children is USG.
Don’t Forget to Solve all the previous Year Question asked on Appendicitis
