Appendicitis

What is Appendicitis

The appendix is a tube that is shaped like a finger. It is connected to the large intestine.

This can lead to a life-threatening infection. It can also cause you to have sores (abscesses). These sores hurt.

Appendicitis means that this tube is swollen (inflamed). Without treatment, the tube can tear (rupture).

What are the causes?

This condition may be caused by something that blocks the appendix, such as:

  • A ball of poop (stool).
  • Lymph glands that are bigger than normal.

Sometimes, the cause is not known.

What are the signs or symptoms?

Symptoms of this condition include:

  • Pain around the belly button (navel).
    • The pain moves toward the lower right belly (abdomen).
    • The pain can get worse with time.
    • The pain can get worse if you cough.
    • The pain can get worse if you move suddenly.
  • Tenderness in the lower right belly.
  • Feeling sick to your stomach (nauseous).
  • Throwing up (vomiting).
  • Not feeling hungry (loss of appetite).
  • A fever.
  • Having a hard time pooping (constipation).
  • Watery poop (diarrhea).
  • Not feeling well.

Acute appendiceal distention initially stimulates visceral afferent pain fibers, producing vague, dull, diffuse pain in the midabdomen (periumbilical) or lower epigastrium. Low-grade fever, anorexia, nausea, and vomiting may occur after the onset of pain. The inflammatory process soon involves the serosa of the appendix and, in turn, the parietal peritoneum, producing the characteristic shift in pain to the right lower quadrant.

Where and what is McBurney’s point? 

Charles McBurney was an American surgeon born in 1845. He presented his treatise on the area of greatest abdominal pain during appendicitis in 1899. His point of maximal tenderness is located over an area at the distal two-thirds along an axis drawn from the umbilicus to the anterior superior iliac spine.

What are the psoas and obturator signs? 

The psoas sign is irritation of the retroperitoneal psoas muscle (pain on right hip extension). The obturator sign refers to internal obturator muscle (pain on internal rotation of the flexed right hip) by an inflamed retrocecal appendix.

What is the Rovsing sign? 

Palpation of the left lower quadrant leads commonly to right lower quadrant pain in acute appendicitis.

The peak incidence of acute appendicitis occurs in what age group? 

The peak incidence occurs in ages 15 to 19 years.

The risk of perforation of the appendix is highest in what age groups? 

Although the overall incidence is not as common as in the teen years, appendiceal perforation is higher in children (younger than 5 years) and older adults (i.e., those who have difficulty seeking out immediate medical attention). In some series, perforation rates approach 75%. Those with diabetes and immunosuppressed patients are also at overall higher risk for complications.

How is Appendicitis diagnosed?

What are the laboratory findings of Appendicitis

Mild leukocytosis (10,000 to 18,000/mm ) is usually present with early, uncomplicated appendicitis. C-reactive protein is elevated as well, with a sensitivity of 93% and a specificity of 80%.

How is this treated?

Usually, this condition is treated by taking out the appendix (appendectomy). There are two ways that the appendix can be taken out:

  • Open surgery. In this surgery, the appendix is taken out through a large cut (incision). The cut is made in the lower right belly. This surgery may be picked if:
    • You have scars from another surgery.
    • You have a bleeding condition.
    • You are pregnant and will be having your baby soon.
    • You have a condition that does not allow the other type of surgery.
  • Laparoscopic surgery. In this surgery, the appendix is taken out through small cuts. Often, this surgery:
    • Causes less pain.
    • Causes fewer problems.
    • Is easier to heal from.

What is the surgical mortality rate for nonperforated appendicitis and for perforated appendicitis? 

The mortality rate is less than 0.1% for nonperforated and as high as 3% for perforated appendicitis. In older adults, the mortality rate for perforated appendicitis can be as high as 15%.

If your appendix tears and a sore forms:

  • A drain may be put into the sore. The drain will be used to get rid of fluid.
  • You may get an antibiotic medicine through an IV tube.
  • Your appendix may or may not need to be taken out.

Differential diagnosis for right lower quadrant pain both in women and in children

The list is considerably longer for women than for men. It includes

  1. ectopic pregnancy
  2. tubo-ovarian abscess
  3. pelvic inflammatory disease (PID)
  4. Mittelschmerz
  5. ovarian torsion
  6. incarcerated hernia
  7. Crohn’s stricture or abscess
  8. diverticulitis
  9. Meckel’s diverticulitis
  10. carcinoid tumor
  11. infectious colitis
  12. cholecystitis
  13. peptic ulcer disease.

Valentino’s sign is pain secondary to gastric or biliary fluid collecting in the right lower quadrant from perforated duodenal ulcer.

In children, gastroenteritis, mesenteric adenitis, and terminal ileitis can be difficult to differentiate from appendicitis.

What is an acceptable incidence rate for negative appendectomy? Has this rate changed with the increasing use of ultrasound and computed tomography (CT) scanning? 

A negative exploration rate of 10% to 15% had been a long-standing standard of surgical care.

In contrast to some earlier large-scale epidemiologic studies showing no difference in negative appendectomy rates (NAR) with the widespread use of preoperative CT, most recent single-institution studies have found improvements, with NARs approaching less than 2%.

What other conditions may mimic acute appendicitis? 

Although numerous abdominal processes may have similar presentations, acute diverticulitis of either a redundant (i.e., right sided) sigmoid colon or the cecum itself may present with right lower quadrant pain, fever, and leukocytosis.

Typhlitis, or neutropenic enterocolitis, is a condition most commonly seen in immunocompromised patients undergoing chemotherapy and involves a breakdown of the mucosal barrier and necrosis of the intestinal wall, most commonly at the cecum.

Mesenteric lymphadenitis is a self-limiting inflammatory process involving the lymph nodes of the ileocecal region and is often exhibited in a population younger than 15 years.

What features of PID can help distinguish it from appendicitis?

High fever, cervical motion tenderness (chandelier sign), cervical discharge, pain related to menses, and tendency for bilateral pain can often differentiate PID from appendicitis.

What is the proper treatment for late or perforated appendicitis that presents as a phlegmon or abscess? 

Radiology-guided drainage (usually CT guided) is indicated in the presence of an established abscess, provided that the patient has no evidence of diffuse peritonitis or uncontrolled sepsis. Although delayed (after 6 to 8 weeks) appendectomy is not always required, rates of recurrent appendicitis can approach 20%, so many surgeons prefer to operate in an elective setting.

What is the most common complication after appendectomy? 

Wound infection is the most common surgical complication after appendectomy. In the setting of perforation or abscess, the wound edges can be left open as a delayed primary closure to prevent this complication. The laparoscopic approach has reduced this complication significantly, although intraabdominal abscess rates remain unchanged.

In what patient population is ultrasound particularly helpful in making the diagnosis of acute appendicitis? 

Ultrasound can be particularly helpful in the pediatric as well as pregnant patients, in whom CT scan is usually avoided. In addition, it is helpful to delineate any gynecologic abnormalities. A noncompressible, distended (larger than 8 mm), painful tubular structure on ultrasound predicts appendicitis, with reported sensitivity of 84% to 94% and specificity of 92%.

During an abdominal exploration for right lower quadrant pain, is removal of a normal appendix appropriate in patients with Crohn’s disease? 

Yes. If the base of the appendix and the surrounding area of the cecum are free of disease, an appendectomy should still be performed in the setting of Crohn’s disease. If an enterocutaneous fistula develops postoperatively, it almost always results from diseased terminal ileum rather than the appendiceal stump.

Is an appendectomy during pregnancy a safe procedure? Is laparoscopic appendectomy safe? 

Acute appendicitis is the most frequently encountered extrauterine disease requiring surgery during pregnancy. The appendix shifts superiorly above the right iliac crest by the fourth month of pregnancy. Abdominal tenderness is less localized because the inflamed appendix is no longer near the parietal peritoneum. These factors, along with the leukocytosis of pregnancy as well as the limited use of CT, can make the clinical diagnosis more difficult. Fetal loss increases from 5% in simple appendicitis to 28% if there is perforation; therefore early intervention is the rule if appendicitis is suspected. Laparoscopic appendectomy has been extensively used during pregnancy. Although prospective trials are lacking, it is generally accepted as safe during all trimesters; however, there is some controversy regarding possible increased risk of fetal loss or preterm labor (up to 9% with both open and laparoscopic techniques). Lowering the pressure of pneumoperitoneum to 10 to 12 mm Hg, using a left-side tilt to decrease pressure from the gravid uterus on the vena cava and an open Hassan entry technique are widely accepted options to decrease operative risk.

If an ovarian tumor is discovered during laparoscopic or open exploration, what steps should be taken? 

The normal appendix should be removed after obtaining peritoneal washings, which are studied for tumor cytologic findings. The ovarian mass itself should not be touched or biopsied. Ovarian cancer is staged with a strictly performed technique and should be done at a later procedure.

Does nonoperative therapy have any role in treating acute appendicitis? 

Treating appendicitis with antibiotics alone is not common practice in North America. European studies have shown some success, but they have documented high recurrence rates (up to 40%) and high costs of delivery. “Interval” appendectomy is more often seen after resolution of contained abscess or inflammation by antibiotics (with or without catheter drainage) in patients after perforation.

What is “stump appendicitis”? 

Stump appendicitis is a rare but increasingly recognized entity in which patients who have had their appendix removed develop delayed (days to years following surgery) right lower quadrant pain and leukocytosis similar to their initial presentation. The entity relates to a small portion of appendiceal lumen left in place during surgery. A recent metaanalysis did not show differences in occurrence rates between laparoscopic and open procedures. A high index of suspicion is often needed to make the diagnosis, and treatment ranges from antibiotic therapy to surgical excision.

What is a Mitrofanoff procedure? 

A Mitrofanoff appendicovesicostomy is a procedure performed to obviate the need for urethral catheterization in those with neurogenic bladder (such as patients with spina bifida). The appendix is removed from its attachments to the cecum while maintaining its blood supply; then one end is sutured to the urinary bladder and the other end is sutured to the skin to form a stoma, usually near the umbilicus.

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