Date post: | 04-Jun-2018 |
Category: |
Documents |
Upload: | kadek-ariarta-mahartama |
View: | 229 times |
Download: | 0 times |
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 127
Acute Appendicitis Review and Update
D MIKE HARDIN JR MDTexas AampM University Health Science Center Temple Texas
Appendicitis is common with a lifetime occurrence of 7 percent Abdominal pain and anorexia are thepredominant symptoms The most important physical examination finding is right lower quadrant tenderness to
palpation A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and
supporting the presence or absence of appendicitis while appendiceal computed tomographic scans and
ultrasonography can be helpful in equivocal cases Delay in diagnosing appendicitis increases the risk of
perforation and complications Complication and mortality rates are much higher in children and the elderly (Am
Fam Physician 1999602027-34)
A ppendicitis is the most common acute surgical condition of the abdomen1 Approximately 7 percent of the
population will have appendicitis in their lifetime2 with the peak incidence occurring between the ages of 10 and30 years3
Despite technologic advances the diagnosis of appendicitis is still based primarily on the patients history and the
physical examination Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent
complications 4 The mortality rate in nonperforated appendicitis is less than 1 percent but it may be as high as 5
percent or more in young and elderly patients in whom diagnosis may often be delayed thus making perforation
more likely1
Pathogenesis
TABLE 1 Common Symptoms of Appendicitis
Common symptomsFrequency()
Abdominal pain ~100
Anorexia ~100
Nausea 90
Vomiting 75
Pain migration 50
Classic symptom sequence (vagueperiumbilical pain toanorexianauseaunsustainedvomiting to migration of pain to rightlower quadrant to low-grade fever)
50
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 227
The appendix is a long diverticulum that extends from the
inferior tip of the cecum5 Its lining is interspersed with
lymphoid follicles3 Most of the time the appendix has an
intraperitoneal location (either anterior or retrocecal) and
thus may come in contact with the anterior parietal peritoneum when it is inflamed Up to 30 percent of the time
the appendix may be hidden from the anterior peritoneum by being in a pelvic retroileal or retrocolic
(retroperitoneal retrocecal) position6 The hidden position of the appendix notably changes the clinical
manifestations of appendicitis
Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis Obstruction has
multiple causes including lymphoid hyperplasia (related to viral illnesses including upper respiratory infection
mononucleosis gastroenteritis) fecaliths parasites foreign bodies Crohns disease primary or metastatic cancer
and carcinoid syndrome Lymphoid hyperplasia is more common in children and young adults accounting for the
increased incidence of appendicitis in these age groups15
History and Physical Examination
Abdominal pain is the most common symptom of appendicitis 3 In multiple studies3-5 specific characteristics of the
abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis ( Table
1) A thorough review of the history of the abdominal pain and of the patients recent genitourinary gynecologic
and pulmonary history should be obtained
Anorexia nausea and vomiting are symptoms that are commonly associated with acute appendicitis The classic
history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50
percent of patients1 Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis1
TABLE 2 Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis
Symptomsign Positive likelihood ratio (LR+) Symptomsign
Negativelikelihoodratio (LR-)
Right lower quadrant
(RLQ) pain
80 RLQ painsect 0 to 028dagger
Pain migration 32 No similar painpreviously||
03
Pain before vomiting 28 Pain migration 05
Anorexia nausea andvomiting
Much lower LR+ than RLQ pain painmigration and pain before vomiting
Guarding 0 to 054dagger
Rigidity 376 Rebound tenderness 0 to 086dagger
Psoas sign 238 Fever rigidity and
--Onset of symptoms typically within past 24 to36 hoursInformation from references 3 through 5
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 327
psoas signpara
Rebound tenderness 11 to 63dagger
Fever 19Dagger
Guarding and rectaltenderness
Much lower LR+ than rigidity psoassign and rebound tenderness
NOTE LR is the amount by which the odds of a disease change with new information as follows
Likelihood ratio Degree of change in probability
gt10 or lt01 Large (often conclusive)
5 to 10 or 01 to 02 Moderate
2 to 5 or 02 to 05 Small (but sometimes important)
1 to 2 or 05 to 1 Small (rarely important)
--These symptoms and signs have much lower LR+dagger--Ratios are presented in ranges for signs and symptoms that had widely varying results in studiesDagger--Fever had only borderline LR+
sect--That is the absence of RLQ pain significantly lowers the odds of having appendicitis||--That is the history of experiencing a similar pain previously lowers the odds of having appendicitispara--These signs have higher LR-Information from references 7 8 and 19
In a recent meta-analysis7 likelihood ratios were calculated for many of these symptoms (Table 2) A likelihood
ratio is the amount by which the odds of a disease change with new information (eg physical examination
findings laboratory results)8 This change can be positive or negative Symptoms such as anorexia nausea and
vomiting commonly occur in acute appendicitis however the presence of these symptoms does not necessarily
increase the likelihood of appendicitis nor does their absence decrease the likelihood of the diagnosis Moreover
other symptoms have more notable positive and
negative likelihood ratios (Table 2)
TABLE 3 Common Signs of Appendicitis
bull Right lower quadrant pain on palpation (the singlemost important sign)bull Low-grade fever (38degC [or 1004degF])--absence of feveror high fever can occurbull Peritoneal signs
bull Localized tenderness to percussionbull Guardingbull Other confirmatory peritoneal signs (absence of thesesigns does not exclude appendicitis)bull Psoas sign--pain on extension of right thigh(retroperitoneal retrocecal appendix)bull Obturator sign--pain on internal rotation of right thigh(pelvic appendix)bull Rovsings sign--pain in right lower quadrant with
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 427
A careful systematic examination of the abdomen is
essential While right lower quadrant tenderness to
palpation is the most important physical examination
finding other signs may help confirm the diagnosis
(Table 3) The abdominal examination should begin
with inspection followed by auscultation gentle
palpation (beginning at a site distant from the pain) and
finally abdominal percussion The rebound tenderness that is associated with peritoneal irritation has been shown
to be more accurately identified by percussion of the abdomen than by palpation with quick release 1
As previously noted the location of the appendix varies When the appendix is hidden from the anterior
peritoneum the usual symptoms and signs of acute appendicitis may not be present Pain and tenderness can
occur in a location other than the right lower quadrant 6 A retrocecal appendix in a retroperitoneal location may
cause flank pain In this case stretching the iliopsoas muscle can elicit pain The psoas sign is elicited in this
manner the patient lies on the left side while the examiner extends the patients right thigh ( Figures 1a and 1b) In
contrast a patient with a pelvic appendix may show no abdominal signs but the rectal examination may elicit
tenderness in the cul-de-sac In addition an obturator sign (pain on passive internal rotation of the flexed right
thigh) may be present in a patient with a pelvic appendix3 ( Figures 2a and 2b)
FIGURE 1A The psoas sign Pain on passiveextension of the right thigh Patient lies on left sideExaminer extends patients right thigh while applyingcounter resistance to the right hip (asterisk)
FIGURE 2A The obturator sign Pain on passive internalrotation of the flexed thigh Examiner moves lower leg laterallywhile applying resistance to the lateral side of the knee(asterisk) resulting in internal rotation of the femur
palpation of left lower quadrantbull Dunphys sign--increased pain with coughingbull Flank tenderness in right lower quadrant(retroperitoneal retrocecal appendix)bull Patient maintains hip flexion with knees drawn up forcomfort
Information from references 3 through 5
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 527
FIGURE 1B Anatomic basis for the psoas signinflamed appendix is in a retroperitoneal location incontact with the psoas muscle which is stretched bythis maneuver
FIGURE 2B Anatomic basis for the obturator sign inflamedappendix in the pelvis is in contact with the obturator internusmuscle which is stretched by this maneuver
The differential diagnosis of appendicitis is broad but the patients history and the remainder of the physical
examination may clarify the diagnosis (Table 4) Because many gynecologic conditions can mimic appendicitis a
pelvic examination should be performed on all women with abdominal pain Given the breadth of the differential
diagnosis the pulmonary genitourinary and rectal examinations are equally important Studies have shown
however that the rectal examination provides useful information only when the diagnosis is unclear and thus can
be reserved for use in such cases5
TABLE 4 Differential Diagnosis of Acute Appendicitis
Gastrointestinal Abdominal paincause unknownCholecystitis
GynecologicEctopicpregnancyEndometriosis
PulmonaryPleuritisPneumonia(basilar)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 627
Laboratory and Radiologic Evaluation
If the patients history and the physical examination do
not clarify the diagnosis laboratory and radiologic
evaluations may be helpful A clear diagnosis of
appendicitis obviates the need for further testing and
should prompt immediate surgical referral
Laboratory Tests
The white blood cell (WBC) count is elevated (greater
than 10000 per mm3 [100 3 109 per L]) in 80 percent of
all cases of acute appendicitis9 Unfortunately the WBC
is elevated in up to 70 percent of patients with other
causes of right lower quadrant pain10 Thus an elevated
WBC has a low predictive value Serial WBC
measurements (over 4 to 8 hours) in suspected cases
may increase the specificity as the WBC count often
increases in acute appendicitis (except in cases of
perforation in which it may initially fall)5
In addition 95 percent of patients have neutrophilia1 and in the elderly an elevated band count greater than 6
percent has been shown to have a high predictive value for appendicitis9 In general however the WBC count and
differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low
specificities
A more recently suggested laboratory evaluation is determination of the C-reactive protein level An elevated C-
reactive protein level (greater than 08 mg per dL) is common in appendicitis but studies disagree on its
sensitivity and specificity45 An elevated C-reactive protein level in combination with an elevated WBC count and
neutrophilia are highly sensitive (97 to 100 percent) Therefore if all three of these findings are absent the chance
of appendicitis is low5
In patients with appendicitis a urinalysis may demonstrate changes such as mild pyuria proteinuria and
hematuria1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose
appendicitis
Crohns diseaseDiverticulitisDuodenal ulcerGastroenteritisIntestinalobstruction
IntussusceptionMeckelsdiverticulitisMesentericlymphadenitisNecrotizingenterocolitisNeoplasm(carcinoidcarcinomalymphoma)Omental torsionPancreatitis
Perforated viscusVolvulus
Ovarian torsionPelvicinflammatorydiseaseRupturedovarian cyst
(follicularcorpusluteum)Tubo-ovarianabscessSystemic DiabeticketoacidosisPorphyriaSickle celldiseaseHenoch-Schoumlnlein
purpura
PulmonaryinfarctionGenitourinary Kidney stoneProstatitisPyelonephritis
TesticulartorsionUrinary tractinfectionWilms tumorOther ParasiticinfectionPsoas abscessRectus sheathhematoma
Reprinted with permission from Graffeo CSCounselman FL Appendicitis Emerg Med Clin North Am 199614653-71
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 727
Radiologic Evaluation
The options for radiologic evaluation of patients with suspected
appendicitis have expanded in recent years enhancing and
sometimes replacing previously used radiologic studies
Plain radiographs while often revealing abnormalities in acute
appendicitis lack specificity and are more helpful in diagnosing
other causes of abdominal pain Likewise barium enema is now
used infrequently because of the advances in abdominal imaging 5
Ultrasonography and computed tomographic (CT) scans are helpful
in evaluating patients with suspected appendicitis11 Ultrasonography
is appropriate in patients in which the diagnosis is equivocal by
history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in
pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is
noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory
bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can
cause false-positive ultrasonography results12
FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix
TABLE 5 Comparison of Ultrasound and
Appendiceal CT Evaluation of
Suspected Appendicitis
Comparisongradedultrasound
Appendicealcomputedtomographicscan
Sensitivity 85 90 to 100
Specificity 92 95 to 97
Use Evaluatepatients withequivocaldiagnosis ofappendicitis
Evaluatepatients withequivocaldiagnosis ofappendicitis
Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females
More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 227
The appendix is a long diverticulum that extends from the
inferior tip of the cecum5 Its lining is interspersed with
lymphoid follicles3 Most of the time the appendix has an
intraperitoneal location (either anterior or retrocecal) and
thus may come in contact with the anterior parietal peritoneum when it is inflamed Up to 30 percent of the time
the appendix may be hidden from the anterior peritoneum by being in a pelvic retroileal or retrocolic
(retroperitoneal retrocecal) position6 The hidden position of the appendix notably changes the clinical
manifestations of appendicitis
Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis Obstruction has
multiple causes including lymphoid hyperplasia (related to viral illnesses including upper respiratory infection
mononucleosis gastroenteritis) fecaliths parasites foreign bodies Crohns disease primary or metastatic cancer
and carcinoid syndrome Lymphoid hyperplasia is more common in children and young adults accounting for the
increased incidence of appendicitis in these age groups15
History and Physical Examination
Abdominal pain is the most common symptom of appendicitis 3 In multiple studies3-5 specific characteristics of the
abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis ( Table
1) A thorough review of the history of the abdominal pain and of the patients recent genitourinary gynecologic
and pulmonary history should be obtained
Anorexia nausea and vomiting are symptoms that are commonly associated with acute appendicitis The classic
history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50
percent of patients1 Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis1
TABLE 2 Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis
Symptomsign Positive likelihood ratio (LR+) Symptomsign
Negativelikelihoodratio (LR-)
Right lower quadrant
(RLQ) pain
80 RLQ painsect 0 to 028dagger
Pain migration 32 No similar painpreviously||
03
Pain before vomiting 28 Pain migration 05
Anorexia nausea andvomiting
Much lower LR+ than RLQ pain painmigration and pain before vomiting
Guarding 0 to 054dagger
Rigidity 376 Rebound tenderness 0 to 086dagger
Psoas sign 238 Fever rigidity and
--Onset of symptoms typically within past 24 to36 hoursInformation from references 3 through 5
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 327
psoas signpara
Rebound tenderness 11 to 63dagger
Fever 19Dagger
Guarding and rectaltenderness
Much lower LR+ than rigidity psoassign and rebound tenderness
NOTE LR is the amount by which the odds of a disease change with new information as follows
Likelihood ratio Degree of change in probability
gt10 or lt01 Large (often conclusive)
5 to 10 or 01 to 02 Moderate
2 to 5 or 02 to 05 Small (but sometimes important)
1 to 2 or 05 to 1 Small (rarely important)
--These symptoms and signs have much lower LR+dagger--Ratios are presented in ranges for signs and symptoms that had widely varying results in studiesDagger--Fever had only borderline LR+
sect--That is the absence of RLQ pain significantly lowers the odds of having appendicitis||--That is the history of experiencing a similar pain previously lowers the odds of having appendicitispara--These signs have higher LR-Information from references 7 8 and 19
In a recent meta-analysis7 likelihood ratios were calculated for many of these symptoms (Table 2) A likelihood
ratio is the amount by which the odds of a disease change with new information (eg physical examination
findings laboratory results)8 This change can be positive or negative Symptoms such as anorexia nausea and
vomiting commonly occur in acute appendicitis however the presence of these symptoms does not necessarily
increase the likelihood of appendicitis nor does their absence decrease the likelihood of the diagnosis Moreover
other symptoms have more notable positive and
negative likelihood ratios (Table 2)
TABLE 3 Common Signs of Appendicitis
bull Right lower quadrant pain on palpation (the singlemost important sign)bull Low-grade fever (38degC [or 1004degF])--absence of feveror high fever can occurbull Peritoneal signs
bull Localized tenderness to percussionbull Guardingbull Other confirmatory peritoneal signs (absence of thesesigns does not exclude appendicitis)bull Psoas sign--pain on extension of right thigh(retroperitoneal retrocecal appendix)bull Obturator sign--pain on internal rotation of right thigh(pelvic appendix)bull Rovsings sign--pain in right lower quadrant with
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 427
A careful systematic examination of the abdomen is
essential While right lower quadrant tenderness to
palpation is the most important physical examination
finding other signs may help confirm the diagnosis
(Table 3) The abdominal examination should begin
with inspection followed by auscultation gentle
palpation (beginning at a site distant from the pain) and
finally abdominal percussion The rebound tenderness that is associated with peritoneal irritation has been shown
to be more accurately identified by percussion of the abdomen than by palpation with quick release 1
As previously noted the location of the appendix varies When the appendix is hidden from the anterior
peritoneum the usual symptoms and signs of acute appendicitis may not be present Pain and tenderness can
occur in a location other than the right lower quadrant 6 A retrocecal appendix in a retroperitoneal location may
cause flank pain In this case stretching the iliopsoas muscle can elicit pain The psoas sign is elicited in this
manner the patient lies on the left side while the examiner extends the patients right thigh ( Figures 1a and 1b) In
contrast a patient with a pelvic appendix may show no abdominal signs but the rectal examination may elicit
tenderness in the cul-de-sac In addition an obturator sign (pain on passive internal rotation of the flexed right
thigh) may be present in a patient with a pelvic appendix3 ( Figures 2a and 2b)
FIGURE 1A The psoas sign Pain on passiveextension of the right thigh Patient lies on left sideExaminer extends patients right thigh while applyingcounter resistance to the right hip (asterisk)
FIGURE 2A The obturator sign Pain on passive internalrotation of the flexed thigh Examiner moves lower leg laterallywhile applying resistance to the lateral side of the knee(asterisk) resulting in internal rotation of the femur
palpation of left lower quadrantbull Dunphys sign--increased pain with coughingbull Flank tenderness in right lower quadrant(retroperitoneal retrocecal appendix)bull Patient maintains hip flexion with knees drawn up forcomfort
Information from references 3 through 5
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 527
FIGURE 1B Anatomic basis for the psoas signinflamed appendix is in a retroperitoneal location incontact with the psoas muscle which is stretched bythis maneuver
FIGURE 2B Anatomic basis for the obturator sign inflamedappendix in the pelvis is in contact with the obturator internusmuscle which is stretched by this maneuver
The differential diagnosis of appendicitis is broad but the patients history and the remainder of the physical
examination may clarify the diagnosis (Table 4) Because many gynecologic conditions can mimic appendicitis a
pelvic examination should be performed on all women with abdominal pain Given the breadth of the differential
diagnosis the pulmonary genitourinary and rectal examinations are equally important Studies have shown
however that the rectal examination provides useful information only when the diagnosis is unclear and thus can
be reserved for use in such cases5
TABLE 4 Differential Diagnosis of Acute Appendicitis
Gastrointestinal Abdominal paincause unknownCholecystitis
GynecologicEctopicpregnancyEndometriosis
PulmonaryPleuritisPneumonia(basilar)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 627
Laboratory and Radiologic Evaluation
If the patients history and the physical examination do
not clarify the diagnosis laboratory and radiologic
evaluations may be helpful A clear diagnosis of
appendicitis obviates the need for further testing and
should prompt immediate surgical referral
Laboratory Tests
The white blood cell (WBC) count is elevated (greater
than 10000 per mm3 [100 3 109 per L]) in 80 percent of
all cases of acute appendicitis9 Unfortunately the WBC
is elevated in up to 70 percent of patients with other
causes of right lower quadrant pain10 Thus an elevated
WBC has a low predictive value Serial WBC
measurements (over 4 to 8 hours) in suspected cases
may increase the specificity as the WBC count often
increases in acute appendicitis (except in cases of
perforation in which it may initially fall)5
In addition 95 percent of patients have neutrophilia1 and in the elderly an elevated band count greater than 6
percent has been shown to have a high predictive value for appendicitis9 In general however the WBC count and
differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low
specificities
A more recently suggested laboratory evaluation is determination of the C-reactive protein level An elevated C-
reactive protein level (greater than 08 mg per dL) is common in appendicitis but studies disagree on its
sensitivity and specificity45 An elevated C-reactive protein level in combination with an elevated WBC count and
neutrophilia are highly sensitive (97 to 100 percent) Therefore if all three of these findings are absent the chance
of appendicitis is low5
In patients with appendicitis a urinalysis may demonstrate changes such as mild pyuria proteinuria and
hematuria1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose
appendicitis
Crohns diseaseDiverticulitisDuodenal ulcerGastroenteritisIntestinalobstruction
IntussusceptionMeckelsdiverticulitisMesentericlymphadenitisNecrotizingenterocolitisNeoplasm(carcinoidcarcinomalymphoma)Omental torsionPancreatitis
Perforated viscusVolvulus
Ovarian torsionPelvicinflammatorydiseaseRupturedovarian cyst
(follicularcorpusluteum)Tubo-ovarianabscessSystemic DiabeticketoacidosisPorphyriaSickle celldiseaseHenoch-Schoumlnlein
purpura
PulmonaryinfarctionGenitourinary Kidney stoneProstatitisPyelonephritis
TesticulartorsionUrinary tractinfectionWilms tumorOther ParasiticinfectionPsoas abscessRectus sheathhematoma
Reprinted with permission from Graffeo CSCounselman FL Appendicitis Emerg Med Clin North Am 199614653-71
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 727
Radiologic Evaluation
The options for radiologic evaluation of patients with suspected
appendicitis have expanded in recent years enhancing and
sometimes replacing previously used radiologic studies
Plain radiographs while often revealing abnormalities in acute
appendicitis lack specificity and are more helpful in diagnosing
other causes of abdominal pain Likewise barium enema is now
used infrequently because of the advances in abdominal imaging 5
Ultrasonography and computed tomographic (CT) scans are helpful
in evaluating patients with suspected appendicitis11 Ultrasonography
is appropriate in patients in which the diagnosis is equivocal by
history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in
pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is
noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory
bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can
cause false-positive ultrasonography results12
FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix
TABLE 5 Comparison of Ultrasound and
Appendiceal CT Evaluation of
Suspected Appendicitis
Comparisongradedultrasound
Appendicealcomputedtomographicscan
Sensitivity 85 90 to 100
Specificity 92 95 to 97
Use Evaluatepatients withequivocaldiagnosis ofappendicitis
Evaluatepatients withequivocaldiagnosis ofappendicitis
Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females
More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 327
psoas signpara
Rebound tenderness 11 to 63dagger
Fever 19Dagger
Guarding and rectaltenderness
Much lower LR+ than rigidity psoassign and rebound tenderness
NOTE LR is the amount by which the odds of a disease change with new information as follows
Likelihood ratio Degree of change in probability
gt10 or lt01 Large (often conclusive)
5 to 10 or 01 to 02 Moderate
2 to 5 or 02 to 05 Small (but sometimes important)
1 to 2 or 05 to 1 Small (rarely important)
--These symptoms and signs have much lower LR+dagger--Ratios are presented in ranges for signs and symptoms that had widely varying results in studiesDagger--Fever had only borderline LR+
sect--That is the absence of RLQ pain significantly lowers the odds of having appendicitis||--That is the history of experiencing a similar pain previously lowers the odds of having appendicitispara--These signs have higher LR-Information from references 7 8 and 19
In a recent meta-analysis7 likelihood ratios were calculated for many of these symptoms (Table 2) A likelihood
ratio is the amount by which the odds of a disease change with new information (eg physical examination
findings laboratory results)8 This change can be positive or negative Symptoms such as anorexia nausea and
vomiting commonly occur in acute appendicitis however the presence of these symptoms does not necessarily
increase the likelihood of appendicitis nor does their absence decrease the likelihood of the diagnosis Moreover
other symptoms have more notable positive and
negative likelihood ratios (Table 2)
TABLE 3 Common Signs of Appendicitis
bull Right lower quadrant pain on palpation (the singlemost important sign)bull Low-grade fever (38degC [or 1004degF])--absence of feveror high fever can occurbull Peritoneal signs
bull Localized tenderness to percussionbull Guardingbull Other confirmatory peritoneal signs (absence of thesesigns does not exclude appendicitis)bull Psoas sign--pain on extension of right thigh(retroperitoneal retrocecal appendix)bull Obturator sign--pain on internal rotation of right thigh(pelvic appendix)bull Rovsings sign--pain in right lower quadrant with
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 427
A careful systematic examination of the abdomen is
essential While right lower quadrant tenderness to
palpation is the most important physical examination
finding other signs may help confirm the diagnosis
(Table 3) The abdominal examination should begin
with inspection followed by auscultation gentle
palpation (beginning at a site distant from the pain) and
finally abdominal percussion The rebound tenderness that is associated with peritoneal irritation has been shown
to be more accurately identified by percussion of the abdomen than by palpation with quick release 1
As previously noted the location of the appendix varies When the appendix is hidden from the anterior
peritoneum the usual symptoms and signs of acute appendicitis may not be present Pain and tenderness can
occur in a location other than the right lower quadrant 6 A retrocecal appendix in a retroperitoneal location may
cause flank pain In this case stretching the iliopsoas muscle can elicit pain The psoas sign is elicited in this
manner the patient lies on the left side while the examiner extends the patients right thigh ( Figures 1a and 1b) In
contrast a patient with a pelvic appendix may show no abdominal signs but the rectal examination may elicit
tenderness in the cul-de-sac In addition an obturator sign (pain on passive internal rotation of the flexed right
thigh) may be present in a patient with a pelvic appendix3 ( Figures 2a and 2b)
FIGURE 1A The psoas sign Pain on passiveextension of the right thigh Patient lies on left sideExaminer extends patients right thigh while applyingcounter resistance to the right hip (asterisk)
FIGURE 2A The obturator sign Pain on passive internalrotation of the flexed thigh Examiner moves lower leg laterallywhile applying resistance to the lateral side of the knee(asterisk) resulting in internal rotation of the femur
palpation of left lower quadrantbull Dunphys sign--increased pain with coughingbull Flank tenderness in right lower quadrant(retroperitoneal retrocecal appendix)bull Patient maintains hip flexion with knees drawn up forcomfort
Information from references 3 through 5
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 527
FIGURE 1B Anatomic basis for the psoas signinflamed appendix is in a retroperitoneal location incontact with the psoas muscle which is stretched bythis maneuver
FIGURE 2B Anatomic basis for the obturator sign inflamedappendix in the pelvis is in contact with the obturator internusmuscle which is stretched by this maneuver
The differential diagnosis of appendicitis is broad but the patients history and the remainder of the physical
examination may clarify the diagnosis (Table 4) Because many gynecologic conditions can mimic appendicitis a
pelvic examination should be performed on all women with abdominal pain Given the breadth of the differential
diagnosis the pulmonary genitourinary and rectal examinations are equally important Studies have shown
however that the rectal examination provides useful information only when the diagnosis is unclear and thus can
be reserved for use in such cases5
TABLE 4 Differential Diagnosis of Acute Appendicitis
Gastrointestinal Abdominal paincause unknownCholecystitis
GynecologicEctopicpregnancyEndometriosis
PulmonaryPleuritisPneumonia(basilar)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 627
Laboratory and Radiologic Evaluation
If the patients history and the physical examination do
not clarify the diagnosis laboratory and radiologic
evaluations may be helpful A clear diagnosis of
appendicitis obviates the need for further testing and
should prompt immediate surgical referral
Laboratory Tests
The white blood cell (WBC) count is elevated (greater
than 10000 per mm3 [100 3 109 per L]) in 80 percent of
all cases of acute appendicitis9 Unfortunately the WBC
is elevated in up to 70 percent of patients with other
causes of right lower quadrant pain10 Thus an elevated
WBC has a low predictive value Serial WBC
measurements (over 4 to 8 hours) in suspected cases
may increase the specificity as the WBC count often
increases in acute appendicitis (except in cases of
perforation in which it may initially fall)5
In addition 95 percent of patients have neutrophilia1 and in the elderly an elevated band count greater than 6
percent has been shown to have a high predictive value for appendicitis9 In general however the WBC count and
differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low
specificities
A more recently suggested laboratory evaluation is determination of the C-reactive protein level An elevated C-
reactive protein level (greater than 08 mg per dL) is common in appendicitis but studies disagree on its
sensitivity and specificity45 An elevated C-reactive protein level in combination with an elevated WBC count and
neutrophilia are highly sensitive (97 to 100 percent) Therefore if all three of these findings are absent the chance
of appendicitis is low5
In patients with appendicitis a urinalysis may demonstrate changes such as mild pyuria proteinuria and
hematuria1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose
appendicitis
Crohns diseaseDiverticulitisDuodenal ulcerGastroenteritisIntestinalobstruction
IntussusceptionMeckelsdiverticulitisMesentericlymphadenitisNecrotizingenterocolitisNeoplasm(carcinoidcarcinomalymphoma)Omental torsionPancreatitis
Perforated viscusVolvulus
Ovarian torsionPelvicinflammatorydiseaseRupturedovarian cyst
(follicularcorpusluteum)Tubo-ovarianabscessSystemic DiabeticketoacidosisPorphyriaSickle celldiseaseHenoch-Schoumlnlein
purpura
PulmonaryinfarctionGenitourinary Kidney stoneProstatitisPyelonephritis
TesticulartorsionUrinary tractinfectionWilms tumorOther ParasiticinfectionPsoas abscessRectus sheathhematoma
Reprinted with permission from Graffeo CSCounselman FL Appendicitis Emerg Med Clin North Am 199614653-71
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 727
Radiologic Evaluation
The options for radiologic evaluation of patients with suspected
appendicitis have expanded in recent years enhancing and
sometimes replacing previously used radiologic studies
Plain radiographs while often revealing abnormalities in acute
appendicitis lack specificity and are more helpful in diagnosing
other causes of abdominal pain Likewise barium enema is now
used infrequently because of the advances in abdominal imaging 5
Ultrasonography and computed tomographic (CT) scans are helpful
in evaluating patients with suspected appendicitis11 Ultrasonography
is appropriate in patients in which the diagnosis is equivocal by
history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in
pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is
noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory
bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can
cause false-positive ultrasonography results12
FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix
TABLE 5 Comparison of Ultrasound and
Appendiceal CT Evaluation of
Suspected Appendicitis
Comparisongradedultrasound
Appendicealcomputedtomographicscan
Sensitivity 85 90 to 100
Specificity 92 95 to 97
Use Evaluatepatients withequivocaldiagnosis ofappendicitis
Evaluatepatients withequivocaldiagnosis ofappendicitis
Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females
More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 427
A careful systematic examination of the abdomen is
essential While right lower quadrant tenderness to
palpation is the most important physical examination
finding other signs may help confirm the diagnosis
(Table 3) The abdominal examination should begin
with inspection followed by auscultation gentle
palpation (beginning at a site distant from the pain) and
finally abdominal percussion The rebound tenderness that is associated with peritoneal irritation has been shown
to be more accurately identified by percussion of the abdomen than by palpation with quick release 1
As previously noted the location of the appendix varies When the appendix is hidden from the anterior
peritoneum the usual symptoms and signs of acute appendicitis may not be present Pain and tenderness can
occur in a location other than the right lower quadrant 6 A retrocecal appendix in a retroperitoneal location may
cause flank pain In this case stretching the iliopsoas muscle can elicit pain The psoas sign is elicited in this
manner the patient lies on the left side while the examiner extends the patients right thigh ( Figures 1a and 1b) In
contrast a patient with a pelvic appendix may show no abdominal signs but the rectal examination may elicit
tenderness in the cul-de-sac In addition an obturator sign (pain on passive internal rotation of the flexed right
thigh) may be present in a patient with a pelvic appendix3 ( Figures 2a and 2b)
FIGURE 1A The psoas sign Pain on passiveextension of the right thigh Patient lies on left sideExaminer extends patients right thigh while applyingcounter resistance to the right hip (asterisk)
FIGURE 2A The obturator sign Pain on passive internalrotation of the flexed thigh Examiner moves lower leg laterallywhile applying resistance to the lateral side of the knee(asterisk) resulting in internal rotation of the femur
palpation of left lower quadrantbull Dunphys sign--increased pain with coughingbull Flank tenderness in right lower quadrant(retroperitoneal retrocecal appendix)bull Patient maintains hip flexion with knees drawn up forcomfort
Information from references 3 through 5
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 527
FIGURE 1B Anatomic basis for the psoas signinflamed appendix is in a retroperitoneal location incontact with the psoas muscle which is stretched bythis maneuver
FIGURE 2B Anatomic basis for the obturator sign inflamedappendix in the pelvis is in contact with the obturator internusmuscle which is stretched by this maneuver
The differential diagnosis of appendicitis is broad but the patients history and the remainder of the physical
examination may clarify the diagnosis (Table 4) Because many gynecologic conditions can mimic appendicitis a
pelvic examination should be performed on all women with abdominal pain Given the breadth of the differential
diagnosis the pulmonary genitourinary and rectal examinations are equally important Studies have shown
however that the rectal examination provides useful information only when the diagnosis is unclear and thus can
be reserved for use in such cases5
TABLE 4 Differential Diagnosis of Acute Appendicitis
Gastrointestinal Abdominal paincause unknownCholecystitis
GynecologicEctopicpregnancyEndometriosis
PulmonaryPleuritisPneumonia(basilar)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 627
Laboratory and Radiologic Evaluation
If the patients history and the physical examination do
not clarify the diagnosis laboratory and radiologic
evaluations may be helpful A clear diagnosis of
appendicitis obviates the need for further testing and
should prompt immediate surgical referral
Laboratory Tests
The white blood cell (WBC) count is elevated (greater
than 10000 per mm3 [100 3 109 per L]) in 80 percent of
all cases of acute appendicitis9 Unfortunately the WBC
is elevated in up to 70 percent of patients with other
causes of right lower quadrant pain10 Thus an elevated
WBC has a low predictive value Serial WBC
measurements (over 4 to 8 hours) in suspected cases
may increase the specificity as the WBC count often
increases in acute appendicitis (except in cases of
perforation in which it may initially fall)5
In addition 95 percent of patients have neutrophilia1 and in the elderly an elevated band count greater than 6
percent has been shown to have a high predictive value for appendicitis9 In general however the WBC count and
differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low
specificities
A more recently suggested laboratory evaluation is determination of the C-reactive protein level An elevated C-
reactive protein level (greater than 08 mg per dL) is common in appendicitis but studies disagree on its
sensitivity and specificity45 An elevated C-reactive protein level in combination with an elevated WBC count and
neutrophilia are highly sensitive (97 to 100 percent) Therefore if all three of these findings are absent the chance
of appendicitis is low5
In patients with appendicitis a urinalysis may demonstrate changes such as mild pyuria proteinuria and
hematuria1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose
appendicitis
Crohns diseaseDiverticulitisDuodenal ulcerGastroenteritisIntestinalobstruction
IntussusceptionMeckelsdiverticulitisMesentericlymphadenitisNecrotizingenterocolitisNeoplasm(carcinoidcarcinomalymphoma)Omental torsionPancreatitis
Perforated viscusVolvulus
Ovarian torsionPelvicinflammatorydiseaseRupturedovarian cyst
(follicularcorpusluteum)Tubo-ovarianabscessSystemic DiabeticketoacidosisPorphyriaSickle celldiseaseHenoch-Schoumlnlein
purpura
PulmonaryinfarctionGenitourinary Kidney stoneProstatitisPyelonephritis
TesticulartorsionUrinary tractinfectionWilms tumorOther ParasiticinfectionPsoas abscessRectus sheathhematoma
Reprinted with permission from Graffeo CSCounselman FL Appendicitis Emerg Med Clin North Am 199614653-71
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 727
Radiologic Evaluation
The options for radiologic evaluation of patients with suspected
appendicitis have expanded in recent years enhancing and
sometimes replacing previously used radiologic studies
Plain radiographs while often revealing abnormalities in acute
appendicitis lack specificity and are more helpful in diagnosing
other causes of abdominal pain Likewise barium enema is now
used infrequently because of the advances in abdominal imaging 5
Ultrasonography and computed tomographic (CT) scans are helpful
in evaluating patients with suspected appendicitis11 Ultrasonography
is appropriate in patients in which the diagnosis is equivocal by
history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in
pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is
noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory
bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can
cause false-positive ultrasonography results12
FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix
TABLE 5 Comparison of Ultrasound and
Appendiceal CT Evaluation of
Suspected Appendicitis
Comparisongradedultrasound
Appendicealcomputedtomographicscan
Sensitivity 85 90 to 100
Specificity 92 95 to 97
Use Evaluatepatients withequivocaldiagnosis ofappendicitis
Evaluatepatients withequivocaldiagnosis ofappendicitis
Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females
More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 527
FIGURE 1B Anatomic basis for the psoas signinflamed appendix is in a retroperitoneal location incontact with the psoas muscle which is stretched bythis maneuver
FIGURE 2B Anatomic basis for the obturator sign inflamedappendix in the pelvis is in contact with the obturator internusmuscle which is stretched by this maneuver
The differential diagnosis of appendicitis is broad but the patients history and the remainder of the physical
examination may clarify the diagnosis (Table 4) Because many gynecologic conditions can mimic appendicitis a
pelvic examination should be performed on all women with abdominal pain Given the breadth of the differential
diagnosis the pulmonary genitourinary and rectal examinations are equally important Studies have shown
however that the rectal examination provides useful information only when the diagnosis is unclear and thus can
be reserved for use in such cases5
TABLE 4 Differential Diagnosis of Acute Appendicitis
Gastrointestinal Abdominal paincause unknownCholecystitis
GynecologicEctopicpregnancyEndometriosis
PulmonaryPleuritisPneumonia(basilar)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 627
Laboratory and Radiologic Evaluation
If the patients history and the physical examination do
not clarify the diagnosis laboratory and radiologic
evaluations may be helpful A clear diagnosis of
appendicitis obviates the need for further testing and
should prompt immediate surgical referral
Laboratory Tests
The white blood cell (WBC) count is elevated (greater
than 10000 per mm3 [100 3 109 per L]) in 80 percent of
all cases of acute appendicitis9 Unfortunately the WBC
is elevated in up to 70 percent of patients with other
causes of right lower quadrant pain10 Thus an elevated
WBC has a low predictive value Serial WBC
measurements (over 4 to 8 hours) in suspected cases
may increase the specificity as the WBC count often
increases in acute appendicitis (except in cases of
perforation in which it may initially fall)5
In addition 95 percent of patients have neutrophilia1 and in the elderly an elevated band count greater than 6
percent has been shown to have a high predictive value for appendicitis9 In general however the WBC count and
differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low
specificities
A more recently suggested laboratory evaluation is determination of the C-reactive protein level An elevated C-
reactive protein level (greater than 08 mg per dL) is common in appendicitis but studies disagree on its
sensitivity and specificity45 An elevated C-reactive protein level in combination with an elevated WBC count and
neutrophilia are highly sensitive (97 to 100 percent) Therefore if all three of these findings are absent the chance
of appendicitis is low5
In patients with appendicitis a urinalysis may demonstrate changes such as mild pyuria proteinuria and
hematuria1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose
appendicitis
Crohns diseaseDiverticulitisDuodenal ulcerGastroenteritisIntestinalobstruction
IntussusceptionMeckelsdiverticulitisMesentericlymphadenitisNecrotizingenterocolitisNeoplasm(carcinoidcarcinomalymphoma)Omental torsionPancreatitis
Perforated viscusVolvulus
Ovarian torsionPelvicinflammatorydiseaseRupturedovarian cyst
(follicularcorpusluteum)Tubo-ovarianabscessSystemic DiabeticketoacidosisPorphyriaSickle celldiseaseHenoch-Schoumlnlein
purpura
PulmonaryinfarctionGenitourinary Kidney stoneProstatitisPyelonephritis
TesticulartorsionUrinary tractinfectionWilms tumorOther ParasiticinfectionPsoas abscessRectus sheathhematoma
Reprinted with permission from Graffeo CSCounselman FL Appendicitis Emerg Med Clin North Am 199614653-71
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 727
Radiologic Evaluation
The options for radiologic evaluation of patients with suspected
appendicitis have expanded in recent years enhancing and
sometimes replacing previously used radiologic studies
Plain radiographs while often revealing abnormalities in acute
appendicitis lack specificity and are more helpful in diagnosing
other causes of abdominal pain Likewise barium enema is now
used infrequently because of the advances in abdominal imaging 5
Ultrasonography and computed tomographic (CT) scans are helpful
in evaluating patients with suspected appendicitis11 Ultrasonography
is appropriate in patients in which the diagnosis is equivocal by
history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in
pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is
noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory
bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can
cause false-positive ultrasonography results12
FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix
TABLE 5 Comparison of Ultrasound and
Appendiceal CT Evaluation of
Suspected Appendicitis
Comparisongradedultrasound
Appendicealcomputedtomographicscan
Sensitivity 85 90 to 100
Specificity 92 95 to 97
Use Evaluatepatients withequivocaldiagnosis ofappendicitis
Evaluatepatients withequivocaldiagnosis ofappendicitis
Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females
More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 627
Laboratory and Radiologic Evaluation
If the patients history and the physical examination do
not clarify the diagnosis laboratory and radiologic
evaluations may be helpful A clear diagnosis of
appendicitis obviates the need for further testing and
should prompt immediate surgical referral
Laboratory Tests
The white blood cell (WBC) count is elevated (greater
than 10000 per mm3 [100 3 109 per L]) in 80 percent of
all cases of acute appendicitis9 Unfortunately the WBC
is elevated in up to 70 percent of patients with other
causes of right lower quadrant pain10 Thus an elevated
WBC has a low predictive value Serial WBC
measurements (over 4 to 8 hours) in suspected cases
may increase the specificity as the WBC count often
increases in acute appendicitis (except in cases of
perforation in which it may initially fall)5
In addition 95 percent of patients have neutrophilia1 and in the elderly an elevated band count greater than 6
percent has been shown to have a high predictive value for appendicitis9 In general however the WBC count and
differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low
specificities
A more recently suggested laboratory evaluation is determination of the C-reactive protein level An elevated C-
reactive protein level (greater than 08 mg per dL) is common in appendicitis but studies disagree on its
sensitivity and specificity45 An elevated C-reactive protein level in combination with an elevated WBC count and
neutrophilia are highly sensitive (97 to 100 percent) Therefore if all three of these findings are absent the chance
of appendicitis is low5
In patients with appendicitis a urinalysis may demonstrate changes such as mild pyuria proteinuria and
hematuria1 but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose
appendicitis
Crohns diseaseDiverticulitisDuodenal ulcerGastroenteritisIntestinalobstruction
IntussusceptionMeckelsdiverticulitisMesentericlymphadenitisNecrotizingenterocolitisNeoplasm(carcinoidcarcinomalymphoma)Omental torsionPancreatitis
Perforated viscusVolvulus
Ovarian torsionPelvicinflammatorydiseaseRupturedovarian cyst
(follicularcorpusluteum)Tubo-ovarianabscessSystemic DiabeticketoacidosisPorphyriaSickle celldiseaseHenoch-Schoumlnlein
purpura
PulmonaryinfarctionGenitourinary Kidney stoneProstatitisPyelonephritis
TesticulartorsionUrinary tractinfectionWilms tumorOther ParasiticinfectionPsoas abscessRectus sheathhematoma
Reprinted with permission from Graffeo CSCounselman FL Appendicitis Emerg Med Clin North Am 199614653-71
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 727
Radiologic Evaluation
The options for radiologic evaluation of patients with suspected
appendicitis have expanded in recent years enhancing and
sometimes replacing previously used radiologic studies
Plain radiographs while often revealing abnormalities in acute
appendicitis lack specificity and are more helpful in diagnosing
other causes of abdominal pain Likewise barium enema is now
used infrequently because of the advances in abdominal imaging 5
Ultrasonography and computed tomographic (CT) scans are helpful
in evaluating patients with suspected appendicitis11 Ultrasonography
is appropriate in patients in which the diagnosis is equivocal by
history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in
pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is
noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory
bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can
cause false-positive ultrasonography results12
FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix
TABLE 5 Comparison of Ultrasound and
Appendiceal CT Evaluation of
Suspected Appendicitis
Comparisongradedultrasound
Appendicealcomputedtomographicscan
Sensitivity 85 90 to 100
Specificity 92 95 to 97
Use Evaluatepatients withequivocaldiagnosis ofappendicitis
Evaluatepatients withequivocaldiagnosis ofappendicitis
Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females
More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 727
Radiologic Evaluation
The options for radiologic evaluation of patients with suspected
appendicitis have expanded in recent years enhancing and
sometimes replacing previously used radiologic studies
Plain radiographs while often revealing abnormalities in acute
appendicitis lack specificity and are more helpful in diagnosing
other causes of abdominal pain Likewise barium enema is now
used infrequently because of the advances in abdominal imaging 5
Ultrasonography and computed tomographic (CT) scans are helpful
in evaluating patients with suspected appendicitis11 Ultrasonography
is appropriate in patients in which the diagnosis is equivocal by
history and physical examination It is especially well suited in evaluating right lower quadrant or pelvic pain in
pediatric and female patients A normal appendix (6 mm or less in diameter) must be identified to rule outappendicitis An inflamed appendix usually measures greater than 6 mm in diameter ( Figure 3) is
noncompressible and tender with focal compression Other right lower quadrant conditions such as inflammatory
bowel disease cecal diverticulitis Meckels diverticulum endometriosis and pelvic inflammatory disease can
cause false-positive ultrasonography results12
FIGURE 3 Ultrasonogram showinglongitudinal section (arrows) of inflamedappendix
TABLE 5 Comparison of Ultrasound and
Appendiceal CT Evaluation of
Suspected Appendicitis
Comparisongradedultrasound
Appendicealcomputedtomographicscan
Sensitivity 85 90 to 100
Specificity 92 95 to 97
Use Evaluatepatients withequivocaldiagnosis ofappendicitis
Evaluatepatients withequivocaldiagnosis ofappendicitis
Advantages SafeRelativelyinexpensiveCan rule outpelvic diseasein females
More accurateBetter identifiesphlegmon andabscessBetter identifiesnormal
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 827
CT specifically the technique of appendiceal CT is more
accurate than ultrasonography (Table 5) Appendiceal CT
consists of a focused helical appendiceal CT after a
Gastrografin-saline enema (with or without oral contrast) and
can be performed and interpreted within one hour
Intravenous contrast is unnecessary12 The accuracy of CT is
due in part to its ability to identify a normal appendix better
than ultrasonography13 An inflamed appendix is greater than 6
mm in diameter but the CT also demonstrates
periappendiceal inflammatory changes14 ( Figures 4 and 5) If
appendiceal CT is not available standard abdominalpelvic CT with contrast remains highly useful and may be
more accurate than ultrasonography12
Treatment
The standard for management of nonperforated appendicitis remains appendectomy Because prompt treatment of
appendicitis is important in preventing further morbidity and mortality a margin of error in over-diagnosis is
acceptable Currently the national rate of negative appendectomies is approximately 20 percent15 Some studies
have investigated nonoperative management with parenteral antibiotic treatment but 40 percent of these patients
eventually required appendectomy3
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or
laparoscopy Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age while
therapeutic laparoscopy may be preferred in certain subsets of patients (eg women obese patients athletes)16
While laparoscopic intervention has the advantages of decreased postoperative pain earlier return to normal
activity and better cosmetic results its disadvantages include greater cost and longer operative time 4 Open
appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted
Better forchildren
appendix
Disadvantages OperatordependentTechnicallyinadequate
studies due togasPain
CostIonizingradiationContrast
Information from references 11 13 20
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 927
FIGURE 4 Computed tomographic scanshowing cross-section of inflamed appendix (A)with appendicolith (a)
FIGURE 5 Computed tomographic scanshowing enlarged and inflamed appendix (A)extending from the cecum (C)
Complications
Appendiceal rupture accounts for a majority of the complications of
appendicitis Factors that increase the rate of perforation are
delayed presentation to medical care17 age extremes (young and
old)18 and hidden location of appendix6 A brief period of in-hospital
observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve
diagnostic accuracy18
Diagnosis of a perforated appendix is usually easier (although immediately after rupture the patients symptoms
may temporarily subside) The physical examination findings are more obvious if peritonitis generalizes with a
more generalized right lower quadrant tenderness progressing to complete abdominal tenderness An ill-defined
mass may be felt in the right lower quadrant Fever is more common with rupture and the WBC count may
elevate to 20000 to 30000 per mm3 (200 to 300 3 109 per L) with a prominent left shift3
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management 4 Nonoperative
management consists of parenteral antibiotics with observation or CT-guided drainage followed by interval
appendectomy six weeks to three months later 1
Special Considerations
The classic history of pain beginning in theperiumbilical region and migrating to theright lower quadrant occurs in only 50percent of patients
The technique of appendiceal computedtomography is more accurate thanultrasonography in confirming the diagnosisof appendicitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1027
While appendicitis is uncommon in young children it poses special
difficulties in this age group Young children are unable to relate a history often have abdominal pain from other
causes and may have more nonspecific signs and symptoms These factors contribute to a perforation rate as high
as 50 percent in this group1
In pregnancy the location of the appendix begins to shift significantly by the fourth to fifth months of gestation
Common symptoms of pregnancy may mimic appendicitis and the leukocytosis of pregnancy renders the WBC
count less useful While the maternal mortality rate is low the overall fetal mortality rate is 2 to 85 percent rising
to as high as 35 percent in perforation with generalized peritonitis As in nonpregnant patients appendectomy is
the standard for treatment3
Elderly patients have the highest mortality rates The usual signs and symptoms of appendicitis may be
diminished atypical or absent in the elderly which leads to a higher rate of perforation More frequent perforation
combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a
mortality rate of up to 5 percent or more1
Final Comment
Prompt diagnosis of appendicitis ensures timely treatment and prevents complications Because abdominal pain is
a common presenting symptom in outpatient care family physicians serve an important role in the diagnosis of
appendicitis Obvious cases of appendicitis require urgent referral while equivocal cases warrant further
evaluation and many times surgical consultation
The author thanks Glen Cryer Department of Publications Scott and White Memorial Hospital Temple Tex for
help with the manuscript
Figures 3 through 5 were provided by Michael L Nipper MD Department of Radiology Scott and White
Memorial Hospital Temple Tex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1127
Appendicitis (Pediatric GI)
Figure 4 Yersinia enterocolitis Several enlarged lymph nodes (cursors) are seen on this sagittal
sonogram of a child whose appendix appeared normal
Imaging
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1227
Sonography and CT are helpful in differentiating Yersinia enterocolitis (frequently associated with right lower
quadrant pain) from appendicitis (Fig 4)
CT has 87-100 sensitive and89-98 specific of diagnosis acute appendicitis
CT findings of normal appendix
Visualized in 67-100
AT posteromedial aspect of cecum Diameter of up to 10 mm
CT findings of Abnormal appendix
Distended lumen (appendix gt7 mm in diameter)
Circumferential wall thickening
Target sign homogeneously enhancing wall with mural stratification
Appendicolith homogeneousringlike calcification (25) Distal appendicitis abnormal tip of appendix + normal proximal appendix and
normal cecal apex
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1327
Read the rest of this entry raquo
Filed under Acute Appendicitis Gastrointestinal Emergency Acute Appendicitis Arrowhead sign CT Findings normal
appendix Target sign
Acute appendicitis Laparocopic diagnosis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1427
Perforated duodenal ulcer
Acute cholecystitis
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1527
Figure X-ray showing a strip of free air along the right paracolic gutterdelineating the lower border of liver (arrow)
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1627
While looking through the archives of ultrasound images I came across a couple of instances of common
diagnoses made through tests that are not commonly done to diagnose them This might become a series of posts
if I stick with the theme
Acute Appendicitis is as everyone knows a common diagnosis on ultrasonography of the Abdomen (TAS =
Transabdominal sonography)
Rarely we do get to see a classical appendicolith on ultrasonography
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1727
What is quite rare is thishellip
Finding an acutely inflammed Appendix during Transvaginal Ultrasonography (TVS also called EVS -
Endovaginal sonography) done to rule out a pelvic cause for Acute Abdominal pain
While I only diagnosed Appendicitis through the transvaginal route there are surgeons in India and the USA who
have removed the inflammed Appendix through the vagina The Indian surgeons who as per the PubMed
abstract were the first in the world to attempt this are from my hometown Coimbatore
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1827
appendicitis Sponsored Links
appendicitis Symtoms amp Treatment
Are You Suffering From appendicitis Relax Get Your Advice Here
top-health-sitecom
What Are The Symptoms Of appendicitis
Get health questions answered now on the improved Askcom Try it
wwwaskcom
appendicitis Symptoms
Check Possible Causes amp Symptoms Diagnose Your Symptoms Fast amp Easy
Healthlinecom
What Is appendicitis
Relax Take a deep breath We have the answers you seek
wwwRightHealthcomappendicitis
What Is Your appendicitis
What Is Your appendicitis Get the Facts at Kosmix
HealthKosmixcom
Ask a Doctor Appendix
14 Doctors Are Online Ask a Question Get an Answer ASAP
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 1927
HealthJustAnswercomAppendicitis
What is appendicitis
Breaking News Expert Tips Member Support Treatment Options amp More
wwwEverydayHealthcom
appendicitis at Amazon
Buy books at Amazoncom and save Qualified orders over $25 ship free
Amazoncombooks
Location of the appendix in the digestive system
Appendicitis is a condition characterized by inflammation of the appendix It is a medical
emergency All cases require removal of the inflamed appendix either by laparotomy or
laparoscopy Untreated mortality is high mainly because of peritonitis and shock
Reginald Fitz first described acute and chronic appendicitis in 1886 and it has been
recognized as one of the most common causes of severe acute abdominal pain worldwide
A correctly diagnosed non-acute form of appendicitis is known as rumbling appendicitis
Symptoms Signs and symptoms of acute appendicitis can be classified into two types typical and
atypical The typical history includes pain starting centrally (periumbilical) before localizing
to the right iliac fossa (the lower right side of the abdomen) this is due to the poor
localizing (spatial) property of visceral nerves from the mid-gut followed by the
involvement of somatic nerves (parietal peritoneum) as the inflammation progresses The
pain is usually associated with loss of appetite and fever although the latter isnt a
necessary symptom Nausea or vomiting may occur as well as drowsiness and malaise
Atypical symptoms may include pain beginning and staying in the right iliac fossa
diarrhea and a more prolonged smoldering course If an inflamed appendix lies in contact
with the bladder there is frequency of urination With post-ileal appendix marked retching
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2027
may occur Tenesmus or downward urge (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases
Unlike acute appendicitis chronic appendicitis symptoms can vary from patient to
patientmdash
so much so that There are no typical findings or routine diagnostic modalities todiagnose chronic relapsing appendicitis It is a diagnosis of exclusion
Signs These include localized findings in the right iliac fossa The abdominal wall becomes very
sensitive to gentle pressure (palpation) Also there is rebound tenderness In case of a
retrocecal appendix however even deep pressure in the right lower quadrant may fail to
elicit tenderness (silent appendix) the reason being that the cecum distended with gas
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix
Similarly if the appendix lies entirely within the pelvis there is usually complete absenceof the abdominal rigidity In such cases a digital rectal examination elicits tenderness in
the rectovesical pouch Coughing causes point tenderness in this area (McBurneys point)
and this is the least painful way to localize the inflamed appendix If the abdomen on
palpation is also involuntarily guarded (rigid) there should be a strong suspicion of
peritonitis requiring urgent surgical intervention
Other signs are
Rovsings sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa This is the
Rovsings sign also known as the Rovsings symptom It is used in the diagnosis of acute
appendicitis Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen
Psoas sign
This is right lower-quadrant pain that is reproduced with the patient lying on his left side
and then extending the hip Because extension elicits pain the patient will lie with the right
hip flexed for pain relief
Obturator sign
If an inflamed appendix is in contact with the obturator internus spasm of the muscle can
be demonstrated by flexing and lateral rotation of the hip This maneuver will cause pain in
the hypogastrium
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2127
Causes On the basis of experimental evidence acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells increasing pressures within the
lumen and the walls of the appendix resulting in thrombosis and occlusion of the small
vessels and stasis of lymphatic flow Rarely spontaneous recovery can occur at this
point As the former progresses the appendix becomes ischemic and then necrotic As
bacteria begin to leak out through the dying walls pus forms within and around the
appendix (suppuration) The end result of this cascade is appendiceal rupture (a burst
appendix) causing peritonitis which may lead to septicemia and eventually death
Among the causative agents such as foreign bodies trauma intestinal worms
lymphadenitis and calcified deposits known as appendicoliths the occurrence of anobstructing fecalith has attracted attention The prevalence of fecaliths in patients with
appendicitis is significantly higher in developed than in developing countries and an
appendiceal fecalith is commonly associated with complicated appendicitis Also fecal
stasis and arrest may play a role as demonstrated by a significantly lower number of
bowel movements per week in patients with acute appendicitis compared with healthy
controls
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal
retention reservoir in the colon and a prolonged transit time From epidemiological data ithas been stated that diverticular disease and adenomatous polyps were unknown and
colon cancer exceedingly rare in communities exempt for appendicitis Also acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis
This is in accordance with the occurrence of a right sided fecal reservoir and the fact that
dietary fiber reduces transit time
Diagnosis Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells Atypical histories often require imaging with
ultrasound andor CT scanning A pregnancy test is vital in all women of child bearing age
as ectopic pregnancies and appendicitis present with similar symptoms The
consequences of missing an ectopic pregnancy are serious and potentially life
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2227
threatening Furthermore the general principles of approaching abdominal pain in women
(in so much that it is different from the approach in men) should be appreciated
Ultrasound
Ultrasound image of an acute appendicitisUltrasonography and Doppler sonography provide useful means to detect appendicitis
especially in children In some cases (15 approximately) however ultrasonography of
the iliac fossa does not reveal any abnormalities despite the presence of appendicitis This
is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing
the appendix technically difficult Despite these limitations in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with
very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes
Computed tomography
In places where it is readily available CT scan has become frequently used especially in
adults whose diagnosis is not obvious on history and physical Concerns about radiation
however exist which tends to limit its use in pregnant women and children A properly
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2327
performed CT scan with modern equipment has a detection rate (sensitivity) of over 95
and a similar specificity Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix direct visualization of appendiceal enlargement (greater than
6 mm in diameter on cross section) and appendiceal wall enhancement (IV dye) The
inflammation caused by appendicitis in the surrounding peritoneal fat (so called fatstranding) can also be observed on CT providing a mechanism to detect early
appendicitis and a clue that appendicitis may be present even when the appendix is not
well seen Thus diagnosis of appendicitis by CT is made more difficult in very thin patients
and in children both of whom tend to lack significant fat within the abdomen The utility of
CT scanning is made clear however by the impact it has had on negative appendectomy
rates For example use of CT for diagnosis of appendicitis in Boston MA has decreased
the chance of finding a normal appendix at surgery from 20 in the pre-CT era to only 3
according to data from the Massachusetts General Hospital
According to a systematic review from UC-San Francisco comparing ultrasound vs CT
scan CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults
and adolescents CT scan has a sensitivity of 94 specificity of 95 a positive likelihood
ratio of 133 (CI 99 to 179) and a negative likelihood ratio of 009 (CI 007 to 012)
Ultrasonography had an overall sensitivity of 86 a specificity of 81 a positive
likelihood ratio of 58 (CI 35 to 95) and a negative likelihood ratio of 019 (CI 013 to 027)
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of
appendiceal rupture among patients with acute appendicitis according to a cohort study
MMP-1 was higher in gangrenous (plt005) and perforated appendicitis (plt001) compared
with controls MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with controls (plt0001)
A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis The most widely used is Alvarado score
Alvarado score
A score below 5 is strongly against a diagnosis of appendicitis while a score of 7 or more
is strongly predictive of acute appendicitis In patients with an equivocal score of 5-6 CT
scan further reduces the rate of negative appendicectomy
Differential diagnosis
In children
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2427
Gastroenteritis mesenteric adenitis Meckels diverticulitis intussusception
Henoch-Schoumlnlein purpura lobar pneumonia urinary tract infection (abdominal pain in
the absence of other symptoms can occur in children with UTI) new-onset Crohns
disease or ulcerative colitis pancreatitis and abdominal trauma from child abuse
distal intestinal obstruction syndrome in children with cystic fibrosis typhlitis inchildren with leukemia in girls menarche dysmenorrhea severe menstrual cramps
Mittelschmerz pelvic inflammatory disease ectopic pregnancy
In adults
regional enteritis renal colic perforated peptic ulcer pancreatitis rectus sheath
hematoma in men testicular torsion new-onset Crohns disease or ulcerative colitis
in women pelvic inflammatory disease ectopic pregnancy endometriosis
torsionrupture of ovarian cyst Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstruation cycle)
In elderly
diverticulitis intestinal obstruction colonic carcinoma mesenteric ischemia
leaking aortic aneurysm
Management
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery An intravenous drip is used to hydrate the patient Antibiotics given intravenouslysuch as cefuroxime and metronidazole may be administered early to help kill bacteria and
thus reduce the spread of infection in the abdomen and postoperative complications in the
abdomen or wound Equivocal cases may become more difficult to assess with antibiotic
treatment and benefit from serial examinations If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used Otherwise spinal anaesthesia may be
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2527
used
Pain management
Pain from appendicitis can be severe Strong pain medications (ie narcotic pain
medications) are recommended for pain management prior to surgery Morphine is
generally the standard of care in adults and children in the treatment of pain from
appendicitis prior to surgery
In the past (and in some medical textbooks that are still published today) it has been
commonly accepted that pain medication no t be given until the surgeon has the chance to
evaluate the patient so as to not corrupt the findings of the physical examination This
line of practice combined with the fact that surgeons may sometimes take hours to come
to evaluate the patient especially if he or she is in the middle of surgery or has to drive in
from home often leads to a situation that is ethically questionable at best More recently
due to better understanding of the importance of pain control in patients it has been
shown that the physical examination is actually not that dramatically disturbed when pain
medication is given prior to medical evaluation Individual hospitals and clinics have
adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation such as 20
to 30 minutes before active pain management is initiated Many surgeons also advocate
this new approach of providing pain management immediately rather than only after
surgical evaluationSurgery
thumb|The stitches on a patient the day after having his appendix removed by surgeryThe
surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy ) Often now the operation can be performed via a laparoscopic
approach or via three small incisions with a camera to visualize the area of interest in the
abdomen If the findings reveal suppurative appendicitis with complications such as
rupture abscess adhesions etc conversion to open laparotomy may be necessary An
open laparotomy incision if required most often centers on the area of maximumtenderness McBurneys point in the right lower quadrant A transverse or a gridiron
diagonal incision is used most commonly
In March 2008 an American woman had her appendix removed via her vagina in a medical
first
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2627
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures laparoscopic procedures seem to have various advantages over the
open procedure Wound infections were less likely after laparoscopic appendicectomy
than after open appendicectomy (odds ratio (OR) 045 confidence interval (CI) 035 to058) but the incidence of intraabdominal abscesses was increased (OR 248 CI 145 to
421) The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures Pain on day 1 after surgery was reduced after laparoscopic procedures by 9
mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale Hospital stay was shortened
by 11 day (CI 06 to 15) Return to normal activity work and sport occurred earlier after
laparoscopic procedures than after open procedures While the operation costs of
laparoscopic procedures were significantly higher the costs outside hospital were
reduced Young female obese and employed patients seem to benefit from thelaparoscopic procedure more than other groups
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission) According to a retrospective case review study no
significant differences in perforation rate among the two groups were noted (P=397)
Various complications (abscess formation re-admission) showed no significant
differences (P=0667 0999) According to this study beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications This finding is
important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during
the night when people may be more tired and there are fewer staff available have higher
rates of surgical complications These findings may fit a theory that acute (typical)
appendicitis and suppurative (atypical) appendicitis are two distinct disease processes
Findings at the time of surgery suggest that perforation occurs at the onset of symptoms
in atypical cases(1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in
complicated cases
After surgery
Hospital lengths of stay typically range from overnight to a few days but can be a few
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy
8132019 Acute Appendicitis[1]
httpslidepdfcomreaderfullacute-appendicitis1 2727
weeks if complications occur
Prognosis Most appendicitis patients recover easily with surgical treatment but complications can
occur if treatment is delayed or if peritonitis occurs Recovery time depends on age
condition complications and other circumstances including the amount of alcohol
consumption but usually is between 10 and 28 days For young children (around 10 years
old) the recovery takes three weeks
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment The patient may have to undergo a medical
evacuation Appendectomies have occasionally been performed in emergency conditions
(ie outside of a proper hospital) when a timely medical evaluation was impossible
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously If appendicitis resolves spontaneously it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early In
either condition prompt diagnosis and appendectomy yield the best results with full
recovery in two to four weeks usually Mortality and severe complications are unusual but
do occur especially if peritonitis persists and is untreatedAnother entity known as appendicular lump is talked about quite often It happens when
appendix is not removed early during infection and omentum and intestine get adherent to
it forming a palpable lump During this period operation is risky unless there is pus
formation evident by fever and toxicity or by USG Medical management treats the
condition
An unusual complication of an appendectomy is stump appendicitis inflammation
occurs in the remnant appendiceal stump left after a prior incomplete appendectomy