Appendicitis

Hamzeh Halawani M.D.

American University of Beirut

Appendicitis

• 7% lifetime risk of developing appendicitis.

• Peak at 10 and 30 years of age, but may occur in men and women of any age.

• Signs and Symptoms?

• Physical Exam?

Signs

• Dunphy sign: increased pain with any coughing or movement

• Rovsing sign: is RLQ pain that is induced by palpation of the left lower quadrant and is highly suggestive of a RLQ inflammatory process.

• The obturator sign: is seen with inflammation of a pelvic appendix and refers to pain on internal rotation of the right hip.

• The iliopsoas sign: is most often seen with a retrocecalappendix and refers to pain on extension of the right hip.

• Aure-Rozanova sign, Bartomier-Michelson's sign, Kocher's (Kosher's) sign, Massouh sign, and Sitkovskiy (Rosenstein)'s sign.

CT scan

• Enlarged appendix >6 mm in diameter• Appendiceal wall thickness >2 mm• Periappendiceal inflammation (fat stranding)• The presence of a fecalith• Wall enhancment• The presence of the arrowhead sign (thickened

cecum funneling contrast toward the appendicealorifice)– The risk of radiation-induced malignancy has been

recently estimated at 0.18% following exposure to abdominal CT.

US

• Non compressable

• >6 mm in diameter

• Free fluid and abscess.

• fecalith

DDx

• inflammatory bowel disease• Crohn's ileitis • Gynecologic pathology (mittelschmerz, salpingitis, ectopic pregnancy,

tubo-ovarian abscess, and endometriosis ). • gastroenteritis. • diverticulitis• Meckel's diverticulitis • Renal Colic• acute mesenteric adenitis. • epiploic appendagitis, torsion, and thrombosis of a pedunculated adipose

structure off the serosal surface of the cecum may resemble appendicitis but can be distinguished on CT scan.

• familial Mediterranean fever (FMF).• Yersenia infection• TB

Open Vs. Lap

– Laparoscopic appendectomy leads to a shortened hospital stay for patients with uncomplicated acute appendicitis, less postoperative pain, faster return to work, and lower total cost of care.

– Laparoscopic appendectomy was associated with a lower incidence of postoperative wound infection than open appendectomy was (3.5% versus 6.7%), but it was also associated with a higher incidence of postoperative intra-abdominal abscess (2.5% versus 1.1%). The length of stay was slightly shorter after laparoscopic appendectomy (1 to 4.9 days; average 2.7 days) than after open appendectomy (1.2 to 5.3 days; average 3.2 days)

• At present, however, the only patients for whom laparoscopic appendectomy appears to offer significant advantages are

– women of childbearing age

– Obese patients

– Patients with an unclear diagnosis.

Chronic appendicitis

• Pain last longer, same location, less intense.

• Much lower incidence of vomiting and nausea.

• WBC normal, CT not diagnostic.

• Appendectomy is curative.