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Appendicitis Ingles

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Appendicitis Appendicitis is inflammation of the appendix. Appen- dicitis commonly presents with right lower abdominal pain, nausea, vomiting, and decreased appetite. [2] How- ever, one third to a half of persons do not have these typi- cal signs and symptoms. [3] Severe complications of a rup- tured appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis. [4] Appendicitis is caused by a blockage of the hollow por- tion of the appendix, [5][6] most commonly by a calcified “stone” made of feces. However, inflamed lymphoid tis- sue from a viral infection, parasites, gallstone, or tumors may also cause the blockage. [7] This blockage leads to in- creased pressures within the appendix, decreased blood flow to the tissues of the appendix, and bacterial growth inside the appendix causing inflammation. [7][8] The com- bination of inflammation, reduced blood flow to the ap- pendix and distention of the appendix causes tissue injury and tissue death. [9] If this process is left untreated, the ap- pendix may burst, releasing bacteria into the abdominal cavity, leading to severe abdominal pain and increased complications. [9][10] The diagnosis of appendicitis is largely based on the person’s signs and symptoms. [8] In cases where the di- agnosis cannot be made based on the person’s history and physical exam, close observation, radiographic imag- ing and laboratory tests can often be helpful. [11] The two most common imaging tests used are ultrasound and computed tomography (CT scan). [11] CT scan has been shown to be more accurate than ultrasound in detecting acute appendicitis. [12] However, ultrasound may be pre- ferred as the first imaging test in children and pregnant women because of the risks associated with radiation ex- posure from CT scans. [11] The standard treatment for acute appendicitis is surgical removal of the appendix. [7][8] This may be done by an open incision in the abdomen (laparotomy) or through a few smaller incisions with the help of cameras (la- paroscopy). Surgery decreases the risk of side effects or death associated with rupture of the appendix. [4] Antibiotics may be equally effective in certain cases of non-ruptured appendicitis. [13] It is one of the most com- mon and significant causes of severe abdominal pain that comes on quickly worldwide. In 2013 about 16 million cases of appendicitis occurred. [14] This resulted in 72,000 deaths globally. [15] In the United States, appendicitis is the most common cause of acute abdominal pain requir- ing surgery. [2] Each year in the United States, more than 300,000 persons with appendicitis have their appendix surgically removed. [16] Reginald Fitz is credited with be- ing the first person to describe the condition in a paper published in 1886. [17] 1 Signs and symptoms Anus Rectum Appendix Cecum Colon Small intestine Stomach Location of the appendix in the digestive system The presentation of acute appendicitis includes abdom- inal pain, nausea, vomiting, and fever. As the appendix becomes more swollen and inflamed, it begins to irritate the adjoining abdominal wall. This leads to the localiza- tion of the pain to the right lower quadrant. This clas- sic migration of pain may not be seen in children under three years. This pain can be elicited through various signs and can be severe. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is se- vere pain on sudden release of deep pressure in the lower abdomen (rebound tenderness). If the appendix is retro- cecal (localized behind the cecum), even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix). This is because the cecum, distended with gas, protects the inflamed appendix from pressure. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity. In such cases, a digital rectal examination elicits tender- ness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney’s point). 1
Transcript
Page 1: Appendicitis Ingles

Appendicitis

Appendicitis is inflammation of the appendix. Appen-dicitis commonly presents with right lower abdominalpain, nausea, vomiting, and decreased appetite.[2] How-ever, one third to a half of persons do not have these typi-cal signs and symptoms.[3] Severe complications of a rup-tured appendix include widespread, painful inflammationof the inner lining of the abdominal wall and sepsis.[4]

Appendicitis is caused by a blockage of the hollow por-tion of the appendix,[5][6] most commonly by a calcified“stone” made of feces. However, inflamed lymphoid tis-sue from a viral infection, parasites, gallstone, or tumorsmay also cause the blockage.[7] This blockage leads to in-creased pressures within the appendix, decreased bloodflow to the tissues of the appendix, and bacterial growthinside the appendix causing inflammation.[7][8] The com-bination of inflammation, reduced blood flow to the ap-pendix and distention of the appendix causes tissue injuryand tissue death.[9] If this process is left untreated, the ap-pendix may burst, releasing bacteria into the abdominalcavity, leading to severe abdominal pain and increasedcomplications.[9][10]

The diagnosis of appendicitis is largely based on theperson’s signs and symptoms.[8] In cases where the di-agnosis cannot be made based on the person’s historyand physical exam, close observation, radiographic imag-ing and laboratory tests can often be helpful.[11] Thetwo most common imaging tests used are ultrasound andcomputed tomography (CT scan).[11] CT scan has beenshown to be more accurate than ultrasound in detectingacute appendicitis.[12] However, ultrasound may be pre-ferred as the first imaging test in children and pregnantwomen because of the risks associated with radiation ex-posure from CT scans.[11]

The standard treatment for acute appendicitis is surgicalremoval of the appendix.[7][8] This may be done by anopen incision in the abdomen (laparotomy) or througha few smaller incisions with the help of cameras (la-paroscopy). Surgery decreases the risk of side effectsor death associated with rupture of the appendix.[4]Antibiotics may be equally effective in certain cases ofnon-ruptured appendicitis.[13] It is one of the most com-mon and significant causes of severe abdominal pain thatcomes on quickly worldwide. In 2013 about 16 millioncases of appendicitis occurred.[14] This resulted in 72,000deaths globally.[15] In the United States, appendicitis isthe most common cause of acute abdominal pain requir-ing surgery.[2] Each year in the United States, more than300,000 persons with appendicitis have their appendixsurgically removed.[16] Reginald Fitz is credited with be-

ing the first person to describe the condition in a paperpublished in 1886.[17]

1 Signs and symptoms

Anus

Rectum

Appendix

CecumColon

Small intestineStomach

Location of the appendix in the digestive system

The presentation of acute appendicitis includes abdom-inal pain, nausea, vomiting, and fever. As the appendixbecomes more swollen and inflamed, it begins to irritatethe adjoining abdominal wall. This leads to the localiza-tion of the pain to the right lower quadrant. This clas-sic migration of pain may not be seen in children underthree years. This pain can be elicited through varioussigns and can be severe. Signs include localized findingsin the right iliac fossa. The abdominal wall becomes verysensitive to gentle pressure (palpation). Also, there is se-vere pain on sudden release of deep pressure in the lowerabdomen (rebound tenderness). If the appendix is retro-cecal (localized behind the cecum), even deep pressurein the right lower quadrant may fail to elicit tenderness(silent appendix). This is because the cecum, distendedwith gas, protects the inflamed appendix from pressure.Similarly, if the appendix lies entirely within the pelvis,there is usually complete absence of abdominal rigidity.In such cases, a digital rectal examination elicits tender-ness in the rectovesical pouch. Coughing causes pointtenderness in this area (McBurney’s point).

1

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2 3 DIAGNOSIS

2 Causes

Video explanation of appendicitis

Acute appendicitis seems to be the end result of a primaryobstruction of the inside (lumen) of the appendix.[5][6]Once this obstruction occurs, the appendix becomes filledwith mucus and swells. This continued production ofmucus leads to increased pressures within the lumen andthe walls of the appendix. This increased pressure re-sults in thrombosis and occlusion of the small vessels,and stasis of lymphatic flow. At this point spontaneousrecovery rarely occurs. As the occlusion of blood ves-sels progresses, the appendix becomes ischemic and thennecrotic. As bacteria begin to leak out through the dyingwalls, pus forms within and around the appendix (suppu-ration). The end result of this cascade is appendiceal rup-ture (a 'burst appendix') causing peritonitis, which maylead to sepsis and eventually death. This cascade of eventsis responsible for the slowly evolving abdominal pain andother commonly associated symptoms.[9]

The causative agents include bezoars, foreign bodies,trauma, intestinal worms, lymphadenitis, and, most com-monly, calcified fecal deposits that are known as appendi-coliths or fecaliths.[18][19] The occurrence of obstructingfecaliths has attracted attention since their presencein persons with appendicitis is higher in developedthan in developing countries.[20] In addition an appen-diceal fecalith is commonly associated with complicatedappendicitis.[21] Also, fecal stasis and arrest may play arole, as demonstrated by persons with acute appendicitishaving fewer bowel movements per week compared withhealthy controls.[19][22]

The occurrence of a fecalith in the appendix was thoughtto be attributed to a right-sided fecal retention reservoirin the colon and a prolonged transit time. However, aprolonged transit time was not observed in subsequentstudies.[23] From epidemiological data, it has been statedthat diverticular disease and adenomatous polyps wereunknown and colon cancer exceedingly rare in communi-ties exempt from appendicitis.[24][25] Also, acute appen-dicitis has been shown to occur antecedent to cancer inthe colon and rectum.[26] Several studies offer evidencethat a low fiber intake is involved in the pathogenesis ofappendicitis.[27][28][29] This low intake of dietary fiber isin accordance with the occurrence of a right-sided fe-

cal reservoir and the fact that dietary fiber reduces transittime.[30]

3 Diagnosis

Diagnosis is based on a medical history (symptoms) andphysical examination which can be supported by an eleva-tion of neutrophilic white blood cells and imaging studiesif needed. (Neutrophils are the primary white blood cellsthat respond to a bacterial infection.) Histories fall intotwo categories, typical and atypical. Typical appendici-tis includes several hours of generalized abdominal painwhich begins in the region of the umbilicus with associ-ated anorexia, nausea, or vomiting. The pain then “local-izes” into the right lower quadrant where the tendernessincreases in intensity. However, it is possible the paincould localize to the left lower quadrant in persons withsitus inversus totalis. The combination of pain, anorexia,leukocytosis, and fever is classic. Atypical histories lackthis typical progression and may include pain in the rightlower quadrant as an initial symptom. Irritation of theperitoneum (inside lining of the abdominal wall) can leadto increased pain on movement, or jolting, for examplegoing over speedbumps.[31] Atypical histories often re-quire imaging with ultrasound and/or CT scanning.[32]

3.1 Clinical

• Aure-Rozanova sign: Increased pain on palpationwith finger in right Petit triangle (can be a positiveShchetkin-Bloomberg’s)

• Bartomier-Michelson’s sign: Increased pain on pal-pation at the right iliac region as the person beingexamined lies on his/her left side compared to whenhe/she lies on his/her back.

• Dunphy’s sign: Increased pain in the right lowerquadrant with coughing.[33]

• Kocher’s (Kosher’s) sign: From the person’s medicalhistory, the start of pain in the umbilical region witha subsequent shift to the right iliac region.

• Massouh sign: Developed in and popular in south-west England, the examiner performs a firm swishwith his/her index and middle finger across the ab-domen from the Xiphoid process to the left and theright iliac fossa. A positive Massouh sign is a gri-mace of the person being examined upon a rightsided (and not left) sweep.

• Obturator sign: The person being evaluated lies onher/his back with the hip and knee both flexed atninety degrees. The examiner holds the person’s an-kle with one hand and knee with the other hand. Theexaminer rotates the hip by moving the person’s an-kle away from the his/her body while allowing the

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3.3 Imaging 3

knee to move only inward. A positive test is painwith internal rotation of the hip.

• Psoas sign: Also known as the “Obraztsova’s sign”is right lower-quadrant pain that is produced witheither the passive extension of the right hip or bythe active flexion of the person’s right hip whilesupine. The pain that is elicited is due to inflamma-tion of the peritoneum overlying the iliopsoas mus-cles and inflammation of the psoas muscles them-selves. Straightening out the leg causes pain becauseit stretches these muscles, while flexing the hip acti-vates the iliopsoas and therefore also causes pain.

• Rovsing’s sign: Pain in the lower right abdominalquadrant with continuous deep palpation startingfrom the left iliac fossa upwards (counterclockwisealong the colon). The thought is there will be in-creased pressure around the appendix by pushingbowel contents and air towards the ileocaecal valveprovoking right sided abdominal pain.[34]

• Sitkovskiy (Rosenstein)'s sign: Increased pain in theright iliac region as the person is being examined lieson his/her left side.

3.2 Blood and urine test

While there is no laboratory test specific for appendicitis,a complete blood count (CBC) is done to check for signsof infection. Although 70-90 percent of people with ap-pendicitis may have an elevated white blood cell (WBC)count, there are many other abdominal and pelvic condi-tions that can cause the WBC count to be elevated.[35]

A urinalysis generally does not show infection but it is im-portant for determining pregnancy status, especially thepossibility of an ectopic pregnancy in woman of child-bearing age. The urinalysis is also important for rulingout a urinary tract infection as the cause of abdominalpain. The presence of more than 20 WBC per high-power field in the urine is more suggestive of a urinarytract disorder.[35]

3.3 Imaging

In children the clinical examination is important fordetermination of which children with abdominal painshould receive immediate surgical consultation and whichshould receive diagnostic imaging.[36] Because of thehealth risks of exposing children to radiation, ultrasoundis the preferred first choice with CT-scan being a legiti-mate follow-up if the ultrasound is inconclusive.[37][38][39]CT scan is more accurate than ultrasound for the diagno-sis of appendicitis in adults and adolescents. CT scan hasa sensitivity of 94%, specificity of 95%. Ultrasonographyhad an overall sensitivity of 86%, a specificity of 81%.[40]

3.3.1 Ultrasound

Ultrasound image of acute appendicitis

Ultrasonography and Doppler sonography provide usefulmeans to detect appendicitis, especially in children. Ul-trasound can also show free fluid collection in the rightiliac fossa, along with a visible appendix without bloodflowwhen using color Doppler, and noncompressibility ofthe appendix, as it is essentially a walled off abscess. Insome cases (15% approximately), however, ultrasonog-raphy of the iliac fossa does not reveal any abnormalitiesdespite the presence of appendicitis. This false negativefinding is especially true of early appendicitis before theappendix has become significantly distended. In addi-tion false negative findings are more common in adultswhere larger amounts of fat and bowel gas make visualiz-ing the appendix technically difficult. Despite these lim-itations, sonographic imaging in experienced hands canoften distinguish between appendicitis and other diseaseswith similar symptoms. Some of these conditions includeinflammation of lymph nodes near the appendix or painoriginating from other pelvic organs such as the ovariesor fallopian tubes.

3.3.2 Computed tomography

Where it is readily available, computed tomography (CT)has become frequently used, especially in people whosediagnosis is not obvious on history and physical exami-nation. Concerns about radiation, however, tend to limituse of CT in pregnant women and children, especiallywith the increasingly widespread usage of MRI.[41][42]

The accurate diagnosis of appendicitis is multi-tiered,with the size of the appendix having the strongest positivepredictive value, while indirect features can either in-crease or decrease sensitivity and specificity. A sizeof over 6 mm is both 95% sensitive and specific forappendicitis.[43]

However, because the appendix can be filled with fecalmaterial, causing intraluminal distention, this criterion

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4 3 DIAGNOSIS

A CT scan demonstrating acute appendicitis (note the appendixhas a diameter of 17.1 mm and there is surrounding fat strand-ing)

A fecalith marked by the arrow which has resulted in acute ap-pendicitis.

has shown limited utility in more recent meta analyses.[44]This is as opposed to ultrasound, in which the wall of theappendix can be more easily distinguished from intralu-minal feces. In such scenarios, ancillary features suchas increased wall enhancement as compared to adjacentbowel, and inflammation of the surrounding fat, or fatstranding, can be supportive of the diagnosis, althoughtheir absence does not preclude it. In severe cases withperforation, an adjacent phlegmon or abscess can be seen.Dense fluid layering in the pelvis can also result, relatedto either pus or enteric spillage. When patients are thinor younger, the relative absence of fat can make both theappendix and surrounding fat stranding difficult to see.[44]

3.3.3 Magnetic resonance imaging

MRI usage has become increasingly common for diag-nosis of appendicitis in children and pregnant patientsdue to the radiation dosage that, while of nearly negli-gible risk in healthy adults, can be harmful to children orthe developing fetus. In pregnancy, it has been found tobe more useful during the second and third trimester, par-ticularly as the enlargening uterus displaces the appendix,

making it difficult to find by ultrasound. The periappen-diceal stranding that is reflected on CT by fat stranding onMRI appears as increased fluid signal on T2 weighted se-quences. First trimester pregnancies are usually not can-didates for MRI, as the fetus is still undergoing organo-genesis, and there are no long term studies to date regard-ing its potential risks or side effects.[45]

3.3.4 X–Ray

In general, plain abdominal radiography (PAR) is not use-ful in making the diagnosis of appendicitis and shouldnot be routinely obtained in a person being evaluated forappendicitis.[46][47] Plain abdominal films may be usefulfor the detection of ureteral calculi, small bowel obstruc-tion, or perforated ulcer, but these conditions are rarelyconfused with appendicitis.[48] An opaque fecalith can beidentified in the right lower quadrant in less than 5% ofpersons being evaluated for appendicitis.[35] Abarium en-ema has proven to be a poor diagnostic tool for appendici-tis. While failure of the appendix to fill during a bariumenema has been associated with appendicitis, up to 20%of normal appendices also do not fill.[48]

3.4 Scoring systems

No excellent scoring system exists to determine if a childhas appendicitis.[49] The Alvarado score and pediatric ap-pendicitis score are okay but not definitive.[49]

The Alvarado score is the most widely used scoring sys-tem. A score below 5 suggests against a diagnosis of ap-pendicitis, whereas a score of 7 or more is predictive ofacute appendicitis. In a person with an equivocal scoreof 5 or 6, a CT scan or ultrasound exam may be used toreduce the rate of negative appendectomy.

3.5 Pathology

Micrograph of appendicitis and periappendicitis. H&E stain.

The definitive diagnosis is based on pathology. Thehistologic finding of appendicitis is neutrophilic infiltrateof the muscularis propria.

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5

Micrograph of appendicitis showing neutrophils in the muscularispropria. H&E stain.

Periappendicits, inflammation of tissues around the ap-pendix, is often found in conjunction with other abdom-inal pathology.[50]

3.6 Differential diagnosis

Children: Gastroenteritis, mesenteric adenitis, Meckel’sdiverticulitis, intussusception, Henoch-Schönlein pur-pura, lobar pneumonia, urinary tract infection (abdom-inal pain in the absence of other symptoms can oc-cur in children with UTI), new-onset Crohn’s diseaseor ulcerative colitis, pancreatitis, and abdominal traumafrom child abuse; distal intestinal obstruction syndromein children with cystic fibrosis; typhlitis in children withleukemia.Women: A pregnancy test is important in all womenof childbearing age since an ectopic pregnancy can havesigns and symptoms similar to those of appendicitis.Other obstetrical/gynecological causes of similar abdom-inal pain in women include pelvic inflammatory disease,ovarian torsion, menarche, dysmenorrhea, endometriosis,and Mittelschmerz (the passing of an egg in the ovariesapproximately two weeks before an expected menstrua-tion cycle).[51]

Men: testicular torsion;Adults: new-onset Crohn’s disease, ulcerative colitis,regional enteritis, renal colic, perforated peptic ulcer,pancreatitis, rectus sheath hematoma and epipliocitis.Elderly: diverticulitis, intestinal obstruction, colonic car-cinoma, mesenteric ischemia, leaking aortic aneurysm.The term “pseudoappendicitis” is used to describe a con-dition mimicking appendicitis.[52] It can be associatedwith Yersinia enterocolitica.[53]

4 Management

Acute appendicitis is typically managed by surgery.However, in uncomplicated cases antibiotics are botheffective and safe.[13] While antibiotics are effectivefor treating uncomplicated appendicitis, 20% of peoplehad a recurrence within a year and required eventualappendectomy.[13]

In people with inflammatory bowel disease such asCrohn’s disease or ulcerative colitis who present with ap-pendicitis, surgical intervention is contraindicated, as thenormal healing response following surgery is impaired bythe underlying disease process, and the patients form nonhealing fistulas, sinus tracts and enteric leakage. In suchscenarios, the underlying disease process must be treatedmedically with DMARDs, as opposed to surgically.[54]

4.1 Pain

Pain medications (such as morphine) do not appear to af-fect the accuracy of the clinical diagnosis of appendici-tis and therefore should be given early in the person’scare.[55] Historically there were concerns among somegeneral surgeons that analgesics would affect the clini-cal exam in children and thus some recommended thatthey not be given until the surgeon in question was ableto examine the person for themselves.[55]

4.2 Surgery

See also: AppendectomyThe surgical procedure for the removal of the ap-

Inflamed appendix removal by open surgery

pendix is called an appendicectomy. Appendectomycan be performed through open or laparoscopic surgery.Laparoscopic appendectomy has several advantagesover open appendectomy as an intervention for acuteappendicitis.[56]

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6 4 MANAGEMENT

Laparoscopic appendectomy.

4.2.1 Open appendectomy

For over a century, Laparotomy (open appendectomy)was the standard treatment for acute appendicitis.[57] Thisprocedure consists of the removal of the infected ap-pendix through a single large incision in the lower rightarea of the abdomen.[58] The incision in a laparotomy isusually 2 to 3 inches (51 to 76 mm) long.During an open appendectomy, the person with suspectedappendicitis is placed under general anesthesia to keepthe muscles completely relaxed and to keep the personunconscious. The incision is two to three inches (76 mm)long and it is made in the right lower abdomen, severalinches above the hip bone.[59] Once the incision opensthe abdomen cavity and the appendix is identified, thesurgeon removes the infected tissue and cuts the appendixfrom the surrounding tissue. After careful and close in-spection of the infected area, and ensuring there are nosigns that surrounding tissues are damaged or infected,the surgeon will start closing the incision. This meanssewing the muscles and using surgical staples or stitchesto close the skin up. In order to prevent infections, theincision is covered with a sterile bandage.

4.2.2 Laparoscopic appendectomy

Laparoscopic appendectomy has become an increasinglyprevalent intervention for acute appendicitis since its in-troduction in 1983.[60] This surgical procedure consists ofmaking three to four incisions in the abdomen, each 0.25to 0.5 inches (6.4 to 12.7 mm) long. This type of appen-dectomy is made by inserting a special surgical tool calledlaparoscope into one of the incisions. The laparoscopeis connected to a monitor outside the person’s body andit is designed to help the surgeon to inspect the infectedarea in the abdomen. The other two incisions are madefor the specific removal of the appendix by using surgicalinstruments. Laparoscopic surgery also requires generalanesthesia and it can last up to two hours. LaparoscopicAppendectomy has several advantages over open appen-dectomy, including a shorter post-operative recovery, less

post-operative pain, and lower superficial surgical site in-fection rate. However, the occurrence of intra-abdominalabscess is almost three times more prevalent in laparo-scopic appendectomy than open appendectomy.[61]

4.2.3 Pre surgery

The treatment begins by keeping the person who will behaving surgery from eating or drinking for a given pe-riod of time, usually overnight. An intravenous drip isused to hydrate the person who will be having surgery.Antibiotics given intravenously such as cefuroxime andmetronidazole may be administered early to help kill bac-teria and thus reduce the spread of infection in the ab-domen and postoperative complications in the abdomenor wound. Equivocal cases may become more difficultto assess with antibiotic treatment and benefit from serialexaminations. If the stomach is empty (no food in thepast six hours) general anaesthesia is usually used. Oth-erwise, spinal anaesthesia may be used.Once the decision to perform an appendectomy has beenmade, the preparation procedure takes approximately oneto two hours. Meanwhile, the surgeon will explain thesurgery procedure and will present the risks that must beconsidered when performing an appendectomy. With allsurgeries there are certain risks that must be evaluated be-fore performing the procedures. However, the risks aredifferent depending on the state of the appendix. If theappendix has not ruptured, the complication rate is onlyabout 3% but if the appendix has ruptured, the compli-cation rate rises to almost 59%.[62] The most usual com-plications that can occur are pneumonia, hernia of the in-cision, thrombophlebitis, bleeding or adhesions. Recentevidence indicates that a delay in obtaining surgery af-ter admission results in no measurable difference in out-comes to the person with appendicitis.[63]

The surgeon will also explain how long the recovery pro-cess should take. Abdomen hair is usually removed in or-der to avoid complications that may appear regarding theincision. In most of the cases persons going in for surgeryexperience nausea or vomiting which requires specificmedication before surgery. Antibiotics along with painmedication may also be administrated prior to appendec-tomies.

4.2.4 After surgery

Hospital lengths of stay typically range from a few hoursto a few days, but can be a few weeks if complicationsoccur. The recovery process may vary depending on theseverity of the condition, if the appendix had ruptured ornot before surgery. Appendix surgery recovery is gener-ally a lot faster if the appendix did not rupture.[64] It is im-portant that persons undergoing surgery respect their doc-tor’s advice and limit their physical activity so the tissuescan heal faster. Recovery after an appendectomy may not

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7

The stitches the day after having the appendix removed by la-paroscopic surgery

require diet changes or a lifestyle change.Length of hospital stays for appendicitis varies on theseverity of the condition. A study from the United Statesfound that in 2010, the average appendicitis hospital staywas 1.8 days. For stays where the person’s appendix hadruptured, the average length of stay was 5.2 days.[10]

After surgery occurs, the patient will be transferred to apostanesthesia care unit so his or her vital signs can beclosely monitored to detect anesthesia- and/or surgery-related complications. Pain medication may also be ad-ministered if necessary. After patients are completelyawake, they are moved into a hospital room to recover.Most individuals will be offered clear liquids the day af-ter the surgery, then progress to a regular diet when theintestines start to function properly. Patients are recom-mended to sit up on the edge of the bed andwalk short dis-tances for several times a day. Moving is mandatory andpain medication may be given if necessary. Full recoveryfrom appendectomies takes about four to six weeks, butcan be prolonged to up to eight weeks if the appendix hadruptured.

5 Prognosis

Most persons with appendicitis recover easily after surgi-cal treatment, but complications can occur if treatmentis delayed or if peritonitis occurs. Recovery time de-pends on age, condition, complications, and other cir-cumstances, including the amount of alcohol consump-tion, but usually is between 10 and 28 days. For youngchildren (around 10 years old), the recovery takes threeweeks.The of life-threatening peritonitis is the reason why acuteappendicitis warrants speedy evaluation and treatment.Persons with suspected appendicitis may have to undergoa medical evacuation. Appendectomies have occasion-ally been performed in emergency conditions (i.e., not ina proper hospital), when a timely medical evacuation was

impossible.Typical acute appendicitis responds quickly to appendec-tomy and occasionally will resolve spontaneously. If ap-pendicitis resolves spontaneously, it remains controver-sial whether an elective interval appendectomy should beperformed to prevent a recurrent episode of appendici-tis. Atypical appendicitis (associated with suppurativeappendicitis) is more difficult to diagnose and is moreapt to be complicated even when operated early. In ei-ther condition, prompt diagnosis and appendectomy yieldthe best results with full recovery in two to four weeksusually. Mortality and severe complications are unusualbut do occur, especially if peritonitis persists and is un-treated. Another entity known as appendicular lump istalked about quite often. It happens when the appendixis not removed early during infection and omentum andintestine adhere to it, forming a palpable lump. Duringthis period, surgery is risky unless there is pus formationevident by fever and toxicity or by USG. Medical man-agement treats the condition.An unusual complication of an appendectomy is“stump appendicitis": inflammation occurs in the rem-nant appendiceal stump left after a prior incompleteappendectomy.[65]

6 Epidemiology

Disability-adjusted life year for appendicitis per 100,000inhabitants in 2004.[66]

no dataless than 2.52.5-55-7.57.5-1010-12.512.5-1515-17.517.5-2020-22.522.5-2525-27.5more than 27.5

Appendicitis is most common between the ages of 5 and40;[67] the median age is 28. It tends to affect males, thosein lower income groups, and, for unknown reasons, peo-ple living in rural areas.[68] In 2013 it resulted in 72,000

Page 8: Appendicitis Ingles

8 7 REFERENCES

deaths globally down from 88,000 in 1990.[15]

In the United States, there were nearly 293,000 hospi-talizations involving appendicitis in 2010.[10] Appendici-tis is one of the most frequent diagnoses for emergencydepartment visits resulting in hospitalization among chil-dren aged 5–17 years in the United States.[69]

7 References[1] MerriamWebster definition

[2] Graffeo, CS; Counselman, FL (1996). “Appendicitis.”.Emergency medicine clinics of North America 14 (4):653–71. doi:10.1016/s0733-8627(05)70273-x. PMID8921763.

[3] Graffeo, CS; Counselman, FL (November 1996). “Ap-pendicitis.”. Emergency medicine clinics of North Amer-ica 14 (4): 653–71. doi:10.1016/s0733-8627(05)70273-x. PMID 8921763.

[4] Hobler, K. (Spring 1998). “Acute and Suppurative Ap-pendicitis: Disease Duration and its Implications forQuality Improvement”. Permanente Medical Journal 2.

[5] Wangensteen OH, Bowers WF (1937). “Signifi-cance of the obstructive factor in the genesis ofacute appendicitis”. Arch Surg 34 (3): 496–526.doi:10.1001/archsurg.1937.01190090121006.

[6] Pieper R, Kager L, Tidefeldt U (1982). “Obstruction ofappendix vermiformis causing acute appendicitis. One ofthe most common causes of this is an acute viral infec-tion which causes lymphoid hyperplasia and therefore ob-struction. An experimental study in the rabbit”. Acta ChirScand 148 (1): 63–72. PMID 7136413.

[7] al.], ed. Dan L. Longo ... [et (2012). Harrison’s principlesof internal medicine. (18th ed.). New York: McGraw-Hill. p. Chapter 300. ISBN 978-0-07174889-6. Re-trieved 6 November 2014.

[8] Tintinalli, editor-in-chief Judith E. (2011). Emergencymedicine : a comprehensive study guide (7. ed.). NewYork: McGraw-Hill. p. Chapter 84. ISBN 978-0-07-174467-6. Retrieved 6 November 2014.

[9] Schwartz’s principles of surgery (9th ed.). New York:McGraw-Hill, Medical Pub. Division. 2010. p. Chap-ter 30. ISBN 978-0-07-1547703.

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8 External links

• CT of the abdomen showing acute appendicitis

• Podcast on the management of appendicitis

• Appendicitis and Appendectomy author Den-nis Lee, M.D. editor Jay Marks, M.D. -MedicineNet.com, Doctor Produced infor-mation plus Patient Discussions provided byMedicineNet.com

• Appendicitis - MayoClinic.com, from the Web siteof the Mayo Clinic

• Appendicitis, history, diagnosis and treatment bySurgeons Net Education

• Appendicitis Research Latest research from the lit-erature on appendicitis

• Acute and Suppurative Appendicitis from the Spring1998 issue of The Permanente Medical Journal

• Appendicitis Update Complete information includ-ing laparoscopic appendectomy

• History of Appendicitis Vermiformis: Its diseasesand treatment. By Arthur C. McCarty, M.D.

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11

• How to Recognize the Symptoms of Appendicitis, ahow-to article from wikiHow

• Appendicitis: Acute Abdomen and Surgical Gas-troenterology from the Merck Manual Professional(Content last modified September 2007)

• Abdominal Emergencies, 'Surgical Abdomen'.ByDR David Bednarczyk; Pediatric Surgery

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12 9 TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

9 Text and image sources, contributors, and licenses

9.1 Text• Appendicitis Source: https://en.wikipedia.org/wiki/Appendicitis?oldid=720712620 Contributors: AxelBoldt, Kpjas, Mav, The Anome,Alex.tan, Codeczero, JimMcKeeth, Zashaw, DopefishJustin, Gabbe, Wapcaplet, Ixfd64, Chadloder, Egil, Jiang, Jengod, Charles Matthews,Bemoeial, Maximus Rex, Metasquares, Renato Caniatti~enwiki, David.Monniaux, Imesj, Robbot, Donreed, Jra, Kneiphof, Giftlite,Mintleaf~enwiki, Robodoc.at, Alison, Michael Devore, Jfdwolff, Saaga, Chowbok, Toytoy, Lylum, Rdsmith4, Cb6, DragonflySixty-seven, Ukexpat, Lacrimosa~enwiki, Discospinster, Vsmith, Smyth, SpookyMulder, Bender235, MisterSheik, Gnu1742, El C, Nonpareil-ity, Diomidis Spinellis, RoyBoy, Kcsefalvay, Bobo192, Arcadian, Giraffedata, Nk, HasharBot~enwiki, Alansohn, Wouterstomp, Boot-stoots, Snowolf, Versageek, Forteblast, Richard Arthur Norton (1958- ), Ixistant, Mel Etitis, 2004-12-29T22:45Z, Mindmatrix, Tiger-Shark, PoccilScript, Urod, Al E., GregorB, Graham87, Magister Mathematicae, FreplySpang, Koolkao, Rjwilmsi, Rogerd, Wikibofh,XP1, SeanMack, FlaBot, Kerowyn, Gurch, Stevenfruitsmaak, David H Braun (1964), Ronebofh, Evands, Drvgaikwad, YurikBot, RobotE,Ste1n, WAvegetarian, Anonymous editor, Chris Capoccia, Gaius Cornelius, Eleassar, Rsrikanth05, Pseudomonas, Grafen, Tetsuo, Lex-icon, Nephron, Evmore, Samir, Mieciu K, BOT-Superzerocool, Bebgsurg, Cinik, IceCreamAntisocial, Wknight94, ReCover, 2over0,Closedmouth, Reyk, Chriswaterguy, Badgettrg, Rathfelder, Andrew73, Jeff Silvers, Jrslim, SmackBot, MattieTK, Elonka, TomGreen,Adam majewski, F, Unyoyega, Rrius, Finavon, Jonathan108, JRSP, Chris the speller, Kurykh, RDBrown, Chlopez, Ctrlfreak13, Emu-farmers, MalafayaBot, Khobler, Patrick925, DHN-bot~enwiki, Cassivs, A. B., SLC1, Mmjones, The Crowing, Versed, JR98664, Nakon,Richard001, Renamed user 8263928762779, DMacks, Vina-iwbot~enwiki, The undertow, Visium, Shadowlynk, Beetstra, Coastiehelo,ImagineWizard, Peyre, Youdontsmellbad, Hu12, Iridescent, Droliver, Brbr28, Tawkerbot2, BruceGrubb, Fvasconcellos, ViruValge, Thede-monhog, CmdrObot, GHe, Xxovercastxx, Drmed36, Shandris, WeggeBot, AndrewHowse, Cydebot, Ryan, Shamesspwns, Fezz, Snrpro,David Santos, Anthonyhcole, Lessthaninfinite, Alaibot, FastLizard4, Lewisskinner, NMChico24, Sweetmoose6, PKT, Thijs!bot, Epbr123,Csol, Loudsox, Headbomb, A3RO, Chris goulet, EdJohnston, Shedinja500, Vaniac, Mercutio.Wilder, Escarbot, Jalan z, DarthShrine,JAnDbot, MER-C, Sliver85, Ph.eyes, Jjacobsmeyer, Hewinsj, Ninjutsu, Magioladitis, Bongwarrior, VoABot II, Fusionmix, SHCarter,Drahreg01, Nyttend, Jrssr5, Catgut, Lasse Havelund, Damuna, Zoofroot, WLU, MartinBot, Gandydancer, Reguiieee, R'n'B, Commons-Delinker, Deans-nl, J.delanoy, Pharaoh of the Wizards, Codeye, Nbauman, Sqush101, Rhinestone K, Katalaveno, Mikael Häggström,Skier Dude, AntiSpamBot, Berserkerz Crit, Molly-in-md, Neeleshj, Treisijs, Pdcook, SoCalSuperEagle, Aigrette, VolkovBot, Jeff G., So-liloquial, Gene Hobbs, Philip Trueman, Filip kocha małgosię, TXiKiBoT, Oshwah, Zeeekl1, Beezer137, Ceah Tomojotkoloff, MuanN,DennyColt, Slysplace, Bodybagger, ^demonBot2, GeneralBelly, Raymondwinn, Vash Must Have Doughnuts, Mr. Absurd, Chibiheart,Greswik, Plutonium27, Sbakka, Synthebot, Lova Falk, Enviroboy, Doc James, Glst2, Riktenkay, Bfpage, SieBot, Nubiatech, Moonrid-dengirl, Ronaldinho101, BService, Keilana, Bentogoa, Wilson44691, JSpung, Oxymoron83, Annalabagaba, Txknight, Fnaq, Dr. Doof,OKBot, Xopusmagnumx, Hordaland, Angel caboodle, Animeronin, ClueBot, Snigbrook, The Thing That Should Not Be, Mr MichaelFowler, Mild Bill Hiccup, Danielcg, MasterXC, Deselliers, Excirial, Wadood Parvez, Kjramesh, Resoru, Purplewowies, Razorflame, Nav-icular, Kablaaaaaa, Thingg, Aitias, 7, Londonsista, XLinkBot, Mavigogun, Chazz26, ZooFari, Anticipation of a New Lover’s Arrival, The,Addbot, Tiggywinkle25, Willking1979, DOI bot, Ente75, Prairieplant, Drjsc, Diptanshu.D, Cst17, Download, Morning277, Glane23, An-dersBot, SamatBot, Woodbinepark, Magnetawan, Tide rolls, Drpdatta, Lightbot, ,55דוד Jarble, Luckas-bot, Yobot, II MusLiM HyBRiD II,Yngvadottir, Drantik, Chris Hadley, Nallimbot, SHAHINOVE, Geneylu, AnomieBOT, KDS4444, Jim1138, Bluerasberry, Materialscien-tist, Citation bot, OllieFury, Roux-HG, LilHelpa, TheRealNightRider, Xqbot, Addihockey10, Acebulf, H2ostra, Tad Lincoln, Quintus314,GrouchoBot, A dullard, Ute in DC, Frankie0607, NobelBot, Doulos Christos, Samwb123, FrescoBot, Lothar von Richthofen, Leightonwal-ter, Age Happens, Citation bot 1, Xxglennxx, Sakha Sire, Buthod, Pinethicket, Jonesey95, MastiBot, Fmohod, Kparavindan, Redbeanpaste,Jauhienij, Natrego, TobeBot, Trappist the monk, Pvkwiki, Lotje, Tbhotch, Stroppolo, Minimac, Clipmobile, Dree12, RjwilmsiBot, Billare,Rampea, Skamecrazy123, DASHBot, EmausBot, John of Reading, Saephus, Igorwells34, Wham Bam Rock II, AvicBot, Skmishrain-dia, Darlingvioletta86, Netha Hussain, Habeeb Anju, Judep21062, L Kensington, Nrsmoll, Jenifer32, Echobase99, Birlanady, Davidbar-rett80850, Jaiganeshkv, Gunbirddriver, ClueBot NG, Jack Greenmaven, Morgankevinj huggle, Ramaguanli, Rinc3wind, CocuBot, Friet-jes, Angoulmois7, Njvfc34, Widr, StanfordPA, DanClarkePro, Helpful Pixie Bot, Schmoozin, Jeraphine Gryphon, BG19bot, Vagobot,Peter Bivolarsky, Dr!ppy, Drchandershekharsharma, Briang7723, DARIO SEVERI, MrBill3, Ronald.W.Martinez, Blackvegit, Glacial-fox, Wwtele, Shaun, Carliitaeliza, Rytyho usa, BattyBot, Biosthmors, TylerDurden8823, JYBot, BrightStarSky, Dexbot, Mogism, Ranze,Joshua Nicholls, Onnagodalavida, ComfyKem, Me, Myself, and I are Here, Epicgenius, Plymptonst, BreakfastJr, Emwhitaker, Haminoon,Monochrome Monitor, Alice Person, Frenzie23, StevenD99, Anrnusna, Noteswork, Monkbot, Demers6, Tigercompanion25, Jessica-RuthCrowley, Mohammad.karimian85, IPalpedia, Plm234, Inksacks101, JMWt, I enjoy sandwiches, KasparBot, Mohammad1985k, Barbara(WVS), Vdongold, Abdopain Doctor and Anonymous: 641

9.2 Images• File:Acute_appendicitis_High_Power.jpg Source: https://upload.wikimedia.org/wikipedia/commons/8/8d/Acute_appendicitis_High_Power.jpg License: CC BY-SA 4.0 Contributors: Government Medical College, Kozhikode Original artist: Department of Pathology,Calicut Medical college

• File:Appendicitis.webm Source: https://upload.wikimedia.org/wikipedia/commons/f/f3/Appendicitis.webm License: CC BY-SA 4.0Contributors: open.osmosis.org Original artist: Osmosis

• File:Appendicitis_-_low_mag.jpg Source: https://upload.wikimedia.org/wikipedia/commons/5/50/Appendicitis_-_low_mag.jpg Li-cense: CC BY-SA 3.0 Contributors: Own work Original artist: Nephron

• File:Appendicitis_world_map_-_DALY_-_WHO2004.svg Source: https://upload.wikimedia.org/wikipedia/commons/2/20/Appendicitis_world_map_-_DALY_-_WHO2004.svg License: CC BY-SA 2.5 Contributors:

• Vector map from BlankMap-World6, compact.svg by Canuckguy et al. Original artist: Lokal_Profil• File:Appendix-Entfernung.jpg Source: https://upload.wikimedia.org/wikipedia/commons/b/b0/Appendix-Entfernung.jpg License:Public domain Contributors:

• Transferred from de.wikipedia to Commons. Original artist: Life-of-hannes.de at German Wikipedia• File:CAT_scan_demonstrating_acute_appendicitis.jpg Source: https://upload.wikimedia.org/wikipedia/commons/7/7c/CAT_scan_demonstrating_acute_appendicitis.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: James Heilman, MD

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• File:Stitches_post_appendicitis_surgery.jpg Source: https://upload.wikimedia.org/wikipedia/commons/c/c5/Stitches_post_appendicitis_surgery.jpg License: Public domain Contributors: Own work Original artist: Lasse Havelund

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