Appendicitis Disease

BASICS

DESCRIPTION

Acute inflammation of the vermiform appendix

First described by Fitz in 1886
McBurney described the point of maximal tenderness
System(s) affected: Gastrointestinal
Genetics: Unknown.
Incidence/Prevalence in USA:
- 10/100,000
- Most common acute surgical condition of abdomen
- 1 in every 15 persons (7%) at some time in their life
Predominant age:
- Ages 10-30 - Male > Female (3:2)
- Over age 30 - Male = Female
Predominant sex: Slight male predominance

SIGNS AND SYMPTOMS

Abdominal pain (100%) - periumbilical then right-lower-quadrant (RLQ). Pain lessened with flexion of thigh.
Muscle guarding
Anorexia (almost 100%)
Nausea (90%)
Vomiting (75%)-mild
Obstipation
Diarrhea-mild
Sequence of symptom appearance (95%) - anorexia, then abdominal pain, then vomiting
Slight temperature (one degree centigrade) elevation
Slight tachycardia
Patient frequently lies motionless with right thigh drawn up
Maximal tenderness at "McBurney's point"
Direct and referred RLQ tenderness
Voluntary and involuntary guarding
Cutaneous hyperesthesia at T10-12
Rovsing's sign - RLQ pain with palpatory pressure in LLQ
Psoas sign-pain with right thigh extension
Obturator sign-pain with internal rotation of flexed right thigh
Retrocecal appendix-flank tenderness in RLQ
Pelvic appendix-local and suprapubic pain on rectal exam

CAUSES

Obstruction of appendiceal lumen
- Fecaliths (most common)
- Lymphoid tissue hypertrophy
- Inspissated barium
- Vegetable, fruit seeds and other foreign bodies
- Intestinal worms (ascarids)
- Strictures

RISK FACTORS

Adolescent males
Familial tendency
Intra-abdominal tumors

DIAGNOSIS

LABORATORY

Moderate leukocytosis - 10,000 to 18,000/mm3 in 75%
Moderate polymorphonuclear predominance
Urinalysis-elevated specific gravity, hematuria (sometimes), pyuria (sometimes), albuminuria (sometimes)

Drugs that may alter lab results:

Antibiotics
Steroids

Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Acute inflammation of the appendix
Local vascular congestion
Obstruction
Gangrene
Perforation with abscess (15-30%)

SPECIAL TESTS

N/A

IMAGING

(Used in differential diagnosis and to detect complications).

KUB: gas-filled appendix; radiopaque fecalith; deformed cecum; fluid level; ileus; free air.
Barium enema-non-filling appendix; RLQ mass effect
Ultrasound-appendiceal inflammation; other pelvic pathology, such as inflammatory mass.
CT scan for periappendiceal abscess

DIAGNOSTIC PROCEDURES

Cornerstone of diagnosis is history and clinical findings
Diagnostic laparoscopy - consider in young adult females
Rectal and pelvic examinations
Intensive in-hospital observation

TREATMENT

APPROPRIATE HEALTH CARE

Inpatient surgery

GENERAL MEASURES

Preoperative preparation
- Correction of fluid and electrolyte deficits
- Consider broad-spectrum antibiotic coverage

SURGICAL MEASURES

Immediate appendectomy; open or laparoscopic
Drainage of abscess, if present

ACTIVITY

Early postoperative ambulation
Return to full activity by 4 to 6 weeks postop

DIET

Regular diet with return of bowel function, usually within 24 to 48 hours postop

PATIENT EDUCATION

Restricted activity for 4 to 6 weeks postop
Contact physician for development of postop anorexia, nausea, vomiting, abdominal pain, fever, or chills

FOLLOW UP

PREVENTION/AVOIDANCE

N/A

POSSIBLE COMPLICATIONS

Wound infection
Intra-abdominal abscess, sometimes diaphragmatic
Fecal fistula
Intestinal obstruction
Incisional hernia
Liver abscess (rare)
Peritonitis with paralytic ileus

EXPECTED COURSE AND PROGNOSIS

Generally uncomplicated course in young adults with non-ruptured appendicitis.
Factors increasing morbidity and mortality are extremes of age and appendiceal rupture.
Morbidity rates:
- 3% with non-perforated appendicitis
- 47% with perforated appendicitis
Mortality rates:
- 0.1% unruptured acute appendicitis
- 3% ruptured acute appendicitis
- 15% elderly patient with ruptured appendix

MISCELLANEOUS

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric:

Rare in infancy
Decreased diagnostic accuracy
Higher fever, more vomiting
Rupture earlier
Rupture rate: 15 to 50%
May return to full activities earlier

Geriatric:

Decreased diagnostic accuracy
Rupture rate: 67 to 90%
Patients over 60 years of age account for 50% of deaths from acute appendicitis

Others: N/A

PREGNANCY

Most common extra-uterine surgical emergency
1 in 2000 pregnancies
Difficult diagnosis
Appendix displaced superolaterally by gravid uterus
Fetal mortality rate: 2 to 8.5%

OTHER NOTES

In a non-surgical candidate, antibiotic therapy can be used - recurrence rate is too high to recommend as a primary therapy in other patients.

ABBREVIATIONS

KUB = kidney, ureter, bladder

Clinical Investigations

ROLE OF HOMOEOPATHY

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