Acute Appendicitis

Epidemiology
• The incidence of appendectomy appears to be
declining due to more accurate preoperative
diagnosis.
• Despite newer imaging techniques, acute
appendicitis can be very difficult to diagnose.
Appendicitis:
• The most common surgical condition of
the abdomen
• Lifetime occurrence of 7%
• Peak incidence 10-30y

• The most common nonobstetric surgical

intervention during pregnancy
Pathogenesis:
• Appendiceal lumen obstruction :
lymphoid hyperplasia
fecaliths
parasites
foreign bodies
crohn’s disease
metastatic cancer
carcinoid syndrome
 Pathophysiology
• Acute appendicitis is thought to begin with
obstruction of the lumen
• Obstruction can result from food matter,
adhesions, or lymphoid hyperplasia
• Mucosal secretions continue to increase
intraluminal pressure
 Pathophysiology
• Eventually the pressure exceeds capillary
perfusion pressure and venous and lymphatic
drainage are obstructed.
• With vascular compromise, epithelial mucosa
breaks down and bacterial invasion by bowel
flora occurs.
 Pathophysiology
• Increased pressure also leads to arterial stasis
and tissue infarction
• End result is perforation and spillage of
infected appendiceal contents into the
peritoneum
 Pathophysiology
• Initial luminal distention triggers visceral
afferent pain fibers, which enter at the 10th
thoracic vertebral level.
• This pain is generally vague and poorly
localized.
• Pain is typically felt in the periumbilical or
epigastric area.
 Pathophysiology
• As inflammation continues, the serosa and
adjacent structures become inflamed
• This triggers somatic pain fibers, innervating
the peritoneal structures.
• Typically causing pain in the RLQ
 Pathophysiology
• The change in stimulation form visceral to
somatic pain fibers explains the classic
migration of pain in the periumbilical area to
the RLQ seen with acute appendicitis.
 Pathophysiology
• Exceptions exist in the classic presentation
due to anatomic variability of the appendix
• Appendix can be retrocecal causing the pain
to localize to the right flank
• In pregnancy, the appendix ca be shifted and
patients can present with RUQ pain
 Pathophysiology
• In some males, retroileal appendicitis can
irritate the ureter and cause testicular pain.
• Pelvic appendix may irritate the bladder or
rectum causing suprapubic pain, pain with
urination, or feeling the need to defecate
• Multiple anatomic variations explain the
difficulty in diagnosing appendicitis
symptoms :
• Pain – RLQ / RUQ / Flank
• Anorexia
• Vomiting
• Nausea
• Pain migration
• Fever
Physical examination:

• Tenderness – RLQ
• Rebound & Guarding (peritoneal signs)
• Rovsing sign
• Dunphy’s sign
• Psoas sign (retroperitoneal retrocecal appendix)
• Obturator sign (pelvic appendix)
• Rectal examination tenderness (cul-de-sac)
• Low grade fever
 Psoas
sign

Obturator
sign
 History
• Primary symptom: abdominal pain
• ½ to 2/3 of patients have the classical
presentation
• Pain beginning in epigastrium or periumbilical
area that is vague and hard to localize
 History
• Associated symptoms: indigestion, discomfort,
flatus, need to defecate, anorexia, nausea,
vomiting
• As the illness progresses RLQ localization
typically occurs
• RLQ pain was 81 % sensitive and 53% specific
for diagnosis
 History
• Migration of pain from initial periumbilical to
RLQ was 64% sensitive and 82% specific
• Anorexia is the most common of associated
symptoms
• Vomiting is more variable, occuring in about ½
of patients
 Physical Exam
• Findings depend on duration of illness prior to
exam.
• Early on patients may not have localized
tenderness
• With progression there is tenderness to deep
palpation over McBurney’s point
 Physical Exam
• McBurney’s Point: just below the middle of a
line connecting the umbilicus and the ASIS
• Rovsing’s: pain in RLQ with palpation to LLQ
• Rectal exam: pain can be most pronounced if
the patient has pelvic appendix
 Physical Exam
• Additional components that may be helpful in
diagnosis: rebound tenderness, voluntary
guarding, muscular rigidity, tenderness on
rectal
 Physical Exam
• Psoas sign: place patient in L lateral decubitus
and extend R leg at the hip. If there is pain
with this movement, then the sign is positive.
• Obturator sign: passively flex the R hip and
knee and internally rotate the hip. If there is
increased pain then the sign is positive
 Physical Exam
• Fever: another late finding.
• At the onset of pain fever is usually not found.
• Temperatures >39 C are uncommon in first 24
h, but not uncommon after rupture
Lab:
• CBC – WBC ( 80%  45% )
• CRP
• Urinalysis - mild pyuria
mild proteinuria
mild hematuria
D.D.:
surgical: gyneco:
• Renal stone • Preterm labor
• Gastroenteritis • Placenta abruptio
• Pancreatitis • Chorioamnionitis
• Cholecystitis • Adnexal torsion
• Mesenteric adenitis • Ectopic pregnancy
• Hernia • Pelvic inflammatory
• Bowel obstruction • Round lig. pain
 Diagnostic problems:
• Position of appendix:
normally 70% intraperitoneal
30% pelvic, retroileal, retrocolic
pregnancy – anatomical changes
gravid uterus  displacement upward &
outward  flank pain (3rd trimester) (Baer,1932)
increased separation of peritoneum  decreased
perception of somatic pain and localization
Diagnostic problems:
• Symptoms complex – physical changes
anorexia, nausea & vomiting in normal
pregnancy
• Lab – relative leukocytosis
• Imaging techniques
 Diagnosis
• Acute appendicitis should be suspected in
anyone with epigastric, periumbilical, right
flank, or right sided abd pain who has not had
an appendectomy
 Diagnosis
• Women of child bearing age need a pelvic
exam and a pregnancy test.
• Additional studies: CBC, UA, imaging studies
 Diagnosis
• CBC: the WBC is of limited value.
• Sensitivity of an elevated WBC is 70-90%, but
specificity is very low.
• But, +predictive value of high WBC is 92% and
–predictive value is 50%
• CRP and ESR have been studied with mixed
results
 Diagnosis
• UA: abnormal UA results are found in 19-40%
• Abnormalities include: pyuria, hematuria,
bacteruria
• Presence of >20 wbc per field should increase
consideration of Urinary tract pathology
Imaging:
• KUB
• Barium enema
• Graded compression ultrasonography
• Helical CT scan
 Diagnosis
• Imaging studies: include X-rays, US, CT
• Xrays of abd are abnormal in 24-95%
• Abnormal findings include: fecalith,
appendiceal gas, localized paralytic ileus,
blurred right psoas, and free air
• Abdominal xrays have limited use b/c the
findings are seen in multiple other processes
Graded compression ultrasound:
• Normal appendix (<6mm) rules out
appendicitis.
• Nonpregnant – Sensitivity 85%
specificity 92%
• Pregnant – cecal displacement & uterine
imposition makes precise examination difficult
(Williams,21 edition)
 Diagnosis
• Graded Compression US: reported sensitivity
94.7% and specificity 88.9%
• Basis of this technique is that normal bowel
and appendix can be compressed whereas an
inflamed appendix can not be compressed
• DX: noncompressible >6mm appendix,
appendicolith, periappendiceal abscess
 Diagnosis
• Limitations of US: retrocecal appendix may
not be visualized, perforations may be missed
due to return to normal diameter
 Diagnosis
• CT: best choice based on availability and
alternative diagnoses.
• In one study, CT had greater sensitivity,
accuracy, -predictive value
• Even if appendix is not visualized, diagnose
can be made with localized fat stranding in
RLQ.
 Diagnosis
• CT appears to change management decisions
and decreases unnecessary appendectomies
in women, but it is not as useful for changing
management in men.
 Special Populations
• Very young, very old, pregnant, and HIV
patients present atypically and often have
delayed diagnosis
• High index of suspicion is needed in the these
groups to get an accurate diagnosis
 Treatment
• Appendectomy is the standard of care
• Patients should be NPO, given IVF, and
preoperative antibiotics
• Antibiotics are most effective when given
preoperatively and they decrease post-op
infections and abscess formation
 Treatment
• There are multiple acceptable antibiotics to
use as long there is anaerobic flora,
enterococci and gram(-) intestinal flora
coverage
• One sample monotherapy regimen is Zosyn
3.375g or Unasyn 3g
• Also, short acting narcotics should be used for
pain management
 Disposition
• Abdominal pain patients can be put in 4
groups
• Group 1: classic presentation for Acute
appendicitis- prompt surgical intervention
• Group 2: suspicious, but not diagnosed
appendicitis- benefit from imaging and 4-6h
observation with surgical consult if serial exam
changes or imaging studies confirm
 Disposition
• Group 3: remote possibility of appendicitis-
observe in ED for serial exams; if no change
and course remains benign patient can D/C
with dx of nonspecific abd pain
• Patients are given instructions to return if
worsening of symptoms, and they should be
seen by PCP in 12-24 h
• Also advised to avoid strong analgesia
 Disposition
• Group 4: high risk population(including
elderly, pediatric, pregnant and
immunocomprimised)- require high index of
suspicion and low threshold for imaging and
surgical consultation
Prognosis:
• Generally good :
Disease found
Surgery complications
The end