Appendicitis

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Appendicitis
Classification and external
resources

An acutely inflamed and enlarged

appendix, sliced lengthwise.

ICD-10 K35. - K37.

ICD-9 540-543

DiseasesDB 885

MedlinePlus 000256

eMedicine med/3430
emerg/41
ped/127
ped/2925

MeSH C06.405.205.099

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.[1] Reginald Fitz first described acute and chronic appendicitis in 1886,[2] and it
has been recognized as one of the most common causes of severe acute abdominal pain
worldwide.
Inflamed appendix removal by open surgery
Contents
[hide]

• 1 Causes
• 2 Symptoms
• 3 Signs
o 3.1 Rovsing's sign
o 3.2 Psoas sign
o 3.3 Obturator sign
• 4 Investigations
o 4.1 Alvarado score
• 5 Treatment
• 6 Differential diagnosis
• 7 Prognosis
• 8 References

• 9 External links

[edit] Causes

Location of the appendix in the digestive system

On the basis of experimental evidence, acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen.[3][4] 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, and
lymphadenitis, the occurrence of an obstructing fecalith has attracted attention. The
prevalence of fecaliths in patients with appendicitis is significantly higher in developed
than in developing countries[5], and an appendiceal fecalith is commonly associated with
complicated appendicitis[6]. 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[7]. 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[8]. From epidemiological data it has been stated that diverticular
disease and adenomatous polyps were unknown and colon cancer exceedingly rare in
communities exempt for appendicitis[9][10]. Also, acute appendicitis has been shown to
occur antecedent to cancer in the colon and rectum[11]. Several studies offer evidence that
a low fiber intake is involved in the pathogenesis of appendicitis[12] [13][14]. This is in
accordance with the occurrence of a right sided fecal reservoir and the fact that dietary
fiber reduces transit time[15].

[edit] Symptoms
Symptoms of acute appendicitis can be classified into two types, typical and atypical.[16]
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 isn't a necessary symptom.
Nausea or vomiting may occur, and also the feeling of drowsiness and the feeling of
general bad health. With the typical type, diagnosis is easier to make, surgery occurs
earlier and findings are often less severe.[16]

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 may occur. Tenesmus or "downward urge" (the feeling that a bowel
movement will relieve discomfort) is also experienced in some cases.[17]

Unlike acute appendicitis, chronic appendicitis symptoms can vary from patient to patient
—so much so that "There are no typical findings or routine diagnostic modalities to
diagnose chronic relapsing appendicitis. It is a diagnosis of exclusion..."[18]

[edit] 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 absence
of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in
the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's 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:

[edit] Rovsing's sign

Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. This is the
Rovsing's sign, also known as the Rovsing's 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.[19]

[edit] Psoas sign

Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with
the right hip flexed for pain results.

[edit] Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can
be demonstrated by flexing and internally rotating the hip. This maneuver will cause pain
in the hypogastrium.

[edit] Investigations
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material may be challenged and removed. (February 2007)

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
and/or CT scanning.[16] 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 ecoptic pregnancy are serious, and potentially life 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 image of an acute appendicitis.

Ultrasonography 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.

In places where it is readily available, CT scan has become the diagnostic test of choice,
especially in adults whose diagnosis is not obvious on history and physical. (The use of
CT in pregnant women and children is significantly limited, however, by concerns
regarding radiation exposure.) A properly 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 "fat stranding") 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 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07
to 0.12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81%, a
positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI,
0.13 to 0.27).[20]
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.
[21]
MMP-1 was higher in gangrenous (p<0.05) and perforated appendicitis (p<0.01)
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 (p<0.001).

A number of clinical and laboratory based scoring systems have been devised to assist
diagnosis. The most widely used is Alvarado score.

[edit] Alvarado score

Symptoms

Migratory right iliac fossa pain 1 point

Anorexia 1 point

Nausea and vomiting 1 point

Signs

Right iliac fossa tenderness 2 points

Rebound tenderness 1 point

Fever 1 point

Laboratory

Leucocytosis 2 points
Shift to left (segmented
1 point
neutrophils)

Total score 10 points

A score below 5 is strongly against a diagnosis of appendicitis[22], 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.

[edit] Treatment
The treatment begins by keeping the patient Nil-By-Mouth (stopping them eating and
drinking), even water, in preparation for surgery. An intravenous drip is used to hydrate
the patient. Antibiotics given intravenously such 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 used.

The 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 maximum tenderness, McBurney's 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.[23]

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 0.45; CI 0.35 to 0.58), but the incidence of
intraabdominal abscesses was increased (odds ratio 2.48; CI 1.45 to 4.21). 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 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5).
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 the laparoscopic procedure more than other
groups. [24]

There is debate whether emergent 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 [25] 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=0.667, 0.999). 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. 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 15 minutes in typical appendicitis in thin patients to several hours
in complicated cases. Hospital lengths of stay usually range from overnight to a matter of
days (rarely weeks in complicated cases.)

[edit] Differential diagnosis

In children:

• Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception,

Henoch-Schönlein purpura, lobar pneumonia

In women

• The passing of an egg in the ovaries approximately two weeks before an expected
menstruation cycle.

In adults:

• regional enteritis, renal colic, perforated peptic ulcer, testicular torsion,

pancreatitis, rectus sheath hematoma, pelvic inflammatory disease, ectopic
pregnancy, endometriosis, torsion/rupture of ovarian cyst

In elderly:

• diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia,

leaking aortic aneurysm.

[edit] 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
(i.e. 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 untreated. Another 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.[26]