Acute appendicitis

Epidemiology

 lifetime risk: 8.6% for males and 6.7% for females, highest incidence in second and third decades

Etiology

 Obstruction of the lumen due to fecaliths or hypertrophy of lymphoid tissue is proposed as the main
etiologic factor in acute appendicitis.

Pathogenesis

 proximal obstruction of the appendiceal lumen produces a closed-loop obstruction

 continuing normal secretion by appendiceal mucosa rapidly produces distension
 distension of the appendix stimulates the nerve endings of visceral afferent stretch fibers, producing vague,
dull, diffuse pain in the mid-abdomen or lower epigastrium.
 distension increases from continued mucosal secretion and from rapid multiplication of the resident
bacteria of the appendix which causes reflex nausea and vomiting, and the visceral pain increases .
 as pressure in the organ increases, venous pressure is exceeded. Capillaries and venules are occluded but
arterial inflow continues, resulting in engorgement and vascular congestion.
 The inflammatory process soon involves the serosa of the appendix and in turn the parietal peritoneum.This
produces the characteristic shift in pain to the right lower quadrant
 As distension, bacterial invasion, compromise of the vascular supply, and infarction progress, perforation
occurs, usually on the antimesenteric border just beyond the point of obstruction.

Microbiology

 60% of aspirates of inflamed appendices have anaerobes compared to 25% from normal appendices
o Tissue specimens: Escherichia coli and Bacteroides
o Fusobacterium nucleatum/necrophorum (62%)- not present in normal cecal flora

Natural history

 circumstantial evidence suggests that not all patients with appendicitis will progress to perforation and
that resolution may be a common event

Clinical Presentation

 Symptoms
o periumbilical and diffuse pain that eventually localizes to the right lower quadrant
o pain in an atypical location or minimal pain
o GI symptoms: nausea, vomiting, anorexia, (GI symptoms before onset of pain suggest a different
etiology)
 Signs
o body temperature and pulse rate may be normal or slightly elevated
o usually move slowly and prefer to lie supine due to the peritoneal irritation
o abdominal palpation: tenderness with a maximum at or near McBurney’s point
o deep palpation: often feel a muscular resistance (guarding) in the right iliac fossa
o (+) rebound tenderness
o Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness are strong indicators of
peritoneal irritation
o Psoas sign
 o Obturator sign

Lab findings

 Acute uncomplicated: mild leukocytosis with PMN predominance

 Possibility of perforated with or without abscess: >18,000 cells/mm3 WBC
 Increased CRP (especially in complicated appendicitis)
 Appendicitis unlikely if white blood cell count, proportion of neutrophils, and CRP are normal

Clinical Scoring Systems

Imaging Studies

 Plain films of the abdomen

o can show the presence of a fecalith and fecal loading in the cecum
o rarely helpful in diagnosing acute appendicitis
 Chest radiograph
o to rule out referred pain from a right lower lobe pneumonic process
 Barium enema
o If the appendix fills on barium enema, appendicitis is unlikely (not indicated)
 US and CT scan
o most commonly used imaging tests; CT more specific and sensitive
 Graded compression ultrasonography
o appendix is identified as a blind-ending, nonperistaltic bowel loop originating from the cecum
o thickening of appendiceal wall and presence of periappendiceal fluid: highly suggestive
o demonstration of an easily compressible appendix measuring <5 mm in diameter excludes the
diagnosis of appendicitis.
 With high-resolution helical CT
o inflamed appendix appears dilated (>5 mm), and the wall is thickened
 o evidence of inflammation: periappendiceal fat stranding, thickened mesoappendix,
periappendiceal phlegmon, and free fluid

Differential diagnosis

 mesenteric adenitis, no organic pathologic condition, acute pelvic inflammatory disease, twisted ovarian
cyst or ruptured graafian follicle, and acute gastroenteritis
 Pediatric Patient: Acute mesenteric adenitis
 Elderly Patient: Diverticulitis or perforating carcinoma of the cecum or of a portion of the sigmoid that
overlies the right lower abdomen
 Female Patient: pelvic inflammatory disease, ruptured graafian follicle, twisted ovarian cyst or tumor,
endometriosis, and ruptured ectopic pregnancy

Treatment

 Uncomplicated appendicitis
o surgical treatment has been the standard of treatment
o concept of nonoperative treatment
 when surgical treatment is not available treatment with antibiotics alone
was noted to be effective
 patients with signs and symptoms consistent with appendicitis who did not pursue
medical treatment would occasionally have spontaneous resolution of their illness.
 Complicated Appendicitis
o refers to perforated appendicitis commonly associated with an abscess or phlegmon
o Children <5 years of age and >65 years of age have the highest rates of perforation
o suspected in the presence of generalized peritonitis and a strong inflammatory response
o some: localized peritonitis
o 2% to 6% of cases, a palpable mass is detected on PE
 could represent a phlegmon: matted loops of bowel adherent to the adjacent inflamed
appendix or a periappendiceal abscess.
 symptoms for a longer duration, 5 to 7 days
o Patients who present with signs of sepsis and generalized peritonitis should be taken to the
operating room immediately with concurrent resuscitation

Operative interventions for the appendix

 Open Appendectomy
 Laparoscopic appendectomy

mesocolic, free and omental taeniae coli