You are on page 1of 17

Presentation and Diagnosis of Acute Appendicitis

Dr Bakhtiar Alam PG, GS - III

Aetiology

Unclear Luminal obstruction Diet Familial factors Multifactorial

Pathology

Bacteria in the lumen initiate infection Small ulcer (due to impacted faecilith) Inflammation sets in oedema of the wall purulent inflammation leading to thrombosis and gangrene Greater omentum or small intestine adhere to appendix and localises sepsis

Patho Contind

Generalized peritonitis results if perforation occurs

Clinical features

50 % have classical presentation Its a mobile structure, clinical pic. Is dictated by the anatomical position of the inflamed organ Abdominal pain, initially central, colicky in obstructive appendix and constant in nonobstructive Pain shifts to RIF as inflammation involves the parietal peritoneum, agg. by movement and coughing

Loss of appetite , constipation and nausea may have vomiting On/Ex.


Pt. is flushed with dry tongue Mild pyrexia Slight tacycardia Tender RIF esp. McBurneys point with rigidity, tenderness on percussion Rebound tenderness offers no added help Rovsings sign PR and vaginal exam. May be normal

Anatomical features influencing presentation

Rectocaecal appendix

Tenderness to deep plapation is lacking and muscular rigidity absent Rt. Hip slightly flexed due to psoas spasm Passive extension or hyperextension of the hip increases the abdominal pain

Post-ileal

Symptoms are vogue and pain is poorly localized Vomiting more persistent Diarrhoea more frequent

Pelvic

Diarrhoea Increased freq. of micturation, microscpic haematuria Rectal of vaginal examination may localize tenderness in the rectovaginal pouch Psoas spasm Passive internal rotation of Rt. Hip may aggravate pain (obturator sign)

Age related features influencing presentation

Young Children

Non specific presentation difficult to differentiate from mesenteric adenitis and enteritis Delay in diagnosis and short greater omentum results in higher rates of peritonitis, perforation and abscess formation

Elderly

Symptoms less pronounced, May be afebrile Normal white cell count Delayed treatment resulting in higher rates of perforation Diminished physiological reserves Increased mortality

Pregnancy

Displaced appendix, Atypical presentaion Nausea/vomiting more pronounced Tenderness on Rt. Side abdomen, not marked US abdomen is helpful Risk of fetal death is 10% (UK) Perforation significantly increases risk to the mother and fetus (mortality 2% and 30% respect.)

Investigations

Ix helpful in variable presentation CP


Leucocytosis in about 90% Predominantly neutrophils Usually normal Leucocytes or red cells in urine in retrocaecal and pelvic appendicitis

Urinalysis

Pregnancy test in all women of reproductive age Radiology

AXR to exclude other cuases Usual findings but not specific, haziness in RIF, dilated distal ileal loops
Can be used in atypical hx and to exclude other pathology

US abdomen

Ix

Laparoscopy

Good visualization of abdomen and pelvis Helpful in atypical presentation, esp young women Rarely required to make diagnosis

CT abdomen

DDs

Thorax

Pneumonia Intestinal Obstruction Ac. Cholecystitis Perf. Peptic ulcer Gastroenteritis Mesenteric adenitis Terminal ileitis Meckels diverticulitis

Abdomen

DDs

Pelvic

Urinary System

Ectopic pregnancy Ruptured ovarian follicle Torted ovarian cyst Salpingitis/ PID Rt. Pyelonephritis Rt. Ureteric colic DKA, Rectus sheath haematoma, Pancreatitis, preherpatic pain on the Rt. 10th and 11th dorsal nerves

Others

Alvarados score