ACUTE

ABDOMEN &
APPENDICITIS
Jonathan Sokal
 Acute Abdomen
Sudden onset of severe abdominal
pain developing over a short time
period
 Has a wide differential diagnosis, ranging from benign to immediate-
life threatening
 Associated symptoms frequently lack specificity and many have
atypical presentations, often making a quick diagnosis difficult
 Abdominal pain comprises 5 to 10 percent of ED visits

 Undifferentiated abdominal pain remains the diagnosis for

approximately 25 percent of patients discharged from the ED
 Approximately 80 percent of patients discharged with undifferentiated
abdominal pain improve or become pain-free within two weeks of
presentation
Surgical
CausesHemorrhage
Infection

Ischemia

Obstruction

Perforation
 Stomach
Liver Gall bladder
(peptic ulcer,
(hepatitis) (gallstones)
gastritis)

Stomach Pancreas Stomach (peptic

Liver Gall bladder Spleen (rupture)
(peptic ulcer, Transverse Pancreas (pancreatitis) ulcer)
(hepatitis) (gallstones) Heart (MI)
gastritis) colon (cancer) (pancreatitis)

Splenic flexure Lung

Hepatic flexure Lung colon (cancer) (pneumonia)
colon (cancer) (pneumonia)

Kidney (stone,
Kidney (stone, Descending colon
Ascending colon hydronephrosis,
hydronephrosis, (cancer)
UTI)
(cancer,)
UTI)

Sigmoid colon Ovaries/fallopian

Caecum (tumour,
Appendix
volvulus, closed
Terminal ileum (diverticulitis, tube (ectopic, cyst,
(Appendicitis) (crohns, mekels) colitis, cancer) PID)
loop obstruction)

Ovaries/fallopian
tube (ectopic, cyst, Ureter (renal colic) Ureter (renal colic)
PID)

Small bowel
Uterus (fibroid, Bladder (UTI, Sigmoid colon (obstruction/ischaemia Aorta (leaking AAA)
cancer) stone) (diverticulitis) )
Red flags for abdominal Immediately life-threatening
pain
Risk Factors
Age > 50 years
diagnoses
Ruptured abdominal aortic aneurysm
 Immunocompromise  Aortic dissection
 Previous abdominal surgery  
 History of CAD and/or atrial fibrillation
Myocardial infarction
Unstable vital signs: hypotension, tachycardia Bowel perforation
Pain characteristics Mechanical bowel obstruction 
 Sudden onset of severe pain
 Pain that interrupts sleep Acute mesenteric ischemia
 Pain out of proportion to abdominal findings
Acute pancreatitis
Accompanying symptoms
 Bilious vomiting Acute cholangitis
 Hematemesis, hematochezia
Ruptured ectopic pregnancy
 Jaundice
Findings on examination
 Possible peritoneal signs 
 Guarding and/or rigidity (focal or diffused) Delays in treatment of serious intraabdominal
 Rebound tenderness (focal or diffused) 
 Absent or tinkling bowel sounds
causes of acute abdominal pain can result in
 Gross abdominal distention bowel necrosis, sepsis, fistula formation,
 Irreducible, tender bulge on abdomen or groin 
and death.
HISTORY – ABDOMINAL PAIN
SOCRATES
 Site and duration
 Onset – sudden vs gradual
 Character – colicky, sharp, dull, burning
 Radiation – ie. Into back or shoulder
 (Associated symptoms – discussed later)
 Timing – constant, coming and going
 Have you had a similar pain previously?
 Does the pain wake you up at night?

 Exacerbating and alleviating factors

 Ie. Eating, movement, position

 Severity – Scale of 1-10

HISTORY
 History of Present Illness – Other symptoms
 GI: bowels last opened, bowel habit (diarrhea/constipation), PR bleeding/melaena, dyspeptic symptoms, vomiting
 Urine: dysuria, hematuria, urgency/frequency
 Gynecological: normal cycle, LMP, IMB, dysmenorrhea/menorrhagia, PV discharge
 Others: fever, appetite, weight loss, distention
 Any previous abdominal investigations and findings

 Past Medical History

 Any underlying conditions
 Ie. hypertension, diabetes, CAD
 Do you see a doctor regularly?
 Surgeries/ hospitalizations
 Medications
 Super important to ask about antiplatelets/anticoagulation
 Allergies
 Family history

 Social History
 Alcohol/ smoking/ drug use
 Female of reproductive age - sexually active

 If suspected – ask about travel, sick contacts, weird diet

PHYSICAL EXAM Vital
Even
signs
if person appears stable – they may noy be
Inspection
Diaphoresis, pallor, dyspnea, decreased alertness
Can warn the examiner it’s serious
Peritoneal inflammation
Patients may appear very still
If patient is fidgeting to find a comfortable position – likely not peritoneal
Scars/asymmetry/distention/rashes
Auscultation
Bowel sounds – not very reliable
Need to listen for at least 2 minutes
Ileus: hearing fewer than one bowel sounds every 15 seconds per quadrant
Bruits for vascular abnormalities
Percussion
Pain
Tympany/ Dullness
Shifting dullness – ascites
Organomegaly
Palpation – next slide
Other exams: rectal, pelvic, testicular
Never hurts to also do a quick cardiac/ respiratory exam
PALPATI
ON
 Point of maximal tenderness

 Features of peritonitis (localized vs generalized)

 Guarding/ Muscle rigidity

 To differentiate voluntary vs involuntary:

 Have patient supine with legs flexed and feet on table

 Have them take a deep breath in while palpating

 Distract patient – maybe a joke

 If you don’t get a laugh, blame it on a painful abdomen!

 Point tenderness

 Rebound tenderness

 Mass

 Specific signs
APPENDI
CITIS
Appendicitis is typically due to an obstruction of the appendiceal lumen

The appendix is vulnerable to this phenomenon because of its small luminal diameter in
relation to its length

Once obstructed, the lumen becomes filled with mucus and distends, increasing luminal
and intramural pressure.

This results in thrombosis and occlusion of the small vessels, and stasis of lymphatic
flow.

As lymphatic and vascular compromise progresses, the wall of the appendix becomes Lymphoid Hyperplasia Appendiceal Fecalith
ischemic and then necrotic.

Neoplasm Parasite Infestation

Once significant inflammation and necrosis occur, the appendix is at risk of perforation,
which leads to localized abscess formation or diffuse peritonitis.
 Uncomplicated Complicated
Appendicitis Appendicitis
• appendicitis with no evidence of • appendicitis associated with
an appendiceal fecalith, an perforation, gangrene, abscess, an
appendiceal tumor, or complications, inflammatory mass, an appendiceal
such as fecalith (concretion of feces that
perforation, gangrene, abscess, or develops in the appendix that can
mass   obstruct the appendiceal lumen), or
an appendiceal tumor
 Bacterial overgrowth occurs within the
diseased appendix.
 Aerobic organisms predominate early in the
course
 Mixed infection is more common in late
appendicitis
EPIDEMIOLOGY
 The incidence of acute appendicitis is approximately 100 per 100,000 person-years.
 Appendicitis occurs most frequently in the second and third decades of life. 
 Incidence is highest in the 10-to-19-year-old age group
 Lowest in children ≤9 year

 It is also higher among men (male-to-female ratio of 1.4:1),

 Lifetime incidence of 8.6 percent for men
 Lifetime incidence of 6.7 percent for women

 Incidence of perforated appendicitis is approximately 29 per 100,000 person-years

 more cases of perforated appendicitis in men than women
 (31 versus 25 per 100,000 person-years)
 The incidence of perforated appendicitis has been rising despite a fall in the overall incidence of acute
appendicitis
Classic Initial
Symptoms
Right lower quadrant abdominal Anorexia Nausea and vomiting
pain • Hamburger Sign – Ask patient if they
• Typically, periumbilical in nature with want their favorite food (ie. a juicy
subsequent migration to the right lower burger)
quadrant as the inflammation progresses • If patient says yes, can help rule out
• This phenomenon remains a reliable disease (80% sensitivity)
symptom of appendicitis and should
serve to further increase the clinician’s
index of suspicion for appendicitis

 Other nonspecific symptoms

 Indigestion
 Flatulence
 Bowel irregularity
 Diarrhea
 Generalized malaise
 The symptoms of appendicitis vary
depending upon the location of the tip of the
appendix
 Anterior appendix produces marked, localized
pain in the right lower quadrant
 Retrocecal appendix may cause a dull
abdominal ache
 Retroperitoneal appendix may present in a
more subacute manner, with flank or back pain
 Appendiceal tip in the pelvis may have
suprapubic pain suggestive of urinary tract
infection
PHYSICAL
EXAM
 Patients with appendicitis typically appear ill.
 Because of localized peritonitis, they lie still as any movement can be painful
 Tachycardia
 Mild dehydration
 Fever is usually present – depends on disease process and severity of the inflammatory
response
 Can range from low-grade temperature elevations (<38.5 C) to high fever
 Absence of fever does not exclude a diagnosis of appendicitis

 Female patients – Pelvic exam

 Cervical motion tenderness (typically associated with PID) can be present in appendicitis
STEP 1 SIGNS THAT CAN AID IN DIAGNOSIS
 McBurney's point tenderness
 Maximal tenderness at 1.5 to 2 inches from the anterior superior
iliac spine (ASIS) on a straight line from the ASIS to the
umbilicus
 Sensitivity 50 to 94 percent; specificity 75 to 86 percent

 Rovsing's sign: pain in the right lower quadrant with

palpation of the left lower quadrant
 Indicative of right-sided local peritoneal irritation
 Sensitivity 22 to 68 percent; specificity 58 to 96 percent

 Psoas sign: Pain with extension of ipsilateral hip

 Associated with a retrocecal appendix
 Sensitivity 13 to 42 percent; specificity 79 to 97 percent

 Obturator sign: Right lower quadrant pain on internal

rotation of the hip
 Associated with a pelvic appendix
 Sensitivity 8 percent; specificity 94 percent
 The sensitivity is low enough that experienced clinicians no longer
perform this assessment.
LABS
 Used to support the clinical picture rather than definitively to prove or to exclude the diagnosis
 CBC: mild leukocytosis with left shift 
 Present in 90% of cases

 CRP: elevated (> 10 mg/L) 

 BMP: Patients with severe vomiting and/or diarrhea there can be ↑ creatinine, electrolyte
abnormalities
 Also important to measure creatinine before using imaging contrast

 Urinalysis: Typically normal in appendicitis

 Possible findings of mild pyuria and/or hematuria 

 Urine/serum β-hCG test – Ruptured ectopic pregnancy may mimic acute appendicitis

ALVARADO
SCORE
Most useful in ruling out
appendicitis
 IMAGING
 What imaging modality to use initially for diagnosis depends on institution and
patient
 Abdominal ultrasound can confirm the diagnosis of acute appendicitis
 Although normal US findings do not reliably rule out appendicitis
 Some hospitals use US initially and save CT for inconclusive findings
 Always 1st line in kids and pregnant adults

 Abdominal CT is the most accurate

 Operator independent and easy to interpret

 MRI
 Reserved for pregnant women and older children when US is inconclusive
Copyrights apply
CT
 Distended appendix (diameter > 6 mm)
 Edematous appendix with periappendiceal fat
stranding
 Possible appendiceal fecalith:
focal hyperdensity within the appendiceal lumen
 Seen in minority of patients

 Evidence of complications 
 Abscess
 Rupture – Fluid in peritoneal cavity
ULTRASOUND
 Noncompressible appendix with double-
wall thickness diameter of >6 mm
 Perforated appendix may be compressible

 Focal pain over appendix with

compression
 Target sign: hyperechoic and
hypoechoic layers due to inflammation
and resulting edema
 Appendicolith
 Fluid in the right lower quadrant
DIFFERENTIA
L Ectopic pregnancy
⌕
⌕ Pseudoappendicitis 
⌕ Yersinia enterocolitica

⌕ Meckel diverticulum
⌕ Diverticulitis 
⌕ Especially in elderly patients

⌕ Inflammatory bowel disease

⌕ Gastroenteritis
⌕ Colon cancer
⌕ Urolithiasis and renal colic
⌕ Urinary tract infections
⌕ Psoas abscess 
⌕ In patients with a positive psoas sign

⌕ Gynecological diseases
⌕ And other causes of acute abdomen
TREATMENT OF UNCOMPLICATED
APPENDICITIS
Keep patients NPO and initiate supportive care: IV fluids, analgesia, antiemetics

 Give empiric antibiotics
 Broad spectrum with gram negative and anaerobic coverage
 Cefazolin + Metronidazole
 In patients allergic to cephalosporins/penicillin: clindamycin + ciprofloxacin/high dose
gentamicin
 Appendectomy within 24 hours of diagnosis
 Some argue within 8 hours but a delay of up to 24 hours has not been shown to
increase perioperative complications
 Prehospital use of aspirin or clopidogrel should not delay appendectomy
MANAGEMENT OF PERFORATED APPENDIX
 Surgical management for perforated appendicitis is similar uncomplicated
appendicitis with a few notable exceptions
 Patient may require a more aggressive resuscitation
 More of a focus on avoiding accidental tissue injury when dealing with inflamed
periappendiceal tissues
 Increased clearance of infectious material, including spilled fecal material or fecaliths from
the abdomen
 Done by suction, irrigation, and removal of large fecal materials

 If abscess cavity is present: a suction drain is inserted and left for several days
 Broad spectrum antibiotics are continued for 4-7 days postoperatively
APPENDECTO
MY
APPENDICEAL ABSCESS 
 Localized collection of pus and necrotic tissue that forms around an
inflamed appendix,
 Typically follows an untreated perforated appendix

 Manifests as a tender mass in the RLQ in an acutely ill patient

 High-grade fever,
 Leukocytosis and signs of sepsis
 Possible paralytic ileus

 Treatment: Nonoperative management

 Appendectomy leads to increased risk of surgical complications
 Abscess < 4 cm: antibiotic therapy alone is usually sufficient
 Abscess > 4 cm: image-guided percutaneous drainage or surgical drainage with cultures
DELAYED PRESENTATION OF
APPENDICITIS
 Patients may occasionally present several days to even weeks after the onset of appendicitis
 Localized right lower quadrant pain and fever, with a history that is compatible with the onset appendicitis
several days prior
 Treatment is managed nonoperatively
 Immediate exploration and attempted appendectomy may result in substantial morbidity, failure to identify
the appendix, postoperative abscess or fistula, and unnecessary extension of the operation to include
ileocecectomy
 Given antibiotics and a drain is inserted

 Interval appendectomy: appendectomy performed 6-8 weeks following acute resolution

 Heavily debated and not routinely recommended
 Risk of surgical complications can be higher than recurrence of appendicitis

 Colonoscopy is recommended as routine follow up

 Perforated tumor of cecum may present similarly
CHRONIC APPENDICITIS
 History of recurrent right lower quadrant pain without systemic illness
 Possible that appendicitis waxes and wanes

 Patients may have thickened appendix on CT with no evidence of acute appendicitis

 Elective appendectomy is sometimes offered
 Limited data although some patients report relief of symptoms
 Examination of appendix can reveal findings of chronic inflammation
NEGATIVE APPENDECTOMY
Normal appendix is identified at operation

 Debate whether to remove appendix

 Appendix is routinely removed anyways
 Important to remember that patient is in sever enough pain that an operation is warranted
 In this case, it is usually worth it to remove the appendicitis from differential diagnosis
 Also, sometimes appendicitis is only identified by pathology examination
APPENDICEAL
NEOPLASMS
Estimated that as many as 50% of
appendiceal neoplasms present as
appendicitis
Diagnosed on pathologic examination of
the surgical specimen
THE MAJORITY OF APPENDICEAL MASSES CONSIST
OF NEUROENDOCRINE TUMORS (ANENS) AND
PRIMARY EPITHELIAL NEOPLASMS
Appendiceal neuroendocrine neoplasms Mucinous tumors of the appendix
(ANENs) (AMNs)
 Most common primary tumor identified in the  Complex tumors that, if ruptured, can
appendix (65%) spread intraperitoneally
 Small, well circumscribed lesions located within  Can lead to pseudomyxoma peritonei
the more distal appendix
 New breakthrough in treatment with CRS-
 Most commonly diagnosed in the second or
HIPEC
third decade of life
 Remove tumor burden
 Five-year survival rates based on Surveillance
 Then heated chemotherapy is added into
Epidemiology and End Results (SEER) data are: peritoneal space
 94% for confined disease
 Goal: eliminate residual tumor burden with
 84.6% for locoregional disease
limited systemic toxicity
 33.7% when distant metastases are present