Appendisitis

• Dr. SUHAEMI, SpPD, FINASIM

Epidemiology
 It affects 6~7 % of the population.

 Peak incidence in adolescents and young

adults, with a slight male predominance
in this age group.

 Infants, elderly, pregnant women and

immunocompromised patients tend to
have atypical presentations and have
higher morbidity and mortality.
 Appendicitis
• Classic presentation
Findings
– Depends
Periumbilical
on duration
pain of symptoms
– Rebound,
Anorexia, voluntary
nausea, vomiting
guarding, rigidity, tenderness on rectal exam
– Psoas
Pain localizes
sign to RLQ
– Obturator
Occurs onlysign
in ½ to 2/3 of patients
• – Fever
26% (a late finding)
of appendices are retrocecal and cause pain in the flank; 4% are in the
• RUQ
Urinalysis abnormal in 19-40%
• A pelvic
CBC appendix
is not canorcause
sensitive suprapubic pain, dysuria
specific
• Males may have
Abdominal xrayspain in the testicles
– Appendiceal fecalith or gas, localized ileus, blurred right psoas muscle, free air
• CT scan
– Pericecal inflammation, abscess, periappendiceal phlegmon, fluid collection,
localized fat stranding
Pathophysiology
 Obstruction-most commonly secondary to
fecalith in adults and lymphoid hyperplasia
in children.

 Continued mucosal secretion.

 Worsened edema, high luminal pressure and

bacterial proliferation.

 Transmural necrosis and bacterial

penetration.
Clinical presentation
 Classical presentation occurs in only 50 %
of patients.

 Pain begins in peri-umbilical or epigastric

region, due to appendiceal distension and
referred pain.

 Pain localizes to the RLO as the parietal

peritoneum in the area becomes irritated.

 Anorexia and nausea occur almost

uniformly after the pain.
Physical examination
 Mild fever may be present.

 Mc-Burney’s point

 Rovsing’s sign

 Psoas sign & Obturator sign

 Rectal examination
Appendicitis: Psoas Sign
Appendicitis: Psoas Sign
 Appendicitis: Obturator Sign

Passively flex
right hip and knee
then internally
rotate the hip
Laboratory and Imaging Findings
 WBC elevation from 10000 to 18000/mm3
 Abdominal radiograph may show a fecalith
in the RLQ, loss of the psoas shadow and/or
a few dilated loops of the bowel.
 Ultrasonography reveals a non-
compressible,
aperistalic appedix larger than 6 mm in
diameter.
 Appendicitis: CT findings

Cecum

Abscess, fat
stranding
Appendicitis - Aim to minimise
perforation and abscess
ALVARADO SCORING SYSTEM
Features Score

Symptoms  
Migratory right iliac fossa pain 1
Nausea/vomiting  1
Anorexia 1
Signs  
Right iliac fossa tenderness 2
Fever >37.30C 1
Rebound pain in right iliac fossa 1
Laboratory test  
Leucocytosis (>10 X 109/L)  2
Neutrophilic shift to the left >75% 1
Total score 10
ALVARADO SCORING SYSTEM

Clinical judgement still required!!

Treatment
 Immediate operative treatment is indicated.

 In the case of a perforated appedix with

phlegmon formation, an “interval”
appedectomy is usually performed with
drains left and skin & subcutaneous tissue
open for weeks.

 Peri-operative antibiotics have been shown

to lower the infectious complications.
Prognosis
 The mortality of appedicitis is the mortality
of delay.

 Most surgeons are therefore believed that a

certain number of negative explorations are
necessary to avoid a high incidence of
perforation and its sequelae.

 Can negative laparotomy be lowered

without a concomitant rise in perforation
rates?
 The value of 99mTc HMPAO labeled
white blood cell scintigraphy
in
acute appendicitis patients
with an equivocal clinical presentation

Eur J Nucl Med (2001) 28:575-580

Introduction

 Up to 30% of patients with proved

appendicitis are misdiagnosed and
discharged.

 The rate of normal appendectomy averages

16%, with females comprising 68% of these
patients.
Materials and methods
 This study was designed as a prospective
clinical trial.
Forty-one patients (24 females and 17 males,
aged 7-70 years) were included. The inclusion
criteria were acute right lower quadrant
abdominal pain with a clinical presentation
equivocal for acute appendicitis, as
determined by the surgeons.

 A WBC count of greater than 3000/mm3

was required for cell labeling.
 Labeling of WBCs

 Imaging
The anterior abdomen and pelvis were
imaged under a camera (Toshiba GCA 602)
equipped with a low-energy all-purpose
collimator starting at 30 min following the
injection of 125-300 MBq 99mTc-HMPAO
WBCs.
Imaging was repeated at 1, 2, and 4 h.
 Interpretation
Negative:
Absence of abnormal intra-abdominal
localization through 4 h of imaging.
Positive:
Focal accumulation of 99mTc-HMPAO
WBCs in the right lower quadrant.

 Decision on surgical intervention was made

on the basis of consensus between the two
surgeons.
 Non-operated patients was followed
for a minimum of 1 month.
Results
Discussion
 There were no false-positive or false-
negative results in this study.*
 We believe that as the number of the patients
studied increases, we may encounter false-
positive results due to other diseases which
cause right lower quadrant inflammation.
 False-negative results can result when the
activity of the appendix superimposed with
the background, such as iliac vascular
activity. This can be prevented by an oblique
imaging technique.
 In our group of patients with presentations
equivocal for acute appendicitis, the
negative laparotomy rate was only 5.8%.

 Fasting reduce the enterohepatic circulation

of the by-products of HMPAO metabolism
and that this increased the specificity of
the test.
Conclusion

 99mTc-HMPAO is a rapid and accurate

method for detecting acute appendicitis
in patients with an equivocal clinical
presentation, which may reduce the
hospital stay and lower unnecessary
laparotomy rate.
 ??? QUESTION #1 ???
• A 45 year-old male patient presents with severe abdominal pain
which is worse with movement. He has fever, tachycardia,
tachypnea and a narrow pulse pressure. There is guarding, and
rebound tenderness in the right lower quadrant. Which of the
following is the most likely diagnosis?

A. Perforated appendicitis
B. Acute unperforated appendicitis
C. Perforated gallbladder
D. Ruptured diverticulum
E. Acute cholecystitis