Click here to Enlarge Appendicitis is an inflammation of the inner lining of the vermiform appendix
Appendix is continuation of the caecum and is first delineated during 5th month of gestation Worm-like extension –> hence called Vermiform Average length is 8-10 cm ( range 2-20 cm ) Has no fixed position ( hence the variation in presentation and diagnostic difficulty )
No longer thought as vestigeal -repository for commensal bacteria that assist in normal digestive processes and may allow for recolonization of the intestinal flora in times of enteric bacterial destruction ( Rosen’s )
Faecolith Normal stool Lymphoid hyperplasia Indigestible food Mucus Parasites Tumours-Increased intraluminal pressure Bacterial overgrowth Ischaemia Necrosis-Perforation & other complications as Appendix mass Adhesions Appendix abscess Peritonitis Sepsis Death
No known genetic cause but increased risk has been observed in some studies in those with a positive family history
Most common acute surgical abdominal emergency Most common non-obstetric surgical emergency in pregnancy Most common between ages 10-20 yrs More common in males Lifetime risk is 8.6 % in males and 6.9 % in females Lifetime appendicectomy rate is 12 % in males and 23 % in females Perforation is found in 13-20 % Normal appendix is found in 15-40 % of patients who have an emergency appendectomy Misdiagnosed in 25-30 % children ( second most common cause of malpractice litigation against emergency physicians ) Risk factors for appendicitis are ○ Age → most common 10-20 yrs ○ Male sex ○ frequent antibiotic use ○ Smoking ( incl exposure to passive smoking ) ○ low fibre diet ○ less than 6 months of breast feeding
Diagnosis-Notoriously difficult to diagnose Classic clinical picture ○ anorexia ○ periumbilical pain followed by nausea RLQ pain ○ Vomiting Nausea and vomiting present in 75 % Vomiting usually occurs once or twice Usually no significant changes in vital signs Fever – mild ( 1* or 1.8 *F rise ) Bowel sounds may be reduced on rt Duration of symptoms is less than 48 hrs in approximately 80 % of adults ( can be longer in elderly or in those with perforation )
Pain-Abdominal pain is the chief complain ○ tenderness on percussion at McBurneys pt ( 2/3rds of the way along a line drawn from umbilicus to the ASISpine ) ○ guarding ○ rebound tenderness Migratory pain -> symptoms begin as peri-umbilical or epigastric pain migrating to the RLQ Sensitivity and specificity of 80 % Positive likelihood ratio of 3.18 Negative likelihood ratio of 0.5 Pain is worse with movement so patients lie down Flex their hips draw their knees up Children – ask them to hop ( refusal indicates pain is worsened by hopping ) Classical abdominal findings will be absent if appendix is in a atypical position ○ only 40 % of patients have the base of appendix within 3 cm of McBurney’s pt ○ 36 % have the base > 5 cm away – they can present with LLQ , Rt flank or back pain Peritoneal signs ( Rovsing’s , Psoas & Obturator ) are less commonly seen
Blood- elevated WCC , CRP , granulocyte count or proportion of polymorphonuclear leukocytes ( > 75 % ) Urine- pregnancy , infection , colic CT ( ideally with contrast ) is the most accurate examination for evaluating patients without a clear clinical diagnosis Scoring systems have been developed ( eg Alvarado score ) but in adults scoring systems have been inadequate as a single method Ultra-sound – limits radiation ( eg preferred in children ) MRI – in pregnancy results comparable following equivocal or inconclusive US
Medical emergency → needs immediate hospital admission Risk of complications increase with duration of symptoms Keep a very low threshold for admitting ○ Infants and young children ○ Elderly people ○ Pregnant women ○ If any signs of complications present It is unclear if antibiotics alone are a suitable treatment for non-complicated appendicitis ( in comparison to surgery )
