Appendicitis

Pathophysiology

Intestinal
Increase bacteria withi
intraluminal appendix
Obstruction of pressure multiply lead
appendiceal (continous to recruitment
lumen secretion of of WBC thus
fluids & mucus causing higher
& stagnation) Intraluminal
pressure

Complications
Perforation Usually consequence of delay on
seeking medical treatment
Generalized peritonitis Cause by large perforation, burst of
appendix that release infectious
bacteria
Appendicular abscess Forms around burst appendix. Painful
collection of pus that occurs as a result
of bodys attempt to fight the infection

Acute Appendicitis

Signs & symptoms

Abdominal discomfort
Pain (in periumbilical abdominal/ epigastric region initially then migrate to right
lower quadrant) distension of appendiceal lumen
Anorexia
Nausea & vomiting
Change in bowel habit
Urinary frequency & dysuria if appendix lies adjacent to the bladder

Differential diagnosis
i. Ruptured tubal pregnancy: presence of adnexal mass, evidence blood loss & positive
pregnancy test
ii. Endometriosis: USG or laparoscopy
iii. UTI: pain usually at suprapubic associated with burning micturition
iv. PID: purulent discharge at cervical os & test of chlamydia trachomatis
v. Acute mesenteric lymphadenitis & acute gastroenteritis: enlarged, slightly reddened lymph
node at root of mesentery. Higher temperature, diarrhea, more diffuse pain, lymphocytosis

Table 300 1 The Anatomic Origin of Periumbilical & Right Lower

Quadrant Pain in the Differential Diagnosis of Appendicitis
Periumbilical
Appendicitis
Small bowel obstruction
 Gastroenteritis
Mesenteric ischemia
Right Lower Quadrant
Gastrointestinal causes
Appendicitis
Inflammatory bowel disease
Right sided diverticulitis
Gastroenteritis
Inguinal hernia
Gynecologic causes
Ovarian tumor/torsion
Pelvic inflammatory disease
Renal causes
Pyelonephritis
Perinephritic abscess
Nephrolithiasis

Diagnostic tool
History
Main presenting complain abdominal pain
Usually constant but may worsen with coughing or movement
Location vary:
o Retrocecal flank/back pain
o Retroileal testicular pain
o Pelvic suprapubic pain
o A long appendix left lower quadrant pain

Physical Exam: vary with time after onset & location of appendix (diagnosis cannot be
established unless tenderness can be elicited
Temperature 37.2 38 . More than 38.3 suggest perforation
Classic sign
Right lower quadrant abdominal tenderness (McBurneys point)
Localized rebound tenderness
Rovsing sign
Pain may be elicited
o Psoas sign
o Obturator sign
Bowel sounds may be reduced

Lab Exam:
Leukocytosis >20,000 cells/ L suggest probable perforation
Urine may contain few WBC/RBC without bacteria if the appendix lies close to the
ureter/bladder

Radiography: rarely of value except when an opaque fecalith is observed in RLQ

Ultrasonic demonstration of enlarged & thick walled appendix
CT scan (abdominal + pelvic) thickened appendix &often presence of fecalith
Urinalysis
Pregnancy test

Infant or child: diarrhea, vomiting, abdominal pain, fever & abdominal distention
Elderly: pain & tenderness often blunted

Management
If diagnosis is in question, 4 -6 H of observation with abdominal exam
Antibiotics should not be administered, since it will mask the perforation
Early operation & appendectomy

Different approach, if palpable mass is found 3 5 days after onset of symptoms

Treated with broad spectrum antibiotics, drainage of abscesses >3cm. parenteral fluid &
bowel rest
Interval appendectomy can be perform 6 12 weeks later

APPENDECTOMY
1. Open appendectomy: a cut/incision about 2 4 inches long is made in the lower right
hand side of abdomen
2. Laparoscopic appendectomy: its done without a large incision. Instead from 1 to 3 tiny
cuts are made. A long, thin tube called laparoscope is put into one of the incisions. It has
tiny video camera & surgical tools.