Acute Apendicitis
Appendicitis is defined as an inflammationo
the inner lining of the vermiform appendix that spreads to its other parts. Despite diagnostidc and therapeutic advancement in medicine appendicitis remains a clinical emergency and is one of the more common causes of acute abdominal pain.
Pathophysiology
=>Reportedly, appendicitis is caused by
obstruction of the appendiceal lumen
from a variety of causes. Independent of
the obstruction is believed to cause an
increase in pressure within the lumen.
Such an increase is related to
continuous secretion of fluids and
mucus from the mucosa and the
stagnation of this material. At the same
time, intestinal bacteria within the
appendix multiply, leading to the
recruitment of white blood cells and the
formation of pus and subsequent higher
intraluminal pressure.
=>If appendiceal obstruction persists,
intraluminal pressure rises ultimately
above that of the appendiceal veins,
leading to venous outflow obstruction.
As a consequence, appendiceal wall
ischemia begins, resulting in a loss of
epithelial integrity and allowing bacterial
invasion of the appendiceal wall.
=>Within a few hours, this localized
condition may worsen because of
thrombosis of the appendicular artery
and veins, leading to perforation and
gangrene of the appendix. As this
process continues, a periappendicular
abscess or peritonitis may occur.
Etiology/causes
=>Appendicitis is caused by obstruction of
the appendiceal lumen. The most
common causes of luminal obstruction
include lymphoid hyperplasia secondary
to inflammatory bowel disease (IBD) or
infections (more common during
childhood and in young adults), fecal
stasis and fecaliths (more common in
elderly patients), parasites (especially in
Eastern countries), or, more rarely,
foreign bodies and neoplasms.
=>Fecaliths form when calcium salts and
fecal debris become layered around a
nidus of inspissated fecal material
located within the appendix. Lymphoid
hyperplasia is associated with various
inflammatory and infectious disorders
including Crohn disease, gastroenteritis,
amebiasis, respiratory infections,
measles, and mononucleosis.
=>Obstruction of the appendiceal lumen
has less commonly been associated
with bacteria (Yersinia species,
adenovirus, cytomegalovirus,
actinomycosis, Mycobacteria species,
Histoplasma species), parasites (eg,
Schistosomes species, pinworms,
Strongyloides stercoralis), foreign
material (eg, shotgun pellet, intrauterine
device, tongue stud, activated charcoal),
tuberculosis, and tumors.
Stages of Appendicitis
The stages of appendicitis can be divided into
early,suppurative,angrenous,perforated,
phlegmonous, spontaneous resolving, recurrent,and chronic.
Clinical Features
Signs and symptoms
The clinical presentation of appendicitis is
notoriously inconsistent. The classic history of anorexia and periumbilical pain folowed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50%% of cases.
Features include the following:
Abdominal pain: Most common
symptom
• Nausea: 61-92% of patients
• Anorexia: 74-78% of patients
• Vomiting: Nearly always follows the
onset of pain; vomiting that precedes
pain suggests intestinal obstruction
• Diarrhea or constipation: As many as
18% of patients
Features of the abdominal pain are as follows:
• Typicaly begins as periumbilical or
epigastric pain, then migrates to the RLQ
• Patients usually lie down, flex their hips,
and draw their knees up to reduce
movements and to avoid worsening their
pain
• The duration of symptoms is less than
48 hours in approximately 80% of adults
but tends to be longer in elderly persons
and in those with perforation.
Physical examination findings include
the following:
1. Rebound tenderness, pain on
percussion, rigidity, and guarding:
Most specific finding
2. RLQ tenderness: Present in 96% of
patients, but nonspecific
May be the major manifestation in
3. Left lower quadrant (LLQ) tenderness:
patients with situs inversus or in
patients with a lengthy appendix that
extends into the LLQ
4. Male infants and children occasionally
present with an inflamed hemiscrotum
5. In pregnant women, RLQ pain and
tenderness dominate in the first
trimester, but in the latter half of
pregnancy, right upper quadrant (RUQ) or
right flank pain may occur
The following accessory signs may be present in a minority of patients:
• Rovsing sign (RLQ pain with palpation
of the LLQ): Suggests peritoneal irritation
• Obturator sign (RLQ pain with internal
and external rotation of the flexed right
hip): Suggests the inflamed appendix is
located deep in the right hemipelvis
• Psoas sign (RLQ pain with extension of
the right hip or with flexion of the right
hip against resistance): Suggests that an
inflamed appendix is located along the
course of the right psoas muscle
• Dunphy sign (sharp pain in the RLQ
elicited by a voluntary cough): Suggests
localized peritonitis
• RLQ pain in response to percussion of a
remote quadrant of the abdomen or to
firm percussion of the patient's heel:
Suggests peritoneal inflammation
• Markle sign (pain elicited in a certain
area of the abdomen when the standing
natient drons from standina on toes to
the heels with a jarring landing): Has a
sensitivity of 74%
Investigations
The following laboratory tests do not have
findings specific for appendicitis, but they may be helpful to confirm diagnosis in patients with an atypical presentation:
a. CBC: WBC >10,500 cells/L: 80-85% of
adults with appendicitis. Neutrophilia
>75-78% of patients
b. C-reactive protein (CRP): CRP levels >1
mg/dL are common in patients with
appendicitis. Very high levels of CRP in
patients with appendicitis indicate
gangrenous evolution of the disease,
especially if it is associated with
leukocytosis and neutrophilia.
c. LFT and pancreatic function tests
d. Urinalysis (for differentiating
appendicitis from urinary tract
conditions)
e. Urinary beta-hCG (for differentiating
appendicitis from early ectopic
pregnancy in women of childbearing
age)
f. Urinary 5-hydroxyindoleacetic acid (5-
HIAA)
CT Abdomen
CT scanning with oral contrast medium or
rectal Gastrografin enema has become the
most evaluation presentations of appendicitis.
study with in thea atypical important imaging of patients
Low-dose abdominal CT may be preferable
for diagnosing children and young adults in
whom exposure to CT radiation is of
particular concern.
USG of Abdomen
=>Ultrasonography may offer a safer
alternative as a primary diagnostic tool
for appendicitis, with CT scanning used
in those cases in which utrasonograms
are negative or inconclusive.
=>In pediatric patients, American College
of Emergency Physicians (ACEP) clinical
policy recommends ultrasonography for
confirmation, but not exclusion, of acute
appendicitis; to definitively exclude
acute appendicitis, the ACEP
recommends CT.
=>A healthy appendix usualy cannot be
viewed with ultrasonography; when
appendicitis occurs, the ultrasonogram
typically demonstrates a
noncompressible tubular structure of 7-9
mm in diameter.
=> Vaginal ultrasonography alone or in
combination with transabdominal scan
may be usefulto determine the
Acute Apendicitis
diagnosis in women of childbearing age.
MRI of abdomen
Useful in pregnant patients if graded compression ultrasonography is
nondiagnostic.
Management
Emergency department care is as follows:
1. Establish IV access and administer
aggressive crystaloid therapy to
patients with clinical signs of
dehydration or septicemia.
2. Keep patients with suspected
appendicitis NP0.
3. Administer parenteral analgesic and
antiemetic as needed for patient
comfort;, no study has shown that
analgesics adversely affect the accuracy
of physical examination.
4. Appendectomy remains the only curative
treatment of appendicitis, but
management of patients with an
appendiceal mass can usually be divided
into the following 3 treatment
categories:
• Phlegmon or a small abscess:
After IV antibiotic therapy, an
interval appendectomy can be
performed 4-6 weeks later
• Larger well-defined abscess:
After percutaneous drainage
with IV antibiotics is performed,
the patient can be discharged
with the catheter in place,
interval appendectomy can be
performed after the fistula is
closed
• Multicompartmental abscess:
These patients require early
surgical drainage
Surgical Management
Preoperative Antibiotics
have demonstrated efficacy in decreasing postoperative wound
infection rate
Penicillin-allergic patients should avoid beta-lactamase type antibiotics and cephalosporins.
Carbapenems are a good option in these
patients.
Pregnant patients should receive pregnancy
category A or B antibiotics.
Urgent Versus Emergent Appendectomy
A retrospective study suggested that the risk of appendiceal rupture is minimal in patients with less than 24-36 hours of untreated symptoms, and another retrospective study suggested that appendectomy presentation is not associated with an increase
in hospital length of stay, operative time, advanced complications compared with appendectomy within 12-24 hours of stages of appendicitis or
performed within 12 hours of presentation.
Emergent versus interval surgery for
Perforated Appendicitis
Historically immediate
(emergent)appendectomy is recommended for all,patients with appendicitis, whether perforated or unperforated. More recent clinical experience suggests appendicitis with mild symptoms and localized
abscess or computed tomography (CT) scans can be initially percutaneous or transrectal drainage of any localized abscess. If the patient's symptoms,
WBC count, and fever satisfactorily resolve,
therapy can be changed to oral antibiotics and
the patient can be discharged home. Then,
delayed performed 4-8 weeks later.
was recommended
all perforated
abdominopelvic
and that patients with phlegmon
on treated with IV
antibiotics
Laparoscopic appendectomy
Best for
• Uncomplicated appendicitis
• Appendicitis in pediatric patients
• Suspected appendicitis in pregnant
Women
• Perforated appendicitis
• Appendicitis in elderly patients
• Appendicitis in obese patients
Medical Management
The goals of therapy are to eradicate the
nfection and to prevent complications. Thus
antibiotics treatment of appendicitis, and all such. Agents
have an
important role in the
treatment of appendicitis, and all such. Agents under consideration must offer full aerobic and anaerobic coverage.
administration is closely related to the stage of appendicitis at the time of the diagnosis.
The duration of
the antibiotic agents are effective in decreasing the rate of postoperative wound infection and in improving outcome in patients with appendiceal
abscess or septicemia. The Surgical Infection
Society antibiotics before surgery, using appropriate spectrum agents for less than 24 hours for nonperforated appendicitis and for less than 5 days for perforated appendicitis. Regimens are
of oonsideration should be given to features such
as medication allergy, pregnancy category (if recommends
starting prophylactic
approximately equal
efficacy, so applicable), toxicity, and cost.
Empiric Therapy Regimens
Preoperative antibiotic prophylaxis should be given in conjunction with surgery for suspected appendicitis. Antibiotics should be stopped after surgery in patients
patients with suspected appendicitis who do not undergo surgery, antimicrobial therapy should
be administered for at least 3 days, until clinical symptoms and signs of infection resolve.
Ampicillin-sulbactam 3 g IV q6h or
Piperacillin + Tazobactam 3.375-4.5 g IV q6-8h or
Ticarcillin-clavulanate 3.1 g q4-6h or
Ceftriaxone 1 g IV q24h plus Metronidazole
500 mg IV q8h or
Cefuroxime 1.5 g IV q8h plus Metronidazole
500 mg IV q8h or
Cefazolin 1-2 g IV q8h plus Metronidazole 500
mg lV q8h or
Ciprofloxacin400 md IV 12 hourly plus
Metronidazole 500 mg IV q8h or
Levofloxacin 500 mg IV daily plus
Metronidazole 500 mg IV q8h or
Ertapenem 1 g IV daily
Complicated appendicitis
Moxifloxacin IV 400 mg IV daily or
Piperacillin + Tazobactam 4.5 g IV q8h or
Meropenem 1 g IV q8h or
Doripenem 500 mg IV q8h or
Levofloxacin 750 mg IV daily plus metronidazole
500 mg IV q8h or
Ciprofloxacin 400mg I V plus
metronidazole 500 mg IV q8h or
q12h
Cefepime 2 g IV q8-12h plus metronidazole 500
mg IV q8h or
peftolozane/tazobactam 1.5 g V q8h plus
metronidazole 500 mg IV q8h or
Aztreonam 1-2 g V q8h plus Metronidazole
500 mg IV q8h or
Cilastatin + Imipenem 500 mg IV qoh
D/D
• Abdominal Abscess
• Bacterial Gastroenteritis
• Cholecystitis and Biliary Colic
• Constipation
• Crohn Disease
• Cystitis in Females
• Diverticulitis
• Ectopic Pregnancy
• Inflammatory Bowel Disease
• Intussusception
• Mesenteric Lymphadenitis
• Nephrolithiasis
• Omental Torsion
• Ovarian Cysts
0 Comments