Appendicitis

Definition
is inflammation of the inner lining of the vermiform appendix that spreads to its other parts

Epidemiology

Predominant age: 10–30 years:

• Rare in infancy
• Ages 10–30 (M:F=3:2)
• Age >30: (Male = Female)
• 1 /1,000 people per year

1/15 persons (7%)
1 in 2,000 pregnancies
Most common -extrauterine surgical emergency

Pathophysiology

• Obstruction of the appendiceal lumen is the primary cause of appendicitis. An anatomic blind pouch, obstruction of the appendiceal lumen leads to distension of the appendix due to accumulated intraluminal fluid.
• Ineffective lymphatic and venous drainage allows bacterial invasion of the appendiceal wall and, in advanced cases, perforation and spillage of pus into the peritoneal cavity.
• Natural history: obstruction à bacterial overgrowth , inflammation/swelling , ↑pressure , localized ischemia à gangrene/perforation à contained abscess or peritonitis.

Etiology
Causes of obstruction:

• Fecaliths (most common)
• Lymphoid tissue hyperplasia (in children)
• Inspissated barium
• Vegetable, fruit seeds
• Other foreign bodies
• Intestinal worms (ascarids)
• Strictures, fibrosis
• Neoplasms

Presentation

Pain	Constant, dull  periumbilical pain that moves to the RIF over the next 4-48h. Pain before vomitting 9 (~100% sensitive) Early: shallow breaths- abdomen move symmetrical with resp), pain on percussion of RIF, guarding Late presentation (perforation) - rebound tenderness(peritonitis/perforation), board like rigidity.
Anorexia	ask if patient is eating ok?
Fever	Low grade fever (37.5-38.5), Nausea,vomiting(75%)
General condition	Tachycardia, furred tongue, lying still, foetor+flushing, coughing hurt,
GI	constipation, diarrhoea, tenesmus amy occur
McBurney’s sign	On an imaginary line drawn from the anterior superior iliac spine to the umbilicus, pain is elicited when 1/3 of the distance from ASIS is palpated
Rovsing’s sign	pain more in the RIF when LIF is pressed
Obturator sign	RLQ pain with internal or external rotation of the flexed right hip) suggests that the inflamed appendix is located deep in the right hemipelvis
Psoas sign	RLQ pain with extension of the right hip) suggests that an inflamed appendix is located along the course of the right psoas muscle.
Orhers	in male infant: may see inflamed hemiscrotum due to migration of an inflamed appendix or pus through a patent processus vaginalis Appendix is higher in pregnancy

Complication
Perforation
Appendix mass –inflamed appendix covered with omentum
Appendix abscess

Differential Diagnosis

• children:-Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, Henoch-Schönlein purpura, lobar pneumonia
• adults:- enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma; in men: testicular torsion; in women: pelvic inflammatory disease, ectopic pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle)
• elderly:-diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.

Investigation
Don’t rely on test à fatal delay

FBC	mild leukocytosis(ie, >12,000/µL), higher in perforation
Urinalysis	differentiate from urinary tract conditions. 1/7 pt has pyuria (relationship of the appendix with the right ureter)
CRP	rapidly increase within the first 12h
LFT	in pt with unclear presentation
beta-hCG	rule out ectopic pregnancy
US & Doppler sonography	demonstrates a noncompressible tubular structure of 7-9 mm in diameter. user-dependent
CT scan	CT scan with oral contrast medium or rectal Gastrografin enema findings are a nonfilling appendix with distention and thickened walls of the appendix and the cecum, enlarged mesenteric nodes, and periappendiceal inflammation or fluid Normal appendix. CT scan of the abdomen demon-strates contrast-filled, blinded tubular structure (arrow) with small amount of air within the lumen corresponding to normal appendix . Uncomplicated appendicitis: The appendix lies behind the caecum and has a light thickened wall.There is the appendicolith as well. Perforated appendicitis with abscess; computed tomography scan. Note the appendicolith (arrow) and air within the abscess. The terminal ileum lies anterior to the appendiceal abscess, and inflammatory change is noted in its wall, which appears thickened (open arrow).

The Alvarado score

Feature	Score
Migration of pain	1
Nausea/vomiting	1
Anorexia	1
RIF tenferness	2
Rebound pain	1
T> 37.3oC	1
WCC >10 x 109/L	2
Neutrophil count >75%	1

<4: unlikely, 5-6: observe, >7: operation required

Management
Appendicectomy

Def	Surgical removal of the vermiform appendix.
Anatomy	The ppendix is at base of cecum where all three taeniae coli converge. The appendix serves no useful function, it will be removed to avoid getting appendicitis in the future. McBurney's point: One-third of distance from anterior superior iliac spine to umbilicus.
Video
Pre-op	NBM, IVI, Antibiotics (Metronidazole 500mg/8h + cefuroxime 1.5g/8h 1-3 doses IV 1h pre-op) Analgesic+ antiemetic
Intra-op	General anaesthesia ,endotracheal intubation,full muscle relaxation, and the patient is positioned supine. The abdomen is prepared and draped Skin incision at mass or McBurney's point. An incision is made perpendicular to this line. ( gridiron or McBurney's incision.) or horizontally Lanz incision) Opening Scarpa's fascia Opening aponeurosis Atraumatic spreading of muscle fibers - prevent hernia Identify and opening of peritoneum Identify cecum and appendix Deliver cecum and appendix Identify and ligate appendiceal artery Crush(ligate) appendix at base Ligate and remove appendix at base If desired place a purse string suture around base of appendix Closing peritoneum Closing aponeurosis Skin closure with staples or stitches. The wound is dressed. The patient will be brought to the recovery room.
Postop	Early diet and ambulation Discharged 24-36 hours after the operation Perforated appendicitis requires a longer hospital stay for intravenous antibiotic treatment. 2-3 inch scar
Follow-up	seen about 1-2 weeks after discharge- inspect scar
Complication	Infection,  dehiscence, intra-abdominal abscess Persistent nausea, vomiting, difficulty with micturition, and persistent pain in the lower limbs may also occur. ileus, small-bowel obstruction, stump appendicitis(rare) In pregnancy- x harm fetus. Risk of fetal death- 5%, 20% if perforated appendicitis

Complication

• Wound infection
• Intra-abdominal abscess; lower rate with antibiotic prophylaxis (2)[A]
• Intestinal fistulas
• Intestinal obstruction
• Incisional hernia
• Liver abscess (rare)
• Paralytic ileus
• Pyelophlebitis

Prognosis
Generally uncomplicated course in young adults with nonruptured appendicitis

Factors increasing morbidity and mortality	Extremes of age, Appendiceal rupture
Morbidity rates	Nonperforated=: 3%, Perforate= 47%
Mortality rates	Unruptured : 0.1% Ruptured: 3% Patients >60 years of age: 50% of deaths Older patients with ruptured appendix: 15%