APPENDICITIS
S Mahnoor Azeem 17-091
Ismail Shah 17-084
DEFINITION
• Appendicitis is an inflammation of appendix that develops
most common in adolescents and young adults.
• Its the most common cause for acute, severe abdominal pain.
• The abdomen is most tender at McBurney’s point – one third of
the distance from the right anterior superior iliac spine to the
umbilicus. This corresponds to the location of the base of the
appendix
RISK FACTORS
• Infection, possibly stomach infection that
has traveled to the site of appendix.
• Obstruction such as a hard piece of stool getting
trapped in the appendix leading to infection of
the appendix.
• Extreme of age
• Previous abdominal surgery
• Acute appendicitis seems to be the
CAUSES
end result of a primary obstruction of
the appendix. FAECOLITH
• Once this obstruction occurs, the appendix
becomes filled with mucus and swells. This
continued production of mucus leads to
increased pressures within the lumen and the
walls of the appendix.
• The increased pressure results in thrombosis
and occlusion of the small vessels, and stasis
of lymphatic flow.
Common Causes
1. Fecal impaction and/or a fecality
• A layered buildup of calcium salts and fecal debris around a piece of fecal
material within the appendix
2. Lymphoid Hyperplasia
• The appendix contains lymphoid (immune system) tissue that can
become inflamed as a result of infection or inflammatory bowel disease
(IBD)
3. Parasites
• Examples: Schistosomes species, pinworms, Strongyloides, stercoralis
Uncommon Causes:
1. Tumors
2. Foreign Material
• A wide variety of foreign objects can become lodged in the appendix.
Some of these include: shotgun pellets, intrauterine devices, tongue
studs, and activated charcoal
• Trauma, intestinal worms, lymphadenitis
TYPES
Acute Appendicitis:
• Acute appendicitis, as its name implies, develops very fast, usually in a
span of several days or hours. It is easier to detect and requires prompt
medical treatment, usually surgery.
• Acute appendicitis occurs when the vermiform appendix is completely
obstructed, either because of a bacterial infection, feces or other types of
blockage. Infection may also cause swelling of the lymph nodes, which
then adds pressure on the appendix, cutting off its blood supply.
Cont..
Appendicitis Can Be Chronic (But It's a Rare Condition)
• Chronic appendicitis is an inflammation that can last for a long time. This is rare
according to a report published in Therapeutic Advances in Gastroenterology, it
only occurs in only 1.5 percent of recorded acute appendicitis cases.
• Basically, chronic appendicitis means that the appendiceal lumen is only partially
obstructed, causing inflammation. The inflammation worsens over time, causing
internal pressure to buildup.
Cont..
Stump Appendicitis: A Rare Appendectomy SideEffect
• In most instances of appendicitis, an appendectomy is the usual procedure
recommended, and it works by completely taking out the appendix to prevent
it from rupturing.
• If the appendix has already ruptured, additional treatment measures are
performed during an appendectomy, as the infection needs to be prevented from
spreading.
CLINICAL MANIFESTATIONS
• Local tenderness is elicited at McBurney’s point when pressure is
applied. Rebound tenderness (ie, production or intensification of
pain when pressure is released) may be present.
Symptoms • Fever 10-20%
• Abdominal pain >95%
• Migration of pain to right lower
• Anorexia >70% quadrant
50-60%
• Constipation 4-16%
• Diarrhea 4-16% • Nausea Vomiting >65%
Signs
• Psoas sign 3-5%
• Abdominal tenderness >95%
• Right lower quadrant tenderness >90% • Obturator sign 5-10%
• Rebound tenderness 30-70% • Rovsing's sign 5%
• Rectal tenderness 30-40% • Palpable mass <5%
• Cervical motion tenderness 30%
• Rigidity 10%
Differential Diagnosis
• Pelvic inflammatory disease (PID) or tubo-ovarian abscess
• Ovarian cyst or torsion
• Ureterolithiasis and renal colic
• Crohn disease
• Colonic carcinoma
• Cholecystitis
• Biliary colic
• Renal colic
• Urinary tract infection (UTI)
• Gastroenteritis
• Pancreatitis
• Perforated duodenal ulcer
ASSESSMENT AND DIAGNOSTIC FINDINGS
Cont..
• Rovsing’s sign: Palpating in the
left lower quadrant causes pain in
the right lower quadrant
• Obturator’s sign: Internal
rotation of the hip causes pain,
suggesting the possibility of an
inflamed appendix located in the
pelvis
• Dunphy's sign: Increased pain in the right lower quadrant with
coughing.
• Iliopsoas sign: Extending the right hip causes
pain along posterolateral back and hip,
suggesting Retrocecal appendicitis.
• Sitkovskiy (Rosenstein)'s sign: Increased pain in the right
iliac region as the person is being examined lies on his/her left
side.
Diagnosis
• Diagnosis is based on results of a complete physical
examination and on laboratory and x-ray findings.
• The complete blood cell count demonstrates an elevated white
blood cell count.
• The leukocyte count may exceed 10,000 cells/mm3, and the
neutrophil count may exceed 75%.
ALVARADO SCORE
• The Alvarado score is the most widely used scoring system. A score
below 5 suggests against a diagnosis of appendicitis, whereas a
score of 7 or more is predictive of acute appendicitis
Abdominal x-ray films
Ultrasound studies
• Aperistaltic, non-
compressible, dilated
appendix (>6 mm outer
diameter)
• Distinct appendiceal wall
layers
• Periappendiceal fluid
collection/enlargement
CT scans
• Dilated appendix with
distended lumen ( >6
mm diameter)
• Thickened and
enhancing wall
• Thickening of the caecal
apex (up to 80%)
MANAGEMENT
• Surgery is indicated if appendicitis is diagnosed.
• To correct or prevent fluid and electrolyte imbalance and dehydration, antibiotics
and intravenous fluids are administered until surgery is performed.
• Analgesics can be administered after the diagnosis is made. (Morphine sulphate 10
mg/ml)
Antibiotics
• Cefotaxime 250mg, 500mg
• Levofloxacin 500 mg
• Metronidazole 500mg/100ml, 400 mg tablet
• Appendectomy (ie, surgical removal of the appendix) is
performed as soon as possible to decrease the risk of
perforation. It may be performed under a general or spinal
anesthetic with a low abdominal incision or by laparoscopy.
Open Appendectomy
Pre-Operative care:
• Assessment History taking physical examinations, Regarding pain,
nausea vomiting, abdominal rebound tenderness, Anorexia
• Monitor vital signs B.P., Temperature for baseline data
• NPO and I.V. Fluids be started
• Naso-gastric aspiration
• Monitor for signs of ruptured appendix and peritonitis
• Position right-side lying or low to semi fowler position to promote
comfort.
Cont..
• Auscultate Bowel Sounds
• Administer antibiotics as prescribed
• Preparation for surgery i.e. physically & psychologically
• Alley anxiety & fears
• Written consent for surgery
• Prepare and send the patient for surgery without delay
• OT clothes and pre medications to be given 45 minutes before operation
Thank You!