Armando Hasudungan
Biology and Medicine videos

Appendicitis

Overview

Overview The appendix is a normal true diverticulum of the caecum that is prone to acute and chronic inflammation. Acute appendicitis is the most common surgical emergency. Lifetime risk: 1 in 15 people. Can occur at any age but peak 10 – 30 years. Slightly more common in males. Acute appendicitis is rare before age 2 as the appendix is cone shaped with a larger lumen.

Definition
Appendix
Appendicitis:
Inflammation of the appendix
Uncomplicated appendicitis:
 Acutely inflamed, phlegmonous, suppurative, or mildly inflamed appendix with or without peritonitis
Complicated appendicitis:
Includes gangernous appendicitis, perforated appendicitis, localised purulent collection at operation, generalised peritonitis and periappendiceal abscess
Appendectomy (appendicetomy): 
Surgical removal of the appendix. A standard treatment for appendicitis. A ruptured appendix is considered a medical emergency. Appendicetomy can be either done open or laproscopic. 

Signs and Symptoms

Clinical Presentation Classically periumbilical pain that moves to the right iliac fossa. Anorexia is an important feature; vomiting is rarely prominent – pain normally precedes vomiting in the surgical abdomen. Constipation is usual. Diarrhoea may occur.

appendicitis


Examination 3 classic maneuvers:

  1. Rovsing sign – peritoneal irritation
  2. Psoas sign – irritation of psoas muscle
  3. Obturator sign – irritation of obturator muscle

 

Differential Diagnosis

Location of pain

Location of pain

Abrupt excruciating pain

Differentials for acute severe pain

Differential Diagnosis based on age

  • Children
    • Non specific abdominal pain
    • Mesenteric adenitis
    • Ovarian cyst
    • Merkel’s diverticulum
  • Adults
    • Ectopic pregnancy
    • Gallstone disease
    • Ovarian torsion
    • Pyelonephritis
  • Older adults
    • Bowel obstruction
    • Malignancy
Remember For female patients rule out ectopic pregnancy and ectopic rupture.

Investigations

  • FBC with WCC differential are elevated ↑PMN.
  • CRP is elevated
  • Urine β-HCG is done to rule out pregnancy or ectopic.
  • Urinalysis
  • LFTs
  • EUC
  • Serum lipase/amylase
  • Ultrasound may help, but the appendix is not always visualized.
  • CT scan has high diagnostic accuracy and is useful if the diagnosis is unclear: it reduces -ve appendicectomy rate but may cause fatal delay.
Remember Acute Appendicitis is a clinical diagnosis and is addressed surgically. When there is a high degree of clinical suspicion, an appendicectomy can be performed without imaging

Diagnosis Armando score (TRAMLINE)

  • Tenderness in the right iliac fossa
  • Rebound tenderness
  • Anorexia
  • Migration to right iliac fossa
  • Leukocytosis
  • I dont know –
  • Nausea/vomiting
  • Elevated temperature
Remember Acute appendicitis is essentially a clinical diagnosis

Management

  • History and examination
  • Prepare for surgery (appendicectomy)
  • Insert cannula on dorsal hand
    • Take bloods
    • Start IV saline; 100mL/hour
    • Antibiotics – metronidazole + cefuroxime  IV starting 1h pre-op (Give a longer course if perforated.)
  • Nil by mouth

Prompt Appendicectomy. Laparoscopy has diagnostic and therapeutic advantages. It is not recommended in cases of suspected gangrenous perforation as the rate of abscess formation may be higher.

DIFFERENCE BETWEEN LAPAROTOMY AND LAPROSCOPY
Laproscopy Open
Indications Routine appendicitis
Obese patients
Elderly patients
Uncertain diagnosis
Pregnancy women
Small children
When Laproscopy is not available
Benefits Earlier resumption of liquid and solid intake
↓Duration of postoperative hospital stay
↓Postoperaitve pain and better cosmetic result
↓Overall complication rate including postoperative ileus
↓Incidence of wound infections
↑Diagnostic accuracy
↓Incidence of intra-abdominal abscess formation
↓Incidence of intraoperative complications
↓Operative time
↓Operative and Inhospital Costs
Risks Adhesions Predisposing to a future right sided direct hernia

Post-Operative

  • Prevent Infection – Continue Antibiotics: Metronidazole + cefuroxime. Inspect incision sites for signs of infection.
  • Restore Bowel Function – Clear liquid diet on same day of operation (if no nausea and vomiting). Commence regular diet the next day as tolerated.
  • Prevention of DVT – Commence physical activity as soon as possible.
  • Other
    • Continue IV fluids
    • Pain Management
    • Arrange Follow Up
    • Monitor for complications

Complications and Prognosis

Complications

  • Perforation
  • Appendix mass
  • Appendix abscess
  • Portal Venous thrombosis
  • Liver Abscess
  • Bacteraemia – sepsis
  • Fistula
  • Pyelonephritis
  • PE/DVT following hospitalization

Prognosis

Appendiceal Carcinoid

Most frequently found incidentally found in the appendix postappendicectomy. Comprise 85% of all appendiceal tumours. If <1cm in diameter, it is considered cured by appendicectomy. If >2cm in diameter (rare), investigate for spread to sentinel lymph nodes. Managed by hemicolectomy.