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.
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.
Examination 3 classic maneuvers:
- Rovsing sign – peritoneal irritation
- Psoas sign – irritation of psoas muscle
- Obturator sign – irritation of obturator muscle
Differential Diagnosis based on age
- Non specific abdominal pain
- Mesenteric adenitis
- Ovarian cyst
- Merkel’s diverticulum
- Ectopic pregnancy
- Gallstone disease
- Ovarian torsion
- Older adults
- Bowel obstruction
|Remember For female patients rule out ectopic pregnancy and ectopic rupture.|
- FBC with WCC differential are elevated ↑PMN.
- CRP is elevated
- Urine β-HCG is done to rule out pregnancy or ectopic.
- 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
- Migration to right iliac fossa
- I dont know –
- Elevated temperature
|Remember Acute appendicitis is essentially a clinical diagnosis|
- 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|
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
|↓Incidence of intra-abdominal abscess formation
↓Incidence of intraoperative complications
↓Operative and Inhospital Costs
|Risks||Adhesions||Predisposing to a future right sided direct hernia|
- 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.
- Continue IV fluids
- Pain Management
- Arrange Follow Up
- Monitor for complications
Complications and Prognosis
- Appendix mass
- Appendix abscess
- Portal Venous thrombosis
- Liver Abscess
- Bacteraemia – sepsis
- PE/DVT following hospitalization
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.