ACUTE APPENDICITIS

Appendicitis is a disease of the young, with 40% of the cases occurring in patients between the
ages of 10 and 29 years.

Most frequently seen in patients in their second through fourth decades of life, with a mean age
of 31.3 years and a median age of 22 years. There is a slight male to female predominance (M:F
1.2 to 1.3:1)

Etiology
 Fecalith is the most common cause of appendiceal obstruction; usually in adults
 Lymphoid hyperplasia is the most coomon cause of appendiceal obstruction in
patients of pediatric age.

Pathogenesis
Luminal obstruction-> bacterial overgrowth, active mucosal secretion & increased luminal
pressure

- Distention of the appendix stimulates nerve endings of visceral afferent stretch fibers,
producing vague, dull, diffuse pain in the mid-abdomen or lower epigastrium. Peristalsis is also
stimulated by the rather sudden distention, so that some cramping may be superimposed on the
visceral pain early in the course of appendicitis.

-Distention continues from continued mucosal secretion and from rapid multiplication of the
resident bacteria of the appendix. Distention of this magnitude usually causes reflex nausea and
vomiting and diffuse visceral pain becomes more severe.

-As pressure in the organ increases, venous pressure is exceeded. Capillaries and venules are
occluded, but arteriolar inflow continues, resulting in engorgement and vascular congestion.

As distention, bacterial invasion, compromise of vascular supply and infarction progress,

perforation occurs, usually through one of the infarcted areas on the antimesenteric border.
Perforation generally occurs just beyond the point of obstruction rather than at the tip because
of the effect of diameter on intraluminal tension.

The sequence is not inevitable, however, and some episodes of the acute appendicitis apparently
subside spontaneously.

Clinical presentation

 Hallmark of appendicitis is poorly localized pain ( due to distention stimulates visceral

afferent pain fibers) that is referred to the periumbilical region (via autonomic
innervation)-> Right lower quadrant pain and tenderness
 Vomiting usually follows abdominal pain
  Anorexia is a constant symptom: if not present, usually precedes abdominal pain
 Variation in the anatomic locations of the appendiceal tip account for the different
manifestation of the abdominal pain
- Retrocecal: Flank or back pain
- Pelvis: findings may be absent; painful DRE exam

 PE Manuevers
- Dumphy’s sign: increased pain during coughing or jumping
- Rovsings sign: pain in the RLQ when pressure is applied on the LLQ this suggest
peritoneal irritation
- Psoas sign: pain on extension of the right thigh with the patient lying on the left
side; this is due to the pain elicited by the stretched psoas muscle irritating the
inflamed appendix
- Obturator’ s sign: pain with passive rotation of the flexed right hip; suggests that
the inflamed tip lies in the appendix.

Diagnostic Work up

 Laboratory findings
1. Moderate leukocytosis with polymorphonuclear predominance (if above 18000-
suspect abscess or perforation)
2. Can also have normal WBC count (1/3 of patients)
3. Minimal albuminuria (+) WBC and (+) RBC in urine if appendix is retrocecal
4. Anemia in elderly should raise suspicion of carcinoma of the cecum

 Imaging
1. Palin abdominal film: fecalith, localized ileus on the RLQ and loss of peritoneal fat
strip
2. Ultrasound: tubular, immobile and noncompressible appendix wall thickness of
>2mm and outer diameter of atleast 6mm are indicative of appendicitis
3. CT Scan thickened by more than 5-7mm and fluid filled, periappendiceal
inflammation along with fat stranding fluid collections and phlegmons.

Treatment:

Medical Management:

-NPO
-IVF: D5LR 1L at 30gtts/min
-Diagnostics: CBC with ABO, Na, K, Crea, PT, PTT, Chest Xray PAL
-Medication: Cefoxitin 1g IV q 8, Omeprazole 40mg IV OD
-For “E” Appendectomy
-VSq1
Surgical Management

Operative Procedure:
Appendectomy

Operative Technique
 Patient in supine position under Subarachnoid Block
 Asepsis and Antisepsis.
 Sterile Drapes done.
 Rocky Davis Incision and continued till the peritoneum
 Inflamed Appendix
 Surgical Ligation of Mesoappendix
 Appendix Ligated
 Hemostasis
 Fascia closed by Vicryl 1-0
 Skin Closed by Silk 2-0
 Dressing done.