1. Acute Appendicitis

2. Epidemiology
The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.
Despite newer imaging techniques, acute appendicitis can be very difficult to diagnose.

3. Appendicitis: The most common surgical condition of the abdomen
Lifetime occurrence of 7%
Peak incidence 10-30y
The most common nonobstetric surgical intervention during pregnancy

4. Pathogenesis: Appendiceal lumen obstruction : lymphoid hyperplasia
fecaliths
parasites
foreign bodies
crohn’s disease
metastatic cancer
carcinoid syndrome

5. Pathophysiology
Acute appendicitis is thought to begin with obstruction of the lumen
Obstruction can result from food matter, adhesions, or lymphoid hyperplasia
Mucosal secretions continue to increase intraluminal pressure

6. Pathophysiology
Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed.
With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.

7. Pathophysiology
Increased pressure also leads to arterial stasis and tissue infarction
End result is perforation and spillage of infected appendiceal contents into the peritoneum

8. Pathophysiology
Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10th thoracic vertebral level.
This pain is generally vague and poorly localized.
Pain is typically felt in the periumbilical or epigastric area.

9. Pathophysiology
As inflammation continues, the serosa and adjacent structures become inflamed
This triggers somatic pain fibers, innervating the peritoneal structures.
Typically causing pain in the RLQ

10. Pathophysiology
The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.

11. Pathophysiology
Exceptions exist in the classic presentation due to anatomic variability of the appendix
Appendix can be retrocecal causing the pain to localize to the right flank
In pregnancy, the appendix ca be shifted and patients can present with RUQ pain

12. Pathophysiology
In some males, retroileal appendicitis can irritate the ureter and cause testicular pain.
Pelvic appendix may irritate the bladder or rectum causing suprapubic pain, pain with urination, or feeling the need to defecate
Multiple anatomic variations explain the difficulty in diagnosing appendicitis

13. symptoms : Pain – RLQ / RUQ / Flank Anorexia Vomiting Nausea
Pain migration
Fever

14. Physical examination:
Tenderness – RLQ
Rebound & Guarding (peritoneal signs)
Rovsing sign
Dunphy’s sign
Psoas sign (retroperitoneal retrocecal appendix)
Obturator sign (pelvic appendix)
Rectal examination tenderness (cul-de-sac)
Low grade fever

15. Psoas
sign
                                                  
                                                  
Obturator
sign

16. History Primary symptom: abdominal pain
½ to 2/3 of patients have the classical presentation
Pain beginning in epigastrium or periumbilical area that is vague and hard to localize

17. History
Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting
As the illness progresses RLQ localization typically occurs
RLQ pain was 81 % sensitive and 53% specific for diagnosis

18. History
Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific
Anorexia is the most common of associated symptoms
Vomiting is more variable, occuring in about ½ of patients

19. Physical Exam Findings depend on duration of illness prior to exam.
Early on patients may not have localized tenderness
With progression there is tenderness to deep palpation over McBurney’s point

20. Physical Exam
McBurney’s Point: just below the middle of a line connecting the umbilicus and the ASIS
Rovsing’s: pain in RLQ with palpation to LLQ
Rectal exam: pain can be most pronounced if the patient has pelvic appendix

21. Physical Exam
Additional components that may be helpful in diagnosis: rebound tenderness, voluntary guarding, muscular rigidity, tenderness on rectal

22. Physical Exam
Psoas sign: place patient in L lateral decubitus and extend R leg at the hip. If there is pain with this movement, then the sign is positive.
Obturator sign: passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positive

23. Physical Exam Fever: another late finding.
At the onset of pain fever is usually not found.
Temperatures >39 C are uncommon in first 24 h, but not uncommon after rupture

24. Lab: CBC – WBC ( 80%  45% ) CRP Urinalysis - mild pyuria
mild proteinuria
mild hematuria

25. D.D.: surgical: gyneco: Renal stone Gastroenteritis Pancreatitis
Cholecystitis
Mesenteric adenitis
Hernia
Bowel obstruction
Preterm labor
Placenta abruptio
Chorioamnionitis
Adnexal torsion
Ectopic pregnancy
Pelvic inflammatory
Round lig. pain

26. Diagnostic problems: Position of appendix:
normally 70% intraperitoneal
30% pelvic, retroileal, retrocolic
pregnancy – anatomical changes
gravid uterus  displacement upward &
outward  flank pain (3rd trimester) (Baer,1932)
increased separation of peritoneum  decreased perception of somatic pain and localization

27. Diagnostic problems: Symptoms complex – physical changes
anorexia, nausea & vomiting in normal
pregnancy
Lab – relative leukocytosis
Imaging techniques

28. Diagnosis
Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain who has not had an appendectomy

29. Diagnosis
Women of child bearing age need a pelvic exam and a pregnancy test.
Additional studies: CBC, UA, imaging studies

30. Diagnosis CBC: the WBC is of limited value.
Sensitivity of an elevated WBC is 70-90%, but specificity is very low.
But, +predictive value of high WBC is 92% and –predictive value is 50%
CRP and ESR have been studied with mixed results

31. Diagnosis UA: abnormal UA results are found in 19-40%
Abnormalities include: pyuria, hematuria, bacteruria
Presence of >20 wbc per field should increase consideration of Urinary tract pathology

32. Imaging: KUB Barium enema Graded compression ultrasonography
Helical CT scan

33. Diagnosis Imaging studies: include X-rays, US, CT
Xrays of abd are abnormal in 24-95%
Abnormal findings include: fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free air
Abdominal xrays have limited use b/c the findings are seen in multiple other processes

34. Graded compression ultrasound:
Normal appendix (<6mm) rules out appendicitis.
Nonpregnant – Sensitivity 85%
specificity 92%
Pregnant – cecal displacement & uterine imposition makes precise examination difficult (Williams,21 edition)

35. Diagnosis
Graded Compression US: reported sensitivity 94.7% and specificity 88.9%
Basis of this technique is that normal bowel and appendix can be compressed whereas an inflamed appendix can not be compressed
DX: noncompressible >6mm appendix, appendicolith, periappendiceal abscess

36. Diagnosis
Limitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameter

37. Diagnosis
CT: best choice based on availability and alternative diagnoses.
In one study, CT had greater sensitivity, accuracy, -predictive value
Even if appendix is not visualized, diagnose can be made with localized fat stranding in RLQ.

38. Diagnosis
CT appears to change management decisions and decreases unnecessary appendectomies in women, but it is not as useful for changing management in men.

39. Special Populations
Very young, very old, pregnant, and HIV patients present atypically and often have delayed diagnosis
High index of suspicion is needed in the these groups to get an accurate diagnosis

40. Treatment Appendectomy is the standard of care
Patients should be NPO, given IVF, and preoperative antibiotics
Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation

46. Treatment
There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage
One sample monotherapy regimen is Zosyn 3.375g or Unasyn 3g
Also, short acting narcotics should be used for pain management

47. Disposition Abdominal pain patients can be put in 4 groups
Group 1: classic presentation for Acute appendicitis- prompt surgical intervention
Group 2: suspicious, but not diagnosed appendicitis- benefit from imaging and 4-6h observation with surgical consult if serial exam changes or imaging studies confirm

48. Disposition
Group 3: remote possibility of appendicitis- observe in ED for serial exams; if no change and course remains benign patient can D/C with dx of nonspecific abd pain
Patients are given instructions to return if worsening of symptoms, and they should be seen by PCP in h
Also advised to avoid strong analgesia

49. Disposition
Group 4: high risk population(including elderly, pediatric, pregnant and immunocomprimised)- require high index of suspicion and low threshold for imaging and surgical consultation

50. Prognosis:
Generally good :
Disease found
Surgery complications

51. The end