Acute Appendicitis Overview

Acute Appendicitis

• An acutely inflamed appendix can rupture within 24 hours, necessitating rapid diagnosis and treatment.

• Due to the urgency and low complication rate, diagnostic testing and preoperative treatment are minimal.

• Patients are admitted to the hospital, IV fluids are initiated, and oral intake is withheld until a diagnosis is confirmed.

Diagnostic Tests

• Abdominal CT scan is the preferred imaging to diagnose acute appendicitis and reduce unnecessary surgery.

• CT scans with or without contrast are used, with contrast providing additional information in cases of ruptured appendix and abscess.

• Ultrasounds are suitable for children who cannot remain still during CT scans and pregnant women.

• MRIs are used for pregnant patients to avoid pressure on or radiation exposure to the abdominal contents.

• Elevated total WBC count with increased immature WBCs (bands) are indicative of appendicitis.

Surgical Treatment

• Appendectomy, surgical removal of the appendix, is the primary treatment for acute appendicitis.

• Procedures include minimally invasive laparoscopic appendectomy, open-incision appendectomy, or abdominal laparotomy with saline irrigation and drainage tubes for ruptured appendix and peritonitis.

• Intravenous hydration is essential for patients undergoing appendectomy.

• Nonsurgical treatment with antibiotics for uncomplicated appendicitis is under investigation but remains controversial due to diagnostic challenges, potential for missed malignant causes, lack of standardized protocols, and a 38% recurrence rate.

Pharmacologic Therapy

• Analgesic drugs are now used preoperatively to alleviate pain and facilitate physical examination and diagnosis, especially when surgery is delayed.

• Post-diagnosis, antibiotics are administered preoperatively within 60 minutes of incision.

• Commonly used antibiotics include cephalosporins (cefepime, cefotaxime, cefotetan, ceftazidime, ceftriaxone), carbapenems (ertapenem, meropenem), combination penicillin antibiotics (piperacillin/tazobactam, ampicillin/sulbactam), or a combination of cephalosporin and metronidazole.

• Antibiotics are repeated before surgery if delayed and are typically not given postoperatively unless perforation or other complications occur.

Acute Appendicitis

• Acute Appendicitis is a serious condition requiring immediate medical attention.
• Uncomplicated Appendicitis is when the appendix hasn't ruptured, and there's no evidence of peritonitis.
• Complicated Appendicitis is when the appendix has ruptured and peritonitis is present.
• Diagnosis is based on physical examination and imaging studies.
• Abdominal CT scan is the preferred imaging method for diagnosis, particularly for distinguishing uncomplicated from complicated cases.
• Ultrasound is an alternative for children and pregnant women.
• MRIs may be used for pregnant patients.
• WBC count with differential can show elevated WBC count with increased immature WBCs (bands).
• Treatment primarily involves surgical removal of the appendix (appendectomy).
• Preoperative analgesics are crucial for pain management and facilitating diagnosis.
• Preoperative Antibiotics are administered within 60 minutes of the incision.
• Postoperative Antibiotics are usually not given unless complications exist.
• Laparoscopic Appendectomy is a minimally invasive surgical approach.
• Open-Incision Appendectomy is a more traditional approach.
• Abdominal Laparotomy is used in cases of ruptured appendix and peritonitis.
• Nonsurgical Management with Antibiotics is a potential alternative treatment for uncomplicated appendicitis, but it has limitations.
• Pain Management pre-operatively is vital for improving patient comfort and accuracy in clinical evaluation.
• Antibiotics can be given post-operatively if complications arise.

Risks of Delaying Treatment

• Perforation of the inflamed appendix can occur within 24 hours.
• Peritonitis can develop due to a ruptured appendix.
• Abscesses can form in the area of the ruptured appendix.

Considerations for Treatment

• Operating Room Availability and staff availability can influence the timing of surgery.
• Preoperative Antibiotics are essential for reducing infection.
• Intravenous Hydration is vital to prevent dehydration.
• Drainage Tubes are used in cases of ruptured appendix to remove pus and fluid.
• Recurrence of Appendicitis can happen in up to 38% of cases.

Appendicitis in Children and Adolescents

• Children under 4 generally do not develop appendicitis.
• Appendicitis progression to rupture in younger children is common due to communication challenges.
• Infants may exhibit listlessness, inconsolability, vomiting, and abdominal distension.
• Appendicitis is a rare condition in infants, delay in diagnosis is a factor in increased rupture, complications, and mortality among them.
• Older children may exhibit atypical signs like lethargy, limited movement, and guarding instead of classic symptoms.
• Cultural factors influence the progression of appendicitis in children.
• A study showed a higher probability of delayed diagnosis in Black, Hispanic, and other children of color.
• These children were less likely to receive definitive diagnostic imaging.
• Black, Hispanic, and other children of color had a significantly higher incidence of perforations compared to white children.
• Discrimination can contribute to delayed diagnosis and increased severity.

Appendicitis in Pregnant Women

• Appendicitis is a common surgical condition during pregnancy.
• Pregnant women may present with atypical symptoms like heartburn, flatulence, nausea, vomiting, and right lower abdominal tenderness.
• Ultrasound imaging is the initial diagnostic tool, followed by MRI if inconclusive.
• Appendix absence on ultrasound does not exclude appendicitis.
• Surgery is the treatment, with similar outcomes as non-pregnant women for non-ruptured cases.
• Rupture in pregnancy increases the risk of fetal loss significantly.

Appendicitis in Older Adults

• Reduced immune function in older adults can result in diminished inflammatory response and atypical presentation.
• Nonspecific signs like confusion, abdominal pain, and other infection indicators can mask appendicitis.
• Delayed care seeking leads to a higher risk of perforation.
• Laparoscopic appendectomy for both uncomplicated and complicated appendicitis in older adults offers benefits like shorter hospital stays, home discharge, and fewer complications.

Nursing Management of Appendicitis

• Prompt assessment is crucial due to the rapid progression of appendicitis from inflammation to perforation.
• Observation and patient interview: Assess onset, duration, progression, aggravating/relieving factors, last food/fluid intake, allergies, medications, and chronic diseases.
• Physical examination: Document vital signs, general health, abdominal shape/contour, bowel sounds, and tenderness to palpation.
• Safety Alert: Keep patients with suspected appendicitis NPO (nothing by mouth). Do not administer laxatives or enemas, or apply heat to the abdomen, as these actions may increase the risk of perforation.
• Diagnosis:
  • Inadequate gas exchange
  • Potential for fluid volume deficit
  • Risk for infection
  • Acute pain
  • Anxiety
  • Fear
• Planning: The collaborative plan of care may include:
  • Patient/family understanding the need for preoperative antibiotics.
  • Patient expressing concerns about surgery.
  • Patient understanding the procedure, reasons, and preoperative instructions.
  • Patient experiencing relief from pain after pain management.
  • Patient receiving appropriate postoperative wound care.
  • Patient understanding self-care instructions before discharge.
  • Patient understanding antibiotic regimens, if required, after discharge.

Nursing Management of Appendicitis

• Prompt assessment is crucial due to the rapid progression of appendicitis from inflammation to perforation.

• Observation and patient interview should include:

  • Onset, duration, progression, and aggravating/relieving factors of symptoms.
  • Most recent food/fluid intake.
  • Known medication and other allergies.
  • Current medications.
  • History of chronic diseases.

• Physical examination should document:

  • Vital signs, including temperature.
  • General health assessment.
  • Abdominal shape and contour.
  • Bowel sounds.
  • Tenderness to light palpation.

Safety Alert

• Keep the patient with suspected appendicitis NPO (nothing by mouth).
• Do not administer laxatives or enemas. These can potentially cause perforation of the appendix.
• Do not apply heat to the abdomen. Increased circulation to the appendix from heat application can worsen the situation.

Nursing Diagnoses for Appendicitis

• Inadequate gas exchange.
• Potential for fluid volume deficit.
• Risk for infection.
• Acute pain.
• Anxiety.
• Fear.

Planning and Interventions

• Patient and family understanding of preoperative antibiotics.
• Patient articulation of concerns about surgery.
• Patient understanding of the surgical procedure, reasons, and preoperative instructions.
• Pain relief following administration of pain management.
• Appropriate postoperative wound care.
• Patient verbalization of self-care instructions prior to discharge.
• Patient understanding of antibiotic regimen after discharge (if required).

This quiz covers important aspects of acute appendicitis, including diagnosis, imaging techniques, and surgical treatment options. Learn about the urgency of identifying an inflamed appendix and the appropriate diagnostic tests utilized in different patient scenarios. Test your knowledge on the critical management of this common surgical condition.