Acute Appendicitis Overview

Acute Appendicitis

• Appendicitis is the acute inflammation of the vermiform appendix.
• Uncomplicated appendicitis has no evidence of fecalith, tumor, or complications like perforation, gangrene, abscess, or mass.
• Complicated appendicitis is associated with perforation, gangrene, abscess, mass, or fecalith.
• Common causes of appendicitis include lymphoid hyperplasia (mostly in children), appendiceal fecalith and fecal stasis (mostly in adults). Neoplasms are less common, and more likely to occur in patients over 50.
• Appendicitis results from obstruction of the appendiceal lumen, leading to bacterial multiplication, increased intraluminal pressure and inflammation.
• This inflammation can spread causing ischemia and gangrene or peritonitis.

Symptoms and Signs

• The primary symptom is migrating abdominal pain that starts periumbilically and localizes to the right lower quadrant (RLQ) within 12-24 hours.
• Associated, non-specific symptoms include nausea, anorexia (in up to 80% of cases), vomiting, low-grade fever, and diarrhea.
• Loss of appetite is a good indicator to consider in the absence of appendicitis.

Physical Examination

• Diagnosis is supported by physical exam findings like McBurney point tenderness, RLQ guarding and rigidity, rebound tenderness (Blumberg sign).
• Rovsing sign (RLQ pain from LLQ pressure) and Psoas/Obturator signs indicate retrocecal/pelvic appendicitis

Diagnosis

• Diagnosis is usually made clinically based on history, examination, and laboratory studies (CBC, CRP, urine/serum β-hCG).
• Imaging (Ultrasound or CT scan) may be necessary to confirm the diagnosis, especially if theclinical diagnosis is uncertain.

Imaging Findings

• Ultrasound can show a distended appendix (> 6mm), non-compressible appendix, a target sign, and possible fecalith.
• A normal ultrasound doesn't rule out appendicitis.
• CT scans may reveal a distended appendix (> 6mm), edematous appendix with periappendiceal fat stranding, possible appendiceal fecalith, or evidence of complications.

Alvarado Score

• The Alvarado score is used to assess the likelihood of acute appendicitis.
• Scores of 4 or less indicate low likelihood.
• Scores of 5-6 indicate moderate likelihood.
• Scores of 7 or more indicate high likelihood requiring urgent surgical consultation.

Treatment

• Treatment usually involves supportive care (bowel rest, intravenous fluids, analgesics).
• Empiric antibiotics that cover gram-negative and anaerobic organisms such as metronidazole, are often necessary.
• Urgent laparoscopic appendectomy is the standard treatment for uncomplicated appendicitis and may be considered within 24 hours of diagnosis.
• Initial operative treatment for abscesses or phlegmons carries a high risk of complications.

This quiz delves into the acute inflammation of the appendix, known as appendicitis. It covers the differences between uncomplicated and complicated cases, common causes, and the key symptoms to look out for. Test your knowledge on this critical surgical condition and its clinical manifestations.