Appendicitis Overview and Clinical Signs

Appendicitis

• Definition: Inflammation of the appendix, a finger-like organ attached to the cecum.
• Location: Located below the ileocecal valve, approximately 10cm (4 inches) in length.
• Function: Fills with food and empties into the cecum.
• Risk Factors: Small lumen makes it prone to obstruction and infection. Fecaliths (pieces of stool) are a common cause of obstruction. Malignant tumors, helminths, and infections can also contribute.
• Causes: Fecalith obstruction, malignant tumors, helminths, and infections.

Clinical Manifestations of Appendicitis

• Pain: Initially generalized in the epigastric or periumbilical area, progressing to localized pain in the right lower quadrant (RLQ). The pain is sharp and localized (parietal pain).
• Signs of Systemic Infection: Fever, nausea, vomiting, and loss of appetite are common.
• Local Tenderness: The appendix is often tender to the touch.
  • McBurney's point: A specific area of tenderness in the RLQ.
• Advanced Appendicitis: If the appendix becomes infected and inflamed, ischemia and gangrene, or death of the appendix due to lack of blood flow, may occur.

Physical Examination Findings

• Rebound Tenderness (Blumberg's sign): Pain when pressure on the abdomen is released.
• Rovsing's Sign: Pain in the right lower quadrant when pressure is applied to the left lower quadrant.
• Psoas Sign: Pain when extending the right thigh while the patient is lying on their left side.
• Obturator Sign: Pain when internally rotating the right thigh, with the patient lying supine.
• Additional Signs: Abdominal distension (paralytic ileus; slowed or stopped bowel movement). Constipation can also be a sign.

Important Considerations for Caregivers

• Avoid Laxatives/Cathartics: Do not give if the individual has fever, nausea, vomiting, and abdominal pain, as it can result in appendiceal perforation.
• Heat Application: Avoid applying heat, as it can cause vasodilation.

Assessment and Diagnosis

• History: Gather patient history, including symptoms and prior medical conditions.
• Physical Examination: Tests like rebound tenderness, Rovsing's sign, psoas sign, and obturator sign may indicate appendicitis.
• Laboratory Tests: Complete blood count (CBC) may reveal elevated white blood cell (WBC) and neutrophil counts.
• Imaging: Abdominal X-ray, ultrasound (UTZ), and CT scans may aid in confirming the diagnosis.
• Differentiating conditions: Pregnancy tests for ectopic pregnancy and urinalysis for urinary tract infections (UTIs) because appendicitis symptoms may overlap with these conditions.

Complications of Appendicitis

• Perforation: Perforation can occur within 24 hours of the onset of pain, leading to peritonitis.
• Peritonitis: Inflammation of the peritoneum, the membrane lining the abdominal cavity.
• Abscess: Pus-filled collections of infection material around the appendix.
• Portal pylephlebitis: Septic thrombosis due to vegetative emboli from the infected intestine.

Geriatric Considerations

• Less common: Appendicitis is less frequently seen in the elderly.
• Variations in Presentation: Pain might be absent or minimal.
• Misdiagnosis: Symptoms may mimic other conditions, such as bowel obstruction.
• Testing: ECG and chest X-ray may be necessary.
• Absence of Signs: Fever and leukocytosis may be absent in older patients.

Medical Management

• Surgical Management (Appendectomy): The standard treatment for appendicitis.
• Treatment of perforation: If perforation occurs, antibiotics may first be administered and the abscess drained before surgery.
• Pre-operative care: Patients may be kept away from food (NPO) to prepare for surgery and manage/prevent imbalances in fluid and electrolytes. Administer IV fluids as needed to maintain balance.
• Nursing Management: Nursing care focuses on alleviating pain, preventing dehydration, managing pain, eliminating infection, and ensuring skin integrity. Paralytic ileus may require nasogastric tube insertion (NGT) for decompression (to empty the stomach). Never use enemas to evacuate bowels.

Post-Operative Care

• Positioning: High Fowler's position is often suggested.
• Pain Management: Opioid analgesics (e.g., morphine sulfate).
• Nutrition: Progress dietary tolerance to oral fluids and foods, based on return of bowel sounds. Normal bowel sounds should be around 20 per minute; hypoactive suggests slower bowel motility and hyperactive sounds can suggest diarrhea.
• Recovery: Instructions on incision care and activity restrictions are given. Allow time for healing (heavy lifting avoided; normal activity resumed 2-4 weeks post-surgery).
• Follow-up: Sutures are removed after 5-7 days. Splinting during coughing can help. Observe for complications such as peritonitis (if present, a drain may be placed for management).

Peritonitis

• Definition: Inflammation of the peritoneum.
• Location: Lining the abdominal cavity, covering the viscera.
• Causes: Bacterial, fungal, or mycobacterial infections resulting from a perforation of an organ in the region. Common causes include appendix rupture, perforated ulcer, diverticulitis, bowel perforation, and abdominal surgeries. Internal reproductive organs can also be a source of infection.
• Causative Organisms: Escherichia coli, Klebsiella, Proteus, Pseudomonas, Streptococcus, and Staphylococcus.
• Pathophysiology: Leakage of abdominal contents into the peritoneal cavity with fluid accumulation leading to decreased circulatory volume, renal perfusion, and potential for acute kidney injury. Respiration may also experience issues due to increased pressure on the diaphragm. Organisms may enter the bloodstream causing bacteremia/septicemia. Bowel movement may be halted due to peritoneal inflammation.
• Clinical Manifestations: Symptoms of the condition causing peritonitis. Features may include localized pain, rigid and distended abdomen (particularly the abdominal muscles). Reduced pain perception may occur, particularly in patients with diabetes, neuropathy, and cirrhosis (with ascites). Patients may report anorexia, nausea, vomiting. Peristaltic movements may slow down. Patients would typically have raised body temperature (37.8 - 38.3°C), increased respiratory rate, and potentially low blood pressure.