Acute Appendicitis PDF

Acute Appendicitis: De nition: Appendicitis is acute in ammation of the vermiform appendix Uncomplicated appendicitis: appendicitis with no evidence of an appendiceal fecalith, an appendiceal tumor, or complications, such as perforation, g...

Acute Appendicitis: De nition: Appendicitis is acute in ammation of the vermiform appendix Uncomplicated appendicitis: appendicitis with no evidence of an appendiceal fecalith, an appendiceal tumor, or complications, such as perforation, gangrene, abscess, or mass. Complicated appendicitis: appendicitis associated with perforation, gangrene, abscess, an in ammatory mass, an appendiceal fecalith. Cause: Caused by obstruction of the appendiceal lumen due to: Lymphoid tissue hyperplasia: most common cause in children and young adults Appendiceal fecalith and fecal stasis: most common cause in adults Neoplasm (uncommon): more likely in patients > 50 years of age Pathophysiology: Obstructed proximal appendiceal lumen (closed-loop obstruction), resulting in: Stasis of mucosal secretions → bacterial multiplication and local in ammation → transmural spread of infection → clinical features of appendicitis Increased intraluminal pressure → obstruction of veins → edema of the appendiceal walls → obstruction of capillaries → ischemia → gangrenous appendicitis with/without perforation ⚠ In ammation can spread to serosa, leading to peritonitis. Signs: The most important and most speci c symptom is migrating abdominal pain. Pain starts in the periubilical region then localizes to the RLQ within 12-24 hours. Associated nonspeci c symptoms: Nausea Anorexia (In up to 80% of cases) - Hamburger sign: If there is no loss of appetite, appendicitis is unlikely. Vomiting Low-grade fever Diarrhea Exam Findings: McBurney point tenderness (RLQ tenderness) RLQ guarding and/or rigidity Rebound tenderness (Blumberg sign), especially in the RLQ Rovsing sign: RLQ pain elicited on deep palpation of the LLQ Psoas sign: Retrocaecal appendicitis Obturator sign: Pelvic appendicitis fl fi fl fi fl fi fl  Risk Strati cation Tool: Alvarado Score (MANTRELS) is used to assess the likelihood of acute appendicitis. Low-likelihood: Alvarado = 7 Urgent surgical consult (take the patient to the OR) Leukocytosis (>10,000) 2 Start empirical antibiotics Shift to the left (>75% neutrophils) 1 Diagnosis: Acute appendicitis is usually a clinical diagnosis based on history, physical examination, and laboratory studies. Imaging is recommended if the clinical diagnosis is uncertain. Laboratory Studies: CBC: mild leukocytosis with left shift CRP: elevated (> 10 mg/L) Urine/serum β-hCG ⚠ Urine/serum β-hCG test should be performed in all women of reproductive age to rule out pregnancy (including ectopic pregnancy) Imaging: Options for rst-line imaging in nonpregnant adults: CT abdomen with IV contrast [Gold Standard] Ultrasound abdomen (typically performed in conjunction with an appendicitis scoring system) First-line imaging for pregnant adults and children: Ultrasound abdomen Ultrasound Findings: Distended appendix (>6 mm) Non-compressible appendix Target sign Possible fecalith ⚠ While abdominal ultrasound can con rm the diagnosis of acute appendicitis, normal ultrasound ndings do not reliably rule out appendicitis. CT Findings: Distended appendix (> 6 mm) Edematous appendix with periappendiceal fat stranding Possible appendiceal fecalith Evidence of complications fi fi fi fi fi  Treatment: Supportive Care: Bowel rest (NPO) Intravenous uids IV analgesics Empiric Antibiotics: Indication: all patients with acute appendicitis Required coverage: against gram-negative and anaerobic organisms (Metronidazole) Operative Management: Laparoscopic Appendectomy within 24 hours of diagnosis is the current standard of care for acute uncomplicated appendicitis. Relative contraindications: Appendiceal mass Appendicular abscess ⚠ Initial operative treatment of appendiceal abscesses or appendiceal phlegmons is associated with a high risk of complications. fl