ACUTE APPENDICITIS

STATUS POST OPERATIVE

APPENDECTOMY
SULBIANO, MARIDEL H.

Definition of the disease

Acute Appendicitis is inflammation of the appendix, the narrow, finger-shaped organ that
branches off the first part of the large intestine on the right side of the abdomen. Although the
appendix is a vestigial organ with no known function, it can become diseased. In fact, acute
appendicitis is the most common reason for abdominal surgery in the world.
If it is not treated promptly, there is the chance that the inflamed appendix will burst, spilling
fecal material into the abdominal cavity. The usual result is a potentially life-threatening infection
(peritonitis), but the infection may become sealed off and form an abscess.
Appendicitis is uncommon among older people, and symptoms are generally mild, so that
diagnosis of the acute episode is often not made. Members of this age group are thus at greater
risk for rupture with peritonitis or abscess formation.

Causes

Appendicitis is usually caused by a bacterial infection, although the reason the appendix
becomes infected is unknown.

The appendix may become obstructed by a lump of feces, calcium salts, and fecal
debris (called fecaliths) or tumors (rarely), leading to inflammation and infection.

Swelling and inflammation lead to infection, blood clot, or rupture of the appendix.

Lymphoid hyperplasia is associated with inflammatory and infectious disorders such as

Crohn disease, measles, amebiasis, gastroenteritis, respiratory infections, and
mononucleosis.

Symptoms
In very young children or people over age 65, symptoms of acute appendicitis may be
deceptively mild. Otherwise, symptoms can vary widely and may include the following:

Vague discomfort or tenderness near the navel (early in an attack), migrating to the right
lower quadrant of the abdomen

Sharp, localized, persistent pain within a few hours

Pain that worsens with movement, deep breathing, coughing, sneezing, walking or being
touched

Constipation and inability to pass gas, possibly alternating with diarrhea

Low fever (below 102F). A high fever (possibly accompanied by chills) may indicate an
abscessed appendix

Rapid heartbeat

Abdominal swelling (in late stages)

Abrupt cessation of abdominal pain after other symptoms occur, indicating the appendix
has burstan emergency

Nausea and vomiting (in some cases)

Loss of appetite

Coated tongue and bad breath

Painful and/or frequent urination

Blood in the urine

Abdominal swelling or bloating, especially in infants

Risk factors
A risk factor is anything that increases a persons chance of getting a disease such as Acute
Appendicitis. Risk factors for Acute Appendicitis are factors that do not seem to be a direct
cause of the disease, but seem to be associated in some way. Having a risk factor for Acute
Appendicitis makes the chances of getting the condition higher but does not always lead to
Appendicitis.
Age: Acute Appendicitis can occur in all age groups but it is more common in adolescents and
young adults.
Gender: A male preponderance exists, with a male to female ratio (1.4:1) and the overall lifetime
risk is 8.6% for males and 6.7% for females.
Hereditary: A particular position of the appendix, which predisposes it to infection, runs in certain
families. Having a family history of Acute Appendicitis may increase a child's risk for the illness.
Race: Acute Appendicitis is most common in whites and Hispanics and less common in African
Americans and Asians and incidence has increased over time and is higher in the summer
months, according to the study by the University of California San Diego.

Epidemiology
Acute appendicitis is one of the most common acute surgical abdominal emergencies. More
than 34,600 cases were treated in UK hospitals in 2006 to 2007. Most cases were in male
subjects (30,120) and occurred predominantly in the 15 to 59 year age group. A large majority
presented (29,576) as medical emergencies. More than 250,000 appendectomies are
performed each year in the US; however, the incidence is lower in populations where a highfiber diet is consumed. The overall lifetime risk of developing acute appendicitis is 8.6% for
males and 6.7% for females; lifetime risk of appendectomy is around 12% in males and 23% in
females. The rate of appendectomy is around 10 per 10,000 cases per year in the US. This
condition is most commonly seen in patients aged between early teens and late 40s. There is a
slight male to female predominance (1.3:1).

Prevention
There are no specific preventive measures. Contrary to popular belief, swallowing seeds from
fruit does not precipitate appendicitis.

Diagnosis
o

Physical examination is necessary to rule out other disorders that produce symptoms
similar to those of appendicitis.

A rectal examination may be performed.

Blood and urine samples will be taken for analysis.

CT (computed tomography) scan or an abdominal x-ray may be necessary.

Treatment
Call your doctor immediately. If you are unsure of your symptoms, take your temperature
every two hours and keep a record for your doctor.

The appendix must be removed (appendectomy) either through a small incision or with
a special instrument (laparoscope). Surgery should not be delayed more than a few
hours.

If an abscess has formed, your doctor may drain it and prescribe antibiotics.
Appendectomy may be scheduled for a later date.

Appendectomy
Appendectomy is the type of surgery done with the client. This is the surgical removal of the
appendix when an infection has made it inflamed and swollen. This infection, called
appendicitis, is considered an emergency because it can be life-threatening if it's not treated
the appendix occasionally bursts less than a day after symptoms start. So it's very important to
have it removed as soon as possible.
Fortunately, appendectomy is a common procedure and complications are rare. And if
appendicitis is promptly diagnosed and an appendectomy is performed, most clients recover
quickly and with little difficulty.

Preoperative Procedures
A number of tests are ordered to assess the client's health before surgery. Usually these tests
are done a few days ahead, but because of the urgency of an appendectomy, the tests and
surgery are frequently performed on the same day. Preoperative tests vary according to the
client's age and health, but a blood test, chest x-ray, and electrocardiogram (EKG) are standard.
An informed consent form must be signed acknowledging that the client understands the
procedure, the potential risks, and that they will receive certain medications.
Before surgery, the anesthesiologist visits the client to do a brief physical examination and to
obtain a medical history. He or she will want to know about any other medical conditions; if the
client is taking any medication (prescription or over-the-counter); if any dietary supplements or
herbal products are being used; if there has been recent illicit drug use; if the client smokes
cigarettes or drinks alcohol; if the client has a history of allergies, especially to medications; or
has had a previous reaction to anesthesia, or a family history of problems with anesthesia.
Clients are required to refrain from eating or drinking after midnight on the day before surgery;
however, because an appendectomy is an emergency procedure, that may not be possible. As
soon as the decision is made to operate, the client must take nothing by mouth, including oral
medications.

Prior to surgery, an intravenous (IV) is started to administer fluid and medications that have
been ordered, including antibiotics and pain medication. A sedative may be given to help the
client relax. Anesthesia is administered in the operating room.

During the Surgery

When the client is taken into surgery, a few devices will be used to prevent any complications,
including:
A nasogastric tube, a slender soft tube that's inserted through the nose or mouth and
down into the stomach to suck out stomach fluids to make sure they don't interfere with
the surgical procedure.
An endotracheal tube, a plastic tube inserted into the throat and the windpipe to help a
client breathe during surgery. This tube is connected to a ventilator that pushes air in and
out of the lungs.

A catheter, a long, thin tube that drains urine from the bladder and empties it. The
catheter is carefully inserted into the client's urethra (which passes urine from the
bladder to the outside of the body), and then into the bladder. A catheter isn't used in all
cases.
Once these monitors are in place, the surgery can begin. The two common types of
appendectomy are:

1) Open Appendectomy
An open appendectomy is the traditional method and the standard treatment for appendicitis.
The surgeon makes an incision in the lower right abdomen, pulls the appendix through the
incision, ties it off at its base, and removes it. Care is taken to avoid spilling purulent material
(pus) from the appendix while it is being removed. The incision is then sutured.
If the appendix has perforated (ruptured), the surgeon cleans the pus out of the abdomen with a
warm saline solution to reduce the risk for infection. A drain may be inserted through the incision
to allow the pus to drain from the abdomen. In this case, the skin is not sutured, but left open
and packed with sterile gauze. The gauze and drain remain in place until the pus is completely
drained and there is no sign of infection.
If the abdomen is so inflamed that the surgeon cannot see the appendix, the infection is drained
and treated with antibiotics, and then the appendix is removed.

2) Laparoscopic Appendectomy

Laparoscopic appendectomy is the standard of care for appendicitis. The procedure has several
advantages, including lower risk for postoperative infection, faster recovery time, a smaller scar,
and a shorter hospital stay.

The surgeon makes a very small incision right below the navel and inserts an instrument called
a laparoscope. The laparoscope is a long tube with a lens at one end and a miniature video
camera at the other. The laparoscope enables the doctor to see the appendix. Several more tiny
incisions are made to allow for the passage of instruments, which are used to cut and clamp off
the appendix.
The laparoscope is also used as a diagnostic tool. The doctor is able to see if the appendix is
inflamed and, if the appendix is not the cause of the patient's symptoms, other organs can be
seen in order to identify the source of the symptoms.

During Open Procedure

For an open appendectomy, the surgeon first cleanses the skin of the abdomen with an
antiseptic solution. Then he or she makes an incision, about 2 inches long, through the skin of
the abdomen, past the abdominal muscles, and into the abdominal wall (layers of tissue that
protect the abdomen). The abdominal muscles are then separated and the appendix is located.
By using sutures (stitches) or a special stapling tool, the surgeon closes the open area of the
appendix connected to the large intestine to prevent it from tearing and spreading bacteria
through the abdomen while it's being removed. (The stapling tool uses stainless steel staples
that are slightly smaller than those used in a standard office stapler.)The surgeon then cuts the
appendix away from the large intestine and pulls it out of the body through the incision. Once
the appendix is removed, the surgeon closes the abdominal wall and abdominal muscles with
dissolvable stitches. Then, the opening on the skin is closed with stitches and is covered with a
bandage.

During Laparoscopic Procedure

As with an open appendectomy, the surgeon first cleanses the skin with an antiseptic solution.
However, instead of making one large incision, the surgeon makes a small incision (about to
1 inch long) in the crease of the bellybutton. This incision allows the laparoscope to be guided to
the appendix.
Two more small incisions are made to allow the surgeon to guide other special instruments to
the appendix area. These instruments are used to close off the appendix and remove it.
The small incisions are closed with dissolvable stitches and covered with small bandages.

Laparoscopic to Open Procedure

In some rare cases, a surgeon might start with the laparoscopic procedure but change to an
open procedure during surgery. This can happen for a variety of reasons: The surgeon might
have trouble finding the appendix with the laparoscope or the patient might have had previous
surgeries that have left scar tissue in the abdominal area, making it difficult to remove the
appendix through laparoscopy.
If the surgeon decides to switch from the laparoscopic procedure to the open procedure, he or
she will either close up the small incisions and immediately begin the open appendectomy or
end the surgery and reschedule the appendectomy for another time.

Postoperative Complications after Appendectomy

Paralytic ileus may occur following the operation. The bowel is normally in constant motion,
digesting food and absorbing nutrients. Disturbing the bowel, even by the surgeon's just
touching it, can cause the motion to come to a standstill. Fluid and gas may then cause the

bowel to swell or distend. A nasogastric tube is passed through the nose and into the stomach
to relieve the distension.
When bowel function returns to normal (evident by passing gas or having a bowel movement),
the tube is removed. Until that time, food and liquid are not permitted by mouth, and hydration is
maintained intravenously. Paralytic ileus is more common when the appendix has perforated.
Wound infection can cause the skin to become red and inflamed and pus to leak from the
incision site. In this case, antibiotics are started and discharge from the hospital may be
delayed, depending on the severity of the infection. On rare occasions, the site must be
reopened to allow the wound to drain.

Postoperative Care after Appendectomy

Following surgery, the client is taken to the postanesthesia care unit (PACU) until the anesthesia
wears off. During this time, the nursing staff checks temperature, heart rate, and breathing at
frequent intervals. When the anesthesia wears off and vital signs stabilize, the patient is
transferred to their hospital room.

Unruptured Appendix
With an unruptured appendix, the client's recovery time is relatively quick. The morning after
surgery, clear liquids are offered. Once those are tolerated, the diet progresses to solid food.
Once the client is eating and drinking, the intravenous is removed. Physical activity, such as
getting out of bed, begins on the same day as surgery or the next morning. Most clients need
medication to relieve the pain in and around the incision. The smaller incisions of a laparoscopic
procedure often cause less pain than the large incision made in open appendectomy.
The nursing staff continues to monitor the client for signs of infection and checks that the
incision is healing. Clients with uncomplicated surgeries usually leave the hospital 1 or 2 days
following surgery.
Once at home, the client must check the incision site. It should be dry and the wound should be
completely closed. If the incision drains blood or pus, or if the edges are pulling apart, the
physician should be notified immediately. Fever and increasing pain at the incision site also
should be reported to the physician.
Normal activities can be resumed within a few days, but it takes 4 to 6 weeks for full recovery.
Heavy lifting and strenuous activity should be avoided during recovery. If antibiotics and/or pain
medication are prescribed, they should be taken as directed.
The open procedure leaves a scar on the lower right side of the abdomen that is a few inches
long and fades over time. Scarring from laparoscopic appendectomy is minimal.

Ruptured Appendix
Recovery from surgery for a perforated appendix is longer, primarily because the infection must
be treated. The hospital stay is at least 4 days and can be longer, if complications develop. The

drain remains in place until the pus stops draining, and the nursing staff changes the gauze
packing as needed. Intravenous antibiotics continue throughout the hospitalization.
When discharged, oral antibiotics are prescribed and should be taken as directed. The drain
and gauze pack remain in place, and instructions are given on proper care of the area. It is
important to inform the physician if the amount of drainage suddenly increases, or if the color
and consistency changes. The drain is removed on an outpatient basis after the infection has
resolved.

Recovery
Typically, a client stays in the hospital for 2 to 3 days after an appendectomy, a little longer if the
appendix burst before it was removed. Many hospitals allow at least one parent to stay with the
child throughout the day and overnight.
Once the doctors decide your child is ready to leave the hospital, you'll get instructions on home
care and when to come back for a follow-up visit with the doctor. This usually happens within a
few weeks.
In cases where the appendix has burst, doctors typically keep a child on antibiotics for a week
or more. Sometimes antibiotics are given through a portable IV that remains in place when the
child leaves the hospital. A nurse comes to the home in the following days to monitor the IV and
remove it.
Other things to think about recovery at home:

Eating and drinking: There probably won't be any food or drink restrictions after the
surgery, but it's likely that your child won't have much of an appetite at first.

Caring for the incision: Be sure to keep the area clean and watch for signs of infection.
Call your doctor if you notice any redness or swelling around the incision, or your child
develops pain or a fever greater than 101 Fahrenheit (38.3 Celsius).

Returning to school: The doctor will let you know when your child can return to school
and get back to normal activities. In most cases, kids can be back within a week of
surgery, longer if the appendix burst.

Resuming physical activity: The doctor may recommend that your child stay out of
gym class, sports, and other physical activities for a few weeks.

With a little rest and care, they will recover from acute appendicitis and an appendectomy with
little difficulty.

Reference:
http://www.healthcommunities.com/appendicitis/what-is-acute-appendicitis.shtml
Source:

Johns Hopkins Symptoms and Remedies: The Complete Home Medical Reference
Simeon Margolis, M.D., Ph.D., Medical Editor
Prepared by the Editors of The Johns Hopkins Medical Letter: Health After 50
Updated by Remedy Health Media
http://bestpractice.bmj.com/best-practice/monograph/290/basics/epidemiology.html
http://www.healthcommunities.com/appendicitis/appendectomy.shtml
http://www.healthcommunities.com/appendicitis/preoperative-procedures-appendectomy.shtml
http://www.healthcommunities.com/appendicitis/open-appendectomy.shtml
http://www.healthcommunities.com/appendicitis/laparoscopic-appendectomy.shtml
http://www.healthcommunities.com/appendicitis/postoperative-complicationsappendectomy.shtml
http://www.healthcommunities.com/appendicitis/postoperative-care-appendectomy.shtml