Acute Appendicitis

Dr Ibrahim Bashayreh
Epidemiology
The incidence of appendectomy appears
to be declining due to more accurate
preoperative diagnosis.
Despite newer imaging techniques, acute
appendicitis can be very difficult to
diagnose.
Pathophysiology
Acute appendicitis is thought to begin with
obstruction of the lumen
Obstruction can result from food matter,
adhesions, or lymphoid hyperplasia
Mucosal secretions continue to increase
intraluminal pressure

Pathophysiology
Eventually the pressure exceeds capillary
perfusion pressure and venous and
lymphatic drainage are obstructed.
With vascular compromise, epithelial
mucosa breaks down and bacterial
invasion by bowel flora occurs.
Pathophysiology
Increased pressure also leads to arterial
stasis and tissue infarction
End result is perforation and spillage of
infected appendiceal contents into the
peritoneum
Pathophysiology
Initial luminal distention triggers visceral
afferent pain fibers, which enter at the 10
th

thoracic vertebral level.
This pain is generally vague and poorly
localized.
Pain is typically felt in the periumbilical or
epigastric area.
Pathophysiology
As inflammation continues, the serosa and
adjacent structures become inflamed
This triggers somatic pain fibers,
innervating the peritoneal structures.
Typically causing pain in the RLQ

Pathophysiology
The change in stimulation form visceral to
somatic pain fibers explains the classic
migration of pain in the periumbilical area
to the RLQ seen with acute appendicitis.
Pathophysiology
Exceptions exist in the classic
presentation due to anatomic variability of
the appendix
Appendix can be retrocecal causing the
pain to localize to the right flank
In pregnancy, the appendix ca be shifted
and patients can present with RUQ pain
Pathophysiology
In some males, retroileal appendicitis can
irritate the ureter and cause testicular pain.
Pelvic appendix may irritate the bladder or
rectum causing suprapubic pain, pain with
urination, or feeling the need to defecate
Multiple anatomic variations explain the
difficulty in diagnosing appendicitis
History
Primary symptom: abdominal pain
to 2/3 of patients have the classical
presentation
Pain beginning in epigastrium or
periumbilical area that is vague and hard
to localize
History
Associated symptoms: indigestion,
discomfort, flatus, need to defecate,
anorexia, nausea, vomiting
As the illness progresses RLQ localization
typically occurs
RLQ pain was 81 % sensitive and 53%
specific for diagnosis
History
Migration of pain from initial periumbilical
to RLQ was 64% sensitive and 82%
specific
Anorexia is the most common of
associated symptoms
Vomiting is more variable, occuring in
about of patients
Physical Exam
Findings depend on duration of illness
prior to exam.
Early on patients may not have localized
tenderness
With progression there is tenderness to
deep palpation over McBurneys point
Physical Exam
McBurneys Point: just below the middle of
a line connecting the umbilicus and the
ASIS
Rovsings: pain in RLQ with palpation to
LLQ
Rectal exam: pain can be most
pronounced if the patient has pelvic
appendix
Physical Exam
Additional components that may be helpful
in diagnosis: rebound tenderness,
voluntary guarding, muscular rigidity,
tenderness on rectal
Physical Exam
Psoas sign: place patient in L lateral
decubitus and extend R leg at the hip. If
there is pain with this movement, then the
sign is positive.
Obturator sign: passively flex the R hip
and knee and internally rotate the hip. If
there is increased pain then the sign is
positive
Physical Exam
Fever: another late finding.
At the onset of pain fever is usually not
found.
Temperatures >39 C are uncommon in
first 24 h, but not uncommon after rupture
Diagnosis
Acute appendicitis should be suspected in
anyone with epigastric, periumbilical, right
flank, or right sided abd pain who has not
had an appendectomy
Diagnosis
Women of child bearing age need a pelvic
exam and a pregnancy test.
Additional studies: CBC, UA, imaging
studies
Diagnosis
CBC: the WBC is of limited value.
Sensitivity of an elevated WBC is 70-90%,
but specificity is very low.
But, +predictive value of high WBC is 92%
and predictive value is 50%
C-Reactive Protien CRP (independent surgical
indication marker for appendicitis) and ESR have been
studied with mixed results
Diagnosis
UA: abnormal UA results are found in 19-
40%
Abnormalities include: pyuria, hematuria,
bacteruria
Presence of >20 wbc per field should
increase consideration of Urinary tract
pathology
Diagnosis
Imaging studies: include X-rays, US, CT
Xrays of abd are abnormal in 24-95%
Abnormal findings include: fecalith,
appendiceal gas, localized paralytic ileu,
and free air
Abdominal xrays have limited use b/c the
findings are seen in multiple other
processes

Diagnosis
Graded Compression US: reported
sensitivity 94.7% and specificity 88.9%
Basis of this technique is that normal
bowel and appendix can be compressed
whereas an inflamed appendix can not be
compressed
Diagnosis
Limitations of US: retrocecal appendix
may not be visualized, perforations may
be missed due to return to normal
diameter
Diagnosis
CT: best choice based on availability and
alternative diagnoses.
In one study, CT had greater sensitivity,
accuracy, -predictive value
Even if appendix is not visualized,
diagnose can be made with localized fat
stranding in RLQ.
Diagnosis
CT appears to change management
decisions and decreases unnecessary
appendectomies in women, but it is not as
useful for changing management in men.
Special Populations
Very young, very old, pregnant, and HIV
patients present atypically and often have
delayed diagnosis
High index of suspicion is needed in the
these groups to get an accurate diagnosis

Treatment
Appendectomy is the standard of care
Patients should be NPO, given IVF, and
preoperative antibiotics
Antibiotics are most effective when given
preoperatively and they decrease post-op
infections and abscess formation