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Appendicitis

Dr. H. Nikijuluw, SPB-KBD


Appendicitis: Epidemiology
Most common condition requiring emergency
surgery in children
~1 in 15 individuals (7%) develop
appendicitis
Peak incidence occurs between 10 to 30 y/o
Male:Female = 2:1
1/3 of cases have associated rupture
<1% mortality overall, increases to ~5% in
young & elderly
Appendicitis: Epidemiology
Up to 30% of appendices are hidden
Not peritoneal
Pelvic, retroileal or retrocolic
Appendicitis:
Pathophysiology
Luminal obstruction
Appendicoliths, parasites (ascaris,
enterobius), FB, carcinoid, CF (inspissated
mucus), lymphoid hyperplasia
Distal mucous production & bacterial
overgrowth
Distention Diminished perfusion
Ischemia Perforation
Appendicitis: Classic
Presentation
Vague periumbilical pain
Anorexia, nausea, vomiting
Migration of pain to RLQ
Fever
Appendicitis: Common
Symptoms
Abdominal pain ~100%
Anorexia ~100%
Nausea ~90%
Vomiting ~75%
Pain Migration ~50%
Classic symptom sequence ~50%
Symptoms lasting over 24-36 hr is
uncommon in nonperforated appendicitis
Appendicitis:PE
RLQ pain tenderness
Fever typically low grade 38.0C
Peritoneal signs
Rebound tenderness best identified
with percussion
Guarding
Appendicitis: PE
Other confirmatory peritoneal signs
Psoas sign
Pain on extension of R thigh
Retroperitoneal retrocecal appendix

Obturator sign
Pain on internal rotation of R thigh
Pelvic appendix

Rovsings sign
Pain in RLQ with palpation of LLQ
Appendicitis: Lab Evaluation
WBC > 10,000
Occurs in 80% of cases of appendicitis
Occurs in 70% of other causes of RLQ
pain
UA
May show mild pyuria, proteinuria &
hematuria
Usually used to r/o urinary tract causes
Appendicitis: Radiologic
evaluatuion
KUB
Non-specific
Ultrasound
Sensitivity 85%
Specificity 92%
CT scan
Sensitivity 90 100%
Specificity 95 97%
Appendicitis: Ultrasound
Advantages Disadvantages
Safe Operator
Relatively Dependant
inexpensive Technically
Can r/o pelvic inadequate studies
disease in females due to bowel gas
Pain
Appendicitis: CT
Advantages Disadvantages
More accurate Cost
Better identifies Ionizing radiation
phlegmon & abcess Contrast
Better identifies
normal appendix
Appendicitis: Treatment
Nonperforated
Appendectomy
National rate of negative appendectomies ~20%
Perforated
Surgery immediate vs. delayed
Nonoperative mangement
Antibiotics
Observation
CT guided drainage
Questions????