The appendix first becomes visible in the 8 week of embryologic development as a protuberance off the terminal portion of the cecum. During both antenatal and postnatal development, the growth rate of the cecum exceeds that of the appendix, displacing the appendix medially toward the ileocecal valve. The relationship of the base of the appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal, or right pericolic position. 3 taenia coli converge at the junction of the cecum with the appendix and can be a useful landmark to identify the appendix Appendix is an immunologic organ that actively participates in the secretion of immunoglobulin A (IgA). Appendix is an integral component of the gut-associated lymphoid tissue (GALT) system. After the age of 60 years, virtually no lymphoid tissue remains within the appendix, and complete obliteration of the appendiceal lumen is common. Inflammationof the vermiform appendix with acute onset Appendicitis is most frequently seen in patients in their second through fourth decades of life, with a mean age of 31.3 years and a median age of 22 years. There is a slight male to female predominance (M:F 1.2 to 1.3:1). Obstruction of the lumen is the dominant causal factor in acute appendicitis. Fecaliths are the usual cause of appendiceal obstruction. Less-common causes are hypertrophy of lymphoid tissue, inspissated barium from previous x-ray studies, tumors, vegetable and fruit seeds, and intestinal parasites. Fecaliths are found in 40% of cases of simple acute appendicitis, 65% of cases of gangrenous appendicitis without rupture, and nearly 90% of cases of gangrenous appendicitis with rupture. Symptom - Migrating abdominal pain. (May vary, depend on variant location of appendix) - Anorexia, although vomiting occurs in nearly 75% of patients, it is neither prominent nor prolonged and most patients vomit only once or twice. Vomiting is caused both by neural stimulation and the presence of ileus. - Obstipation, but it some patient, particularly children may cause diarrhea. Sign - Vital signs are minimally changed. Temperature elevation is rarely more than 1°C (1.8°F) and the pulse rate is normal or slightly elevated. - Patients with appendicitis usually prefer to lie supine, with the right thigh drawn up. If asked to move, they do so slowly and with caution. - McBurney tenderness, Rovsing sign (+), Right sided Hyperesthesia T 10, 11, 12 - Psoas and obturator sign (+) indicate muscle and pelvic irritation. Rovsing’s sign Obturator sign Psoas sign When the inflamed appendix hangs into the pelvis, abdominal findings may be entirely absent, and the diagnosis may be missed unless the rectum is examined. As the examining finger exerts pressure on the peritoneum of the cul-de-sac of Douglas, pain is felt in the suprapubic area, as well as locally within the rectum. Mild leukocytosis, ranging from 10,000 to 18,000/mm3, is usually present in patients with acute, uncomplicated appendicitis and is often accompanied by a moderate polymorphonuclear predominance. Acute Mesenteric Adenitis Acute gastroenteritis Most often confused with Common in childhood but can acute appendicitis in usually be easily children. differentiated from The pain is usually appendicitis. diffuse, and tenderness is Viral gastroenteritis, an acute not as sharply localized as self-limited infection of in appendicitis. diverse causes, is Voluntary guarding is characterized by profuse sometimes present, but watery diarrhea, nausea, and true rigidity is rare. vomiting. Generalized Hyperperistaltic abdominal lymphadenopathy may be cramps precede the watery noted. Laboratory stools. The abdomen is procedures : relative relaxed between cramps, and lymphocytosis, when there are no localizing signs. present, suggests Laboratory values are normal. mesenteric adenitis. Meckel's diverticulitis causes a clinical picture similar to that of acute appendicitis. The Meckel's diverticulum is located within the distal 2 feet of the ileum. Intussusception Differentiate intussusception from acute appendicitis as the treatment is different. Appendicitis is very uncommon in children younger than age 2 years, whereas nearly all idiopathic intussusceptions occur in children younger than age 2 years. Intussusception occurs typically in a well- nourished infant who is suddenly doubled up by apparent colicky pain. Between attacks of pain, the infant appears well. After several hours, the patient usually passes a bloody mucoid stool. A sausage-shaped mass may be palpable in the right lower quadrant. As the intussusception progresses distally, the right lower quadrant feels abnormally empty. Crohn’s enteritis The manifestations of acute regional enteritis—fever, right lower quadrant pain and tenderness, and leukocytosis—often simulate acute appendicitis. Diarrhea and the infrequency of anorexia, nausea, and vomiting favor a diagnosis of enteritis but are not sufficient to exclude acute appendicitis.
Pelvic Inflammatory Disease
The infection is usually bilateral, but if confined to the right tube, may mimic acute appendicitis. Nausea and vomiting often are present in patients with appendicitis, but only in approximately 50% of those with pelvic inflammatory disease. The greatest value of these symptoms for establishing a diagnosis of pelvic inflammatory disease is their absence. Pain and tenderness are usually lower, and motion of the cervix is exquisitely painful. Intracellular diplococci may be demonstrable on smear of the purulent vaginal discharge Ruptured Ectopic Ureteral Stone Pregnancy Pain referred to the Rupture of right tubal labia, scrotum, or or ovarian penis; hematuria; pregnancies can and/or absence of mimic appendicitis. fever or leukocytosis Patients usually give a suggest the presence history of abnormal of a ureteral stone. menses; either Pyelography and CT missing one or two scanning without oral periods or noting only contrast usually slight vaginal confirm the diagnosis. bleeding. The development of right lower quadrant or pelvic pain may be the first symptom. Diagnosis of acute appendicitis in young children is more difficult than in the adult. The more rapid progression to rupture and the inability of the underdeveloped greater omentum to contain a rupture lead to significant morbidity rates in children.
Antibiotic coverage is limited to 24 to 48 hours in cases of
nonperforated appendicitis. For perforated appendicitis, 7 to 10 days of antibiotics is recommended. Intravenous antibiotics are usually given until the white blood cell count is normal and the patient is afebrile for 24 hours.
Laparoscopic appendectomy has been shown to be safe and
effective for the treatment of appendicitis in children. Although the incidence of appendicitis in the elderly is lower than in younger patients, the morbidity and mortality are significantly increased in this patient population. Delays in diagnosis, a more rapid progression to perforation, and comorbid disease are all contributing factors. In patients older than age 80 years, perforation rates of 49% and mortality rates of 21% The incidence is approximately 1 in 2000 pregnancies. Acute appendicitis can occur at any time during pregnancy, but is more frequent during the first two trimesters. As fetal gestation progresses, the diagnosis of appendicitis becomes more difficult as the appendix is displaced laterally and superiorly (Fig. 29-7). Nausea and vomiting after the first trimester or new-onset nausea and vomiting should raise the consideration of appendicitis. Abdominal pain and tenderness will be present, although rebound and guarding are less frequent because of laxity of the abdominal wall. Elevation of the white blood cell count above the normal pregnancy levels of 15,000 to 20,000/L, with a predominance of polymorphonuclear cells, is usually present. When the diagnosis is in doubt, abdominal ultrasound may be beneficial. Laparoscopy may be indicated in equivocal cases, especially early in pregnancy. The performance of any operation during pregnancy carries a risk of premature labor of 10 to 15%, and the risk is similar for both negative laparotomy and appendectomy for simple appendicitis. The incidence of acute appendicitis in HIV- infected patients is reported to be 0.5%. 67 This is higher than the 0.1 to 0.2% incidence reported for the general population. 68 The presentation of acute appendicitis in HIV- infected patients is similar to that of noninfected patients. The majority of HIV- infected patients with appendicitis will have fever, periumbilical pain radiating to the right lower quadrant (91%), right lower quadrant tenderness (91%), and rebound tenderness (74%). HIV-infected patients will not manifest an absolute leukocytosis. Open appendectomy Death is usually attributable to uncontrolled sepsis—peritonitis, intra-abdominal abscesses, or gram-negative septicemia. Pulmonary embolism continues to account for some deaths. Aspiration is a significant cause of death in the older patient group. Principalfactors in mortality are whether rupture occurs before surgical treatment and the age of the patient. The overall mortality rate for a general anesthetic is 0.06%. The overall mortality rate in ruptured acute appendicitis is about 3%—a 50-fold increase. The mortality rate of ruptured appendicitis in the elderly is approximately 15%—a fivefold increase from the overall rate. Characteristically, the pain lasts longer and is less intense than that of acute appendicitis, but is in the same location. There is a much lower incidence of vomiting, but anorexia and occasionally nausea, pain with motion, and malaise are characteristic. Leukocyte counts are predictably normal and CT scans are generally nondiagnostic.
At operation, surgeons can establish the diagnosis with 94% specificity
and 78% sensitivity. There is an excellent correlation between clinical symptomatology, intraoperative findings, and histologic abnormalities. Laparoscopy can be effectively used in the management of this clinical entity. Appendectomy is curative. Symptoms resolve postoperatively in 82 to 93% of patients. Many of those whose symptoms are not cured or recur are ultimately diagnosed with Crohn's disease. A number of intestinal parasites cause appendicitis. While Ascaris lumbricoides is the most common, a wide spectrum of helminths have been implicated, including Enterobius vermicularis, Strongyloides stercoralis, and Echinococcus granulosis. The live parasites occlude the appendiceal lumen, causing obstruction. The presence of parasites in the appendix at operation makes ligation and stapling of the appendix technically difficult. Once appendectomy has been performed and the patient recovered, therapy with helminthicide is necessary to clear the remainder of the gastrointestinal tract. Amebiasis can also cause appendicitis. Invasion of the mucosa by trophozoites of Entamoeba histolytica incites a marked inflammatory process. Appendiceal involvement is a component of more generalized intestinal amebiasis. Appendectomy must be followed by appropriate antibiotic therapy (metronidazole).