Acute Appendicitis
It is amongst the most common surgical emergency encountered worldwide,
it is a condition where the mucosa of the vermiform appendix gets inflamed due to secondary infection with or without obstruction.
Before diving into the topic let’s learn more about this unique organ.
Vermiform Appendix
The term “vermiform” comes from Latin which means “worm-shaped.
It is a finger-like, blind-ended (opens at one end only) tube connected to the cecum, which is a pouch-like structure present at the junction of the large and small intestine. It is 2-20cm long with a capacity of 0.1ml.
For decades, Appendix was considered a vestigial organ but recently researchers find it to be associated with a crucial purpose, it may serve as a reservoir for beneficial gut bacteria and might provide immunity.
Etiology (Cause)
It is a disease of affluent society just like diabetes & obesity, though it’s more common in Europe, American and Australia mostly because of their low residue dietary habits.
Obstruction of the lumen of the appendix with faecolith, foreign body, roundworm or threadworm eggs, a stricture,
Tumour (e.g Carcinoid Tumor),
and indiscriminate use of purgatives can all contribute to the aetiology of this condition.
It is common in May and August-seasonal variation called epidemic appendicitis.
Viral infection may cause mucosal oedema and inflammation which later gets infected by bacteria causing appendicitis.
Family history may be relevant in 30% of diseases in children with appendicitis occurring in first degree relatives.
Signs & Symptoms of Acute Appendicitis
Clinically two varieties are seen
A. Non-obstructive type and
B. Obstructive type.
Non-obstructive variety progresses slowly, whereas obstructive type progresses very fast, gangrene and perforation are commonly seen in this type.
The pain is dull aching in character in the non-obstructive type of appendicitis,
whereas this is colicky in obstructive appendicitis.
Pain is followed by nausea and vomiting along with anorexia depending on the degree of distension of the appendix.
The most common position is retrocausal (75%), while the least common is post ileal. The most dangerous type is Pelvic since abdominal signs are not marked in pelvic appendicitis.
Migratory Pain
The patient gets pain around the umbilicus or in the epigastrium in the beginning and later this pain shifts to the right iliac fossa(right lower flank region).
This is the most characteristic of Acute Appendicitis.
The initial pain is visceral and felt on the midline irrespective of the position of the appendix, since developmentally the midgut, from which the appendix develops, is a median organ.
The second pain is due to irritation of the parietal peritoneum lying close to the appendix, therefore it depends on the position of the appendix.
Urinary frequency: Inflamed appendix may come in contact with bladder and can cause bladder irritation.
Diarrhoea as a result of rectum irritation is seen with pelvic appendicitis.
‘Murphy’s syndrome ‘
The triad of pain, vomiting and temperature sequentially is known as Murphy’s syndrome. It’s important to note the sequence of these symptoms since any change in the manifestation of these symptoms must let you think of any other infective cause to be ruled out first hence a careful history must be taken.
Clinical Signs in Acute Appendicitis
- Aaron’s Sign: Patient feels pain when the epigastrium(part above umbilicus) is pressed.
- Dunphy’s sign: patient feels pain on coughing.
- Rovsings Sign:When left illiac fossa(left lower flank region) is pressed, pain is felt at right illiac fossa (right lower flank). This is the most characteristic sign of Acute Appendicitis. It is due to the bowel shift which irritates the parietal peritoneum.
- Baldwing’s test:when legs are lifted off the bed with knee extended, the patient complains of pain while pressing over the flanks. It is positive in Retrocaecal appendix.
- Obturator sign: Pain on internal rotation of right thigh over hip joint. It is positive in Pelvic Appendix.
- Ten Horn sign: done for male patients. Pain is perceived on gentle traction of right testes.
Diagnosis of Acute Appendicitis
The diagnosis of acute appendicitis is done using Alvarado or MANTRELS score.
Parameters taken into account are
Migratory Pain
Anorexia
Nausea, Vomiting
Tenderness
Rebound Tennessee
Elevated temperature (Fever)
Leucocytosis: Elevated White blood cell count.
Shift to Left: It indicates the rise of immature cell types in our blood particularly neutrophil-precursor band cells, thus signifying bandemia.
Every parameter is given a score of 1 except tenderness and shift to left which has a score of 2 respectively.
A score of 9 to 10 means the diagnosis is certain.
A score of 7 to 8 indicates a high likelihood of diagnosis.
A score of 5 to 6 is considered as equivocal and is most dangerous since we are unable to make the diagnosis and we have to do more investigation to find the cause, CECT ( contrast-enhanced computed tomography ) is done in such cases.
A score of 1-4 is indicated as negative for acute appendicitis, other causes for the symptoms should be looked upon.
Differential Diagnosis of Acute Appendicitis
- Crohn’s disease
- Ruptured or twisted ovarian cyst
- Acute pancreatitis
- Acute cholecystitis
- Meckel’s diverticulitis
- Right ureteric colic
- Perforated peptic ulcer
- Enterocolitis
- Salpingitis
- Right acute pyelonephritis
- Diabetic abdomen
- Mesenteric lymphadenitis
Sonography suggestive of Appendicitis
Usually done in children for diagnosis.
- Noncompressible appendix of size >6 mm AP diameter, hyperechoic thickened appendix wall >2 mm-target sign.
- Appendicolith.
- Interruption of submucosal continuity.
- Periappendicular fluid.
In children with appendicitis, there is poor localisation and so
peritonitis is common.
Hence conservative therapy should be avoided.
Surgery is the only choice of treatment otherwise early peritonitis
is the danger.
Often infection gets localised by omentum, dilated ileum, cecum and parietal peritoneum leading to appendicular mass.
Appendicular lump is diagnosed by CECT.
Appendicular mass is initially treated with Ochsner Sherren
regime (conservative management using Antibiotics while maintaining the fluid intake and monitoring patient)
After 6 weeks, interval appendicectomy is done.
Treatment of Acute Appendicitis
The gold standard treatment for acute appendicitis remains Appendicectomy ( surgical removal of appendix done either Laparoscopically Or Open).
Since the management is surgical, this article focuses more on diagnosing the disease better and making its reader more familiar with the condition because it is very common worldwide.
Perforated Appendix
Risk factors for Appendicular Perforation
Immunocompromised state,
Diabetes Mellitus,
Fecolith obstruction,
Pelvic appendix,
history of previous surgeries.
People in extremes of age (<5years, >65years) are more prone to disease.
Clinical Features
The manifestation temporarily improves with the disappearance of pain, but very soon the features of spreading peritonitis appear. Pain has complained of all over the abdomen, vomiting may become more marked, but more important is the pulse rate
which gradually rises and the temperature becomes subnormal.
Restricted movement of the abdominal wall, ‘board-like’ rigidity, the spread of tenderness from the right iliac to the left iliac fossa and ‘silent abdomen’ on auscultation is suggestive of spreading peritonitis. In estimating the degree of spread, the pulse rate is an important guide.
Treatment for perforated appendix
The patient is given broad-spectrum antibiotics intravenously. The abdominal cavity is washed using saline along with surgical removal of Appendix.
