Appendicitis

*Preferred treatment is still appendectomy prior to perforation (rupture)* -Classical treatment; takes about an hour -McBurney or Rocky-Davis incision *Type of procedure?*

"Open" appendectomy

*Pathogenesis:* obstruction of lumen, distention, infection Fecal material (or inflammation of lymphatic tissue in appendix) -> *obstruction* of lumen -> *distention* of lumen ->ischemia of appendiceal wall -> bacterial invasion *(infection)*

*Appendicitis*

*Antibiotics for Appendicitis:* Whatever antibiotics are available to treat what? -Classical: --*What three meds?* --Erythromycin if penicillin allergic (alternate for ampicillin) -More modern *mono*therapy: --Cefoxitin, ampicillin/sulbactam, cefotetan, ceftizoxime, others -2nd or 3rd gen cephalosporin *with* metronidazole, others -Choice depends on your hospital's formulary.

*Gram neg rods, anaerobes, and Strep,* Ampicillin, clindamycin, gentamicin

*Complications of what?* Can lead to generalized peritonitis, sepsis, death -Does *not* involve bleeding. It is an *infection.* Clinical manifestations - not necessarily always present -Patient becomes more ill; higher fever. -Higher WBC (maybe not in very young or old) -Abdomen becomes distended. -Peritonitis causes ileus - few bowel sounds. -Palpable mass (abscess or phlegmon) in RLQ or in pelvis, discovered on rectal exam.

*Rupture (perforation)* of Appendix

*Diagnostic tests & imaging for Appendicitis:* -Might show uncompressible inflamed appendix -Fast and lower cost

*Ultrasound*

*Post-op diagnosis: Nomenclature of appendicitis* 1. Based on degree of infection -___________ - early; this is desireable time to diagnosis it -___________ - part of wall is necrotic; almost perforated -___________ - can present in 2 ways: --___________ - best to operate soon --___________ - ---Antibiotics + US or CT-guided percutaneous drainage, if possible ---Then appendectomy (classically 6 weeks later) - now controversial whether or not delayed appendectomy is needed.

-Suppurative -Gangrenous -Perforated --Generalized peritionitis --Localized abscess

*Other imaging procedures* -____________ - when available --If appendix compresses, maybe it is NOT appendicitis. --If appendix does NOT compress, maybe it IS. --Often non-diagnostic -> another imaging procedure? -_____ - used more and more to diagnose appendicitis. -_____ - expensive! May be useful in early pregnancy (Theoretically, why MRI rather than CT in pregnancy?) -Waiting for these additional tests can actually delay the treatment by many hours.* -Why do we not want to delay diagnosis and treatment of appendicitis?

-Ultrasound -CT -MRI

*Management (pending surgery)* -NPO -IV fluids at greater than maintenance rate --Has she been vomiting? Does she need fluid bolus? -Antibiotics - for what organisms? -Optional - NG suction if still vomiting after NPO -Pain medication - controversial --Not in prehospital setting? (unless prolonged transport) --Might obscure signs and symptoms? --Might delay needed surgery?

Appendicitis

*More signs and symptoms* -Fever (not very high initially) / leukocytosis -Abdominal distention (later) -Possible superficial hyperesthesia - --Sensitivity when stroking skin in RLQ -Right testicular symptoms (depending on location of appendix) -"Rebound tenderness,"positive heel tap," and other signs of peritonitis are *not specific* for appendicitis.

Appendicitis

*Pathology:* -*Obstruction* of lumen -*Distention* of appendix -Appendix wall starts to lose blood supply -Bacteria invade wall -> infection (suppurative appendicitis) -Appendix wall perforates -Feces and bacteria spill out (perforated appendicitis)

Appendicitis

*Symptoms/Signs:* -Periumbilical pain, nausea, later vomiting, not tender yet -Pain / tenderness RLQ -Low grade fever -Mildly increased WBC -More pain / tenderness -More fever, higher WBC

Appendicitis

History prior to onset of disease -sometimes upper respiratory infection *Incidence -* -Most common in 10 - 40 year olds -But can occur at any age Cause - obstruction in lumen of appendix causes swelling and eventually decreased blood supply to the wall of the appendix.

Appendicitis

Pain "goes away" after perforation?? -Distention of the lumen -> peri-umbilical pain -After perforation, there is no more distention of the lumen, so maybe no more *peri-umbilical* pain. -But with pus spilling out into the RLQ, causing peritonitis, there must STILL be RLQ pain! -There is no reason for the RLQ pain to "go away" after perforation.

Appendicitis

*Management:* -Goal is to operate prior to perforation (rupture). -Out of >31,000 patients, 26% were perforated* --Perforation is more common *in very young* and *old.* ----*More than half of those over 65 were perforated.** ----Due to delay in diagnosis? *"Risk of rupture was minimal within ___ hours of symptom onset.* *Beyond that point, there was about a 5% risk of rupture in each ensuing ___ hour period." ++* *-Perforation (rupture) does not involve bleeding!* *-No need to ask for Type and Crossmatch prior to appendectomy.*

Appendicitis, *36 hours,* *12 hour*

*Symptoms and signs of appendicitis* -PERIUMBILICAL PAIN first (distention), then RLQ pain (inflammation) -Almost always ANOREXIA, usually VOMITING -Later develops TENDERNESS --McBurney's point (if appendix is in iliac fossa) --Rectal (if appendix is in the pelvis) --Flank (if appendix is retrocecal) -These take MANY HOURS to DAYS to develop. -Appendicitis is generally NOT characterized by *sudden* onset of RLQ pain.

Appendicits

*Diagnostic tests & imaging for Appendicitis:* Often performed these days on nearly everyone with abdomen pain -Slower to obtain; costs more -Can cause delay in diagnosis and treatment

CT

*Appendicitis in special populations* Higher rate of perforation -Unusual diagnosis in the very young (infants and toddlers), but because of this, diagnosis is often delayed, allowing perforation.

Children

*Colon* conditions confused with appendicitis: -Age - usually older patients -Often guaiac positive stools -Right sided ___________ might mimic appendicitis *-Might have had change in bowel habits over weeks or months*

Colon Cancer

*Pathophysiology of appendicitis* ____________ of appendix -Due to trapped secretions -Causes peri-umbilical pain (distention of hollow organ) _______________ -> SUPPURATION -Due to invasion of bacteria into wall -Causes RLQ pain (localized peritonitis) __________________ -Due to increasing distention -Decreased blood supply to wall of appendix results in gangrenous wall that more easily breaks

DISTENTION INFLAMMATION PERFORATION (same as "rupture")

*Colon* conditions confused with appendicitis: -Age - usually older patients -Often ________ positive stools -Usually *left-sided* in western countries (maybe right-sided in Asians)

Diverticulitis, Guaiac

*Appendicitis in special populations* Again, higher rate of perforation, and therefore more septic complications (septic = infection)

Elderly

-Piece of stool in the appendix is a __________ or a _______________. -This might become calcified, and visible on abdominal film. -Don't count on this finding - it is usually not present.

Fecolith or Appendicolith

*What Location of Appendix?* *Symptoms/Signs:* -RLQ pain and tenderness -No psoas sign

IIiac fossa (anterior) near anterior abdominal wall

*Preferred treatment is still appendectomy prior to perforation (rupture)* -Gives better visualization of abdomen and pelvis. -If it is not appendicitis, one can look for other causes. -If structures are not well seen, or if there is complication, convert to "open" appendectomy. In selected cases with phlegmon (inflammation without gross pus), surgery may be delayed. -Initial treatment NPO, IV fluids, IV antibiotics *Type of procedure?*

Laparoscopic appendectomy

*Diagnostic tests & imaging for Appendicitis:* *Acute abdomen series* -Flat + upright abdomen and CXR -Few *specific* findings for appendicitis --Maybe ______________ of bowel with air, calcified appendicolith, lumbar spine bending toward the right (due to guarding)

Low tech, Sentinel Loop

*Small bowel conditions confused with appendicitis* If appendix appears normal, what does the surgeon look for? -Inflammation -Usually remove appendix (even if it appears normal). -Removing uncomplicated Meckel's - controversial.

Meckel's diverticulum

Diagnostic lab tests for Appendicitis usually includes what?

Mostly CBC, UA, pregnancy test

*GYN* conditions confused with appendicitis: -___________ - *not* an infection! --Usually no vomiting or fever --But very commonly mistaken for appendicitis -Ectopic pregnancy - LMP, HCG -____________________ --It's an *infection* - so expect fever and high WBC --*Bilateral* adnexal tenderness (rather than just RLQ) --Cervical motion tenderness --Discharge from cervical os

Ovarian Cyst PID (Pelvic Inflammatory Disease)

Patient is s/p appendectomy, seen in clinic 1 week later. What complication occurred? *-Wound infection is a common complication of appendicitis.* --More common with perforation. *-Might be superficial, involving only skin.* --Maybe treat as out-patient ---Remove sutures or staples. ---Irrigate wound and dress it. ---Oral antibiotics ---Daily follow-up until better *-More serious - _____________* --Might have diarrhea, and/or tender mass on rectal exam. --Patient is more ill -> in-patient care, IV antibiotics

Pelvic abscess

*What Location of Appendix?* *Symptoms/Signs:* -Pain below McBurney's point -Tender rectal / pelvic exam -Few RBC / WBC in urine -Maybe *obturator sign*

Pelvis (low) near rectum or bladder

-Don't count on diagnosing appendicitis this way. -But this one shows a *sentinel loop* of air in small bowel (?) in RLQ, suggesting localized inflammation. -Also, patient is bent toward right side, suggesting guarding due to pain. -Not diagnostic of, but consistent with, appendicitis.

Plain abdominal image

*Appendicitis in special populations* -Appendicitis and gallbladder disease are common general surgery abdominal emergencies in pregnancy. -US is often non-diagnostic, but if US is positive for appendicitis, no other imaging (CT, MRI) is needed before proceeding to surgery.+ -Fetal demise after appendectomy+ --With complicated appendicitis - 6%; with normal appendix - 4% --Not necessarily better if done laparoscopically rather than "open."

Pregnancy

*Small bowel conditions confused with appendicitis* If appendix appears normal, what does the surgeon look for? -Usually don't remove the Crohn's - treat medically -If cecum is not inflamed, usually remove the appendix (even if it appears normal).

Regional enteritis (Crohn's disease)

*What Location of Appendix?* *Symptoms/Signs:* -*Flank pain* and tenderness -No pain on rectal exam -Few RBC / WBC in urine (near ureter) -Maybe *psoas sign*

Retrocecal (posterior) near psoas muscle and ureter

Can cause flank pain, CVA tenderness, *positive psoas sign,* few WBCs / RBCs in urine (near ureter)

Retrocecal Appendicitis

*Conditions confused with acute appendicitis* Gastroenteritis -____________ --Chief complaint is usually *diarrhea* (not abd pain). --Maybe fever and chills --Do not expect signs of peritonitis.

Salmonella, Campylobacteria, etc

*Urinary conditions* confused with appendicitis: -Urinalysis will usually show *many* WBCs. -Pelvic appendicitis can cause *some* WBC in urine if inflamed appendix lies near the bladder. -Retrocecal appendicitis can cause *some* WBC in urine if inflamed appendix lies near the ureter. -Symptoms should differentiate from appendicitis.

UTI

*Urinary conditions* confused with appendicitis: -Rather SUDDEN onset of severe pain; *no* peritonitis -Urinalysis usually shows *many* RBC.

Uretal Stone

*Conditions confused with acute appendicitis* Gastroenteritis -__________ --Chief complaint is usually *diarrhea* (not abd pain). --hyPERactive bowel sounds (not hypo-) --Probably no signs of peritonitis

Viral

*Post-op diagnosis: Nomenclature of appendicitis* 2. Based on location - iliac fossa, pelvic, retrocecal -"suppurative iliac fossa appendicitis" -gangrenous pelvic appendicitis" -"perforated retrocecal appendicitis"

Yup

*Surgeon's Pre-op Note* -Written in the record (paper or electronic) before surgery S - Worsening abd pain for past 12 hrs. Vomited twice, no diarrhea. No prior abd surgery. LMP 2 wks ago. O - 20 yo WF otherwise healthy. Temp 99. Abd flat, decreased bowel sounds, tenderness to percussion, tenderness and guarding in RLQ. WBC 12,000. U/A normal. CXR normal. KUB nonspecific. A - appendicitis P - IV fluids, antibiotics, appendectomy tonight Discussed benefits, risks and alternatives with patient, who agrees to proceed.

Yup

*What the surgeon can tell the patient in pre-op counseling* -Usually when I operate for appendicitis, that's what I find. I remove the appendix, and in a day or so you get well and go home. -Sometimes you have to stay longer if the infection is very bad, or if infection develops in the wound. -Sometimes you seem to be well when you go home, but in several days you get a wound infection, and have to come back. But that doesn't usually happen. -Sometimes it's not appendicitis at all. I look around to see what else it could be. Usually there is nothing else to treat. I remove the appendix, and you get well and go home, maybe the next day.

Yup

*What the surgeon can tell the patient* -Why remove the appendix if it's normal? (In the Army, I am paid the same whether or not I remove it.) The reason is this: the next time you come in with abdominal pain, whoever hears your history or sees that scar (or scars) will think you have already had the appendix removed. I don't want to leave it in and cause confusion. -Rarely, it's not appendicitis but it's something else that needs an operation. If I can't do it through that small incision (or laparoscopically), I make a larger incision down the center. -Still, MOST of the time when we operate for appendicitis, that's what it is. We remove the appendix, and you get well and go home in a day or so.

Yup

-Typical appearance of suppurative appendicitis. -There is swelling and injection of distal half. -There is purulent exudate, not only on appendix itself, but on other structures that it touches. -This takes HOURS to develop. -There can *not* be sudden onset of symptoms.

Yup

So in areas of the world where there is no radiology, or no US or CT, how do we diagnose appendicitis? -Use history and physical to make the diagnosis. -Basic lab tests, if available: CBC and U/A -Basic x-rays, if available: CXR, KUB

Yup