Appendicitis

Appendicitis is caused by luminal obstruction of the vermiform appendix, typically by a fecalith. Other causes include obstruction by tumor, lymphatic tissue, gallstone or parasites.

-Approximately 9% of men and 7% of women will experience an episode during their lifetime.

-The most common abdominal surgical emergency

-It is most common in patients aged 10 to 19 years

– the most frequent cause of atraumatic abdominal pain in children >1 year old

– the most common non-obstetric surgical emergency in pregnancy

So, consider appendicitis in any patient with acute atraumatic abdominal pain without prior appendectomy.

Symptoms and Signs:

-Appendicitis usually begins with vague, often colicky periumbilical or epigastric pain. Within 12 hours the pain shifts to the right lower quadrant, manifested as a steady ache that is worsened by walking or coughing. Almost all patients have nausea with one or two episodes of vomiting.

-A worsening pain with deep inspiration may be present if there is peritoneal irritation. -Individuals may state that the trip to the hospital was painful, particularly when encountering bumps in the road.

-Low-grade fever (below 38°C) is typical.

–Flank pain, dysuria, or hematuria can occur, given the typical proximity of the appendix to the urinary tract.

Pregnancy: A right lower quadrant location of pain remains the most common location of pain in pregnant women with appendicitis. However, abdominal organ displacement from a gravid uterus may lead to right upper quadrant tenderness in pregnancy.

-the classic migration of pain to the right lower quadrant, to McBurney’s point, located one third of the distance from the anterior superior iliac spine to the umbilicus.

-On physical examination, localized tenderness with guarding in the right lower quadrant can be elicited with gentle palpation with one finger. When asked to cough, patients may be able to precisely localize the painful area, a sign of peritoneal irritation.

The psoas sign: Pain on passive extension of the right hip causes pain along posterolateral back and hip, suggesting retrocecal appendicitis

The obturator sign: Pain with passive flexion and internal rotation of the right hip, suggesting the possibility of an inflamed appendix in the pelvis

The Rovsing’s sign: Palpating in the left lower quadrant causes pain in the right lower quadrant if the appendix is located there.

Gastroenteritis vs. Appendicitis: In GastroeNteritis, Nausea comes first, then abdominal pain. In Appendicitis, Abdominal pain comes first, then nausea.

All patients should undergo a rectal examination.

Diagnosis:

Labs: Moderate leukocytosis  with ‘left shift’ neutrophilia; inflamed appendix that abuts the ureter or bladder may cause pyuria or hematuria.  

Imaging:

Abdominal ultrasound: wall thickening, an increased appendiceal diameter, and the presence of free fluid.

CT Scanning: dilatation >6 mm with wall thickening, a lumen that does not fill with enteric contrast, and fatty tissue stranding or air surrounding the appendix

Every woman of childbearing age should have a pregnancy test.

Treatment:

Pain: Control severe pain with narcotics

Infection: Broad-spectrum antibiotics

Surgery: Surgical appendectomy

Prognosis: If untreated, gangrene and perforation develop within 36 hours.

Q: What is the most common symptoms of appendicitis? Abdominal pain.

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