Appendicitis

Epidemiology:

 Most frequently occurs in 2nd & 3rd decades of life

 Lifetime incidence: ♂ = 8.6% | ♀ = 6.7%

Clinical Presentation:

 Begins with anorexia  vague periumbilical pain  several hours later: localized sharp, severe & constant RLQ pain w/ RLQ
tenderness, guarding & rebound (McBurney’s point) | n/v
o Note: migratory pain occurs in only 50-60% pts
o Additional S/Sx include indigestion | flatulence | diarrhea | generalized malaise |
low-grade fever reaching 101.0°F (38.3°C) | leukocytosis

Pathophysiology:

 Initial inflammation of appendiceal wall which leads to localized ischemia | perforation |

development of contained abscess | generalized peritonitis
 Variations in position of appendix leads to variations in pain localization (see pic)
o Retrocecal appendix  dull abdominal pain
o Pelvic appendix tip  tenderness below McBurney’s
 Signs:
o McBurney’s point  maximal tenderness 1.5-2 inches superior to ASIS on
straight line from ASIS to umbilicus
o Rovsing’s sign  RLQ pain w/ palpation of LLQ | indicates right-sided local
peritoneal irritation
o Psoas sign  assoc. w/ retrocecal appendix | RLQ pain w/ passive R hip
extension, extending R iliopsoas | appendix may lie against R psoas, causing pt to
shorten muscle by drawing up R knee
o Obturator sign  assoc. w/ pelvic appendix | appendix lying against obturator
internus | RLQ pain w/ passive R hip & knee flexion followed by R hip internal
rotation

Diagnosis:

 CT or ultrasound

Differential Dx:

 Perforated appendix | Cecal

diverticulitis | Meckel’s diverticulitis
|Acute ileitis | Crohn’s Dz
 Tubo-ovarian abscess | PID |
Ovarian cyst rupture |
Mittelschmerz | torsion |
endometriosis | ectopic pregnancy
 Renal colic | testicular torsion |
epididymitis | appendix testis
torsion

Treatment:

 See diagram
 Despite evidence that antibiotics
alone may be sufficient for
managing the initial presentation of
appendicitis, routine use for adult patients presenting with uncomplicated appendicitis is not recommended.