NAME: KHRO VIVONO IMD14(A)

SURGERY DEPARTMENT

APPENDICITIS
ABSTRACT :
Background- Appendicitis is the most common abdominal emergency. While the clinical diagnosis may be
straightforward in patients who present with classic signs and symptoms, atypical presentations may result
in diagnostic confusion and delay in treatment. Abdominal pain is the primary presenting complaint of
patients with acute appendicitis. Nausea, vomiting, and anorexia occur in varying degrees.
Objective- This study is aimed at assessing the magnitude, pattern and outcomes of acute appendicitis.
Result- Abdominal examination reveals localised tenderness and muscular rigidity after localisation of the
pain to the right iliac fossa. Laboratory data upon presentation usually reveal an elevated leukocytosis with
a left shift. Measurement of C-reactive protein is most likely to be elevated. The advances in imaginology
trend to diminish the false positive or negative diagnosis. Radiographic image of faecal loading image in the
caecum has a sensitivity of 97% and a negative predictive value that is 98%. In experienced hands,
ultrasound may have a sensitivity of 90% and specificity higher than 90%. Helical CT has reported a
sensitivity that may reach 95% and specificity higher than 95%.
Conclusion- Appendicitis is a condition that is prevalent in the developed world and should have minimal
complications. Surgical action should be taken without delay. If left untreated there is a risk of peritonitis,
which is the main complication of this condition. Despite all medical advances, the diagnosis of acute
appendicitis continues to be a medical challenge.

KEYWORD: Appendicitis, Suppurative Appendectomy, Appendix, Acute abdomen, Rupture Appendix.

INTRODUCTION:
Appendicitis is a common condition. Appendicitis affects 1 in every 500 people in the each year.
The risk of appendicitis increases with age, peaking between ages 15 and 30. Appendicitis is
defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other
parts. This condition is a common and urgent surgical illness with protean manifestations,
generous overlap with other clinical syndromes, and significant morbidity, which increases with
diagnostic delay. In fact, despite diagnostic and therapeutic advancement in medicine,
appendicitis remains a clinical emergency and is one of the more common causes of acute
abdominal pain.

No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal
inflammation in all cases, and the classic history of anorexia and periumbilical pain followed by
nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.

Appendicitis may occur for several reasons, such as an infection of the appendix, but the most
important factor is the obstruction of the appendiceal lumen (Inside of the appendix where mucus,
created by the appendix, travels and empties into the large intestines). Left untreated, appendicitis
has the potential for severe complications, including perforation or sepsis, and may even cause
death. However, the differential diagnosis of appendicitis is often a clinical challenge because
appendicitis can mimic several abdominal conditions. [1][4]

Appendectomy remains the only curative treatment of appendicitis. The surgeon's goals are to
evaluate a relatively small population of patients referred for suspected appendicitis and to
minimize the negative appendectomy rate without increasing the incidence of perforation. The
emergency department (ED) clinician must evaluate the larger group of patients who present to
the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the
diagnosis in a time-, cost-, and consultation-efficient manner.

PATIENT INFORMATION:
A 26 year old female, G2P2 presented with abdominal pain that migrated from RUQ to RLQ for 5days, on a
pain scale of 8/10. No vomiting, no fever, no anorexia were noted. Due to persisted abdominal pain patient
sought for consultation hence admitted subsequently.
Alvarado score
Particulars Score
migration of pain 1
Anorexia- 0
Nausea 1
Tenderness in RLQ 2
Rebound pain 1
Elevated temperature 1
Leucocytosi 2
Shift of WBC to the left 1
Total 9

Physical examination revealed

• awake, comfortable, Not in respiratory distress.
• Positive RLQ pain.
• BP-104/72mmhg
• HR-81bpm
• RR-21cpm
• Temp- 36°C
Patient has no past medical history of hypertension, Diabetes Mellitus, PTB.
Neurologic exam revealed GCS 15 conscious, coherent, oriented to time, place and person, follows
commands and intact memory. Cranial nerves intact. Motor with no atrophy and fasciculation.

CLINICAL FINDINGS:
An ER Chemistry report revealed Low sodium of 131.0mmol/L (normal is 136.00-144.00) and ER complete
blood count revealed a elevated white blood cell (WBC) count of 11.00per L, Low haemoglobin of 114.0
g/dl (normal is 13.5–17.5 g/dl) and a normal haematocrit of 0.36. The patient had elevated neutrophil of
76%, Low Lymphocyte of 16%, Low Basophil and Low MCHC of 31.8g/dl.

TIMELINE:

• Patient sought consultation at the Emergency room. Admitted in GS2 ward - surgery annex
(January 8,2020.9:06am)

• History and Physical Examination reviewed with requests for Labs and Imaging. (January 8, 2020.
11:45am)

• Patient under Anesthetic Pre operative monitoring, NPO. (January 9, 2020. 12:05am)

• Patient underwent post operative assessment, S/P Appendectomy. Treated with Paracetamol 1gm
IVTT q6hrs then shift to Tramadol+Paracetamol 325mg, 1tab q8hrs for 3days, Ketoralac 30gm
 q6hrsfor 24hours then shift to Celecoxib 200g/tab, BID for 5days and Omeprazole 40gm IVTT for
2days (January 10,2020)

• Patient was stabilized and on possible MGH. (january 11, 2020)

• The patient was also made aware of the benefits on diet, and medication compliance and
discharged on the 6th day.

DIAGNOSTIC ASSESSMENT :
To rule out other potential health issues, thorough check on the patient’s medical history. These
include: any other medical conditions or surgeries the patient has or has had in the past, whether
the patient takes any medications or supplements, whether the patient drinks alcohol or takes any
recreational drugs.
Physical exam to find out more about the patient’s stomach pain, applying pressure to or touch
certain areas of the abdomen. Pelvic exam, Blood and urine tests can help confirm an appendicitis
diagnosis or detect signs of other health issues. Blood or urine samples to check for pregnancy. If
necessary, the doctor may also order imaging tests, such as an abdominal ultrasound, MRI exam,
or CT scan. These imaging tests can show: an enlarged or burst appendix, inflammation, a
blockage inside the appendix, an abscess. A number of scoring systems have been developed to
try to identify people who are likely to have appendicitis. The performance of scores such as
the Alvarado score and the Pediatric Appendicitis Score however are variable. [1]

THERAPEUTIC INTERVENTION:
Appendicitis treatment usually involves surgery to remove the inflamed appendix. Before surgery
you may be given medications to treat infection.

OUTCOME:
Acute appendicitis is the most common reason for emergency abdominal surgery. Appendectomy
carries a complication rate of 4-15%, as well as associated costs and the discomfort of
hospitalization and surgery. Therefore, the goal of the surgeon is to make an accurate diagnosis
as early as possible. Delayed diagnosis and treatment account for much of the mortality and
morbidity associated with appendicitis.
People who need surgery often stay in the hospital two to three days (if the appendix did not
rupture). People who have an appendectomy normally recover completely. In cases of a ruptured
appendix, the hospital stay is usually longer. Although it is rare, a person can die of appendicitis if
a ruptured appendix spreads infection throughout the abdomen and into the blood.[5]
The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to
surgical intervention. The mortality rate in children ranges from 0.1% to 1%; in patients older than
70 years, the rate rises above 20%, primarily because of diagnostic and therapeutic delay.

Appendiceal perforation is associated with increased morbidity and mortality compared with non
perforating appendicitis. The mortality risk of acute but not gangrenous appendicitis is less than
0.1%, but the risk rises to 0.6% in gangrenous appendicitis. The rate of perforation varies from
16% to 40%, with a higher frequency occurring in younger age groups (40-57%) and in patients
older than 50 years (55-70%), in whom misdiagnosis and delayed diagnosis are common.
Complications occur in 1-5% of patients with appendicitis, and postoperative wound infections
account for almost one third of the associated morbidity. [1][4]

People who need surgery often stay in the hospital two to three days (if the appendix did
not rupture). People who have an appendectomy normally recover completely. In cases of
a ruptured appendix, the hospital stay is usually longer. Although it is rare, a person can
die of appendicitis if a ruptured appendix spreads infection throughout the abdomen and
into the blood.

SURGICAL INTERVENTION:

The standard treatment for acute appendicitis is surgical removal of the appendix.The surgery,
called an appendectomy, should be done as soon as possible to reduce the risk of the
appendix rupturing This may be done by an open incision in the abdomen (laparotomy) or
through a few smaller incisions with the help of cameras (laparoscopy). Surgery decreases the risk
of side effects or death associated with rupture of the appendix. Antibiotics may be equally
effective in certain cases of non-ruptured appendicitis. [5]

Appendectomy remains the only curative treatment of appendicitis, but management of patients
with an appendiceal mass is usually be divided into the following 3 treatment categories:
• Patients with a phlegmon or a small abscess: After intravenous (IV) antibiotic therapy, an
interval appendectomy can be performed 4-6 weeks later.
• Patients with a larger well-defined abscess: After percutaneous drainage with IV antibiotics is
performed, the patient can be discharged with the catheter in place. Interval appendectomy
can be performed after the fistula is closed.
• Patients with a multi compartmental abscess: These patients require early surgical drainage.

DISCUSSION:
The appendix is a wormlike extension of the cecum and, for this reason, has been called the
vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm). The
appendix appears during the fifth month of gestation, and several lymphoid follicles are scattered
in its mucosa. Such follicles increase in number when individuals are aged 8-20 years. A normal
appendix is seen below.[1][2]

Fig: Normal appendix; barium enema radiographic examination. A complete contrast-filled

appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis. [2]
 Fig:Appendicitis image[6.

Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of
luminal obstruction include lymphoid hyperplasia secondary to inflammatory bowel disease (IBD)
or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more
common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign
bodies and neoplasms.[2][3][4]
Obstruction of the appendiceal lumen has less commonly been associated with bacteria
(Yersinia species,adenovirus,cytomegalovirus,actinomycosis, Mycobacteria species, Histoplasma
species),parasites (eg, Schistosomes species, pinworms, Strongyloides stercoralis), foreign
material (eg, shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis,
and tumors.[1][2]
Symptoms
The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant
(RLQ) pain, and vomiting occurs in only 50% of cases. Nausea is present in 61-92% of patients;
anorexia is present in 74-78% of patients. In addition, when vomiting occurs, it nearly always
follows the onset of pain. Vomiting that precedes pain is suggestive of intestinal obstruction, and
the diagnosis of appendicitis should be reconsidered. Diarrhea or constipation is noted in as many
as 18% of patients and should not be used to discard the possibility of appendicitis. [1][4]

The most common symptom of appendicitis is abdominal pain. Typically, symptoms begin as
periumbilical or epigastric pain migrating to the right lower quadrant (RLQ) of the abdomen. This
pain migration is the most discriminating feature of the patient's history, with a sensitivity and
specificity of approximately 80%, a positive likelihood ratio of 3.18, and a negative likelihood ratio
of 0.5. [1] Patients usually lie down, flex their hips, and draw their knees up to reduce movements
and to avoid worsening their pain. Later, a worsening progressive pain along with vomiting,
nausea, and anorexia are described by the patient. Usually, a fever is not present at this stage.

Stages of Appendicitis
The stages of appendicitis can be divided into early, suppurative, gangrenous, perforated,
phlegmonous, spontaneous resolving, recurrent, and chronic. [1][4]


Early stage appendicitis
In the early stage of appendicitis, obstruction of the appendiceal lumen leads to mucosal
edema, mucosal ulceration, bacterial diapedesis, appendiceal distention due to
accumulated fluid, and increasing intraluminal pressure. The visceral afferent nerve fibers
are stimulated, and the patient perceives mild visceral periumbilical or epigastric pain,
which usually lasts 4-6 hours.
 • Suppurative appendicitis
Increasing intraluminal pressures eventually exceed capillary perfusion pressure, which is
associated with obstructed lymphatic and venous drainage and allows bacterial and
inflammatory fluid invasion of the tense appendiceal wall. Transmural spread of bacteria
causes acute suppurative appendicitis. When the inflamed serosa of the appendix comes in
contact with the parietal peritoneum, patients typically experience the classic shift of pain
from the periumbilicus to the right lower abdominal quadrant (RLQ), which is continuous
and more severe than the early visceral pain. [1]
• Gangrenous appendicitis
Intramural venous and arterial thromboses ensue, resulting in gangrenous appendicitis.
• Perforated appendicitis
Persisting tissue ischemia results in appendiceal infarction and perforation. Perforation can
cause localized or generalized peritonitis.
• Phlegmonous appendicitis or abscess
An inflamed or perforated appendix can be walled off by the adjacent greater omentum or
small-bowel loops, resulting in phlegmonous appendicitis or focal abscess.
• Spontaneously resolving appendicitis
If the obstruction of the appendiceal lumen is relieved, acute appendicitis may resolve
spontaneously. [21, 22] This occurs if the cause of the symptoms is lymphoid hyperplasia or
when a fecalith is expelled from the lumen.
• Recurrent appendicitis
The incidence of recurrent appendicitis is 10%. The diagnosis is accepted as such if the
patient underwent similar occurrences of RLQ pain at different times that, after
appendectomy, were histopathologically proven to be the result of an inflamed appendix.
• Chronic appendicitis
Chronic appendicitis occurs with an incidence of 1% and is defined by the following: (1) the
patient has a history of RLQ pain of at least 3 weeks’ duration without an alternative
diagnosis; (2) after appendectomy, the patient experiences complete relief of symptoms; (3)
histopathologically, the symptoms were proven to be the result of chronic active
inflammation of the appendiceal wall or fibrosis of the appendix.

Causes of appendicitis
A blockage in the lining of the appendix that results in infection is the likely cause of appendicitis.
The bacteria multiply rapidly, causing the appendix to become inflamed, swollen and filled with
pus. If not treated promptly, the appendix can rupture. [5]

Complications- Appendicitis can cause serious complications, such as:

• A ruptured appendix: A rupture spreads infection throughout your abdomen (peritonitis).

Possibly life-threatening, this condition requires immediate surgery to remove the appendix
and clean your abdominal cavity. [8]
 • A pocket of pus that forms in the abdome: If your appendix bursts, you may develop a
pocket of infection (abscess). In most cases, a surgeon drains the abscess by placing a tube
through your abdominal wall into the abscess. The tube is left in place for about two weeks,
and you're given antibiotics to clear the infection. [7]

Conclusions: To conclude, although anyone can develop appendicitis, most often it occurs in
people between the ages of 10 and 30. The exact role of the appendix is not clear. It may be an
area that hosts friendly bacteria, which help digestion and fight infection. It may also be related to
the immune system and influence the body’s ability to fight off infection. Appendicitis probably
happens because either a stomach infection moves to the appendix or a hard piece of stool
becomes trapped in the appendix, causing infection. The most common symptom of appendicitis
is abdominal pain

Countries with lower incidences of appendicitis also tend to have more fiber in their diets. It may
be that a high-fiber diet helps reduce the chances of developing appendicitis by creating softer
stools are less likely to get trapped in the appendix. Appendectomy, removal of the appendix,
is the standard treatment f or acute appendicitis, it is important to immediately remove
the appendix after the diagnosis to prevent the occurrence of the life
threatening complication of appendix. The most frequent complication of appendicitis is
[7]
perforation. Perforation of the appendix can lead to a periappendiceal abscess (a collection of
infected pus) or diffuse peritonitis [8] (infection of the entire lining of the abdomen and the
pelvis). The major reas on f or appendic eal perforation[4] is delay in diagnosis and treatment.

In general, the longer the delay between diagnos is and surgery, the more likely is
perforation. Theref ore, onc e appendicitis is diagnos ed, surgery should be done without
unnecessary delay.

PATIENT PERSPECTIVE:
Patients preferred surgical intervention over antibiotics alone in treatment of acute uncomplicated
appendicitis for quick recovery and to avoid recurrence.

INFORMED CONSENT: Written informed consent was written by the patient

REFERENENCES:
1.Appendicitis: Practice Essentials, Background, Anatomy
https://emedicine.medscape.com/article/773895-overview
2. Appendicitis
https://emedicine.medscape.com/article/363818-workup
3. Definition: appendiceal lumen - RadiologyInfo.org
https://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=938
4. Appendicitis Clinical Presentation: History, Physical
https://emedicine.medscape.com/article/773895-clinical
5. Appendicitis Guide: Causes, Symptoms and
https://www.drugs.com/health-guide/appendicitis.html
6. https://www.drugs.com/mayo/media/CB080E7A-90C9-4D40-AC46-D8864B36810B.jpg

7. Appendicular abscess
https://radiopaedia.org/articles/appendicular-abscess
8. Appendicitis - Complications - NHS

https://www.nhs.uk/conditions/appendicitis/complications/