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Acute Appendicitis Notes From Schwartz
Acute Appendicitis Notes From Schwartz
Acute Appendicitis Notes From Schwartz
Epidemiology
lifetime risk: 8.6% for males and 6.7% for females, highest incidence in second and third decades
Etiology
Obstruction of the lumen due to fecaliths or hypertrophy of lymphoid tissue is proposed as the main
etiologic factor in acute appendicitis.
Pathogenesis
Microbiology
60% of aspirates of inflamed appendices have anaerobes compared to 25% from normal appendices
o Tissue specimens: Escherichia coli and Bacteroides
o Fusobacterium nucleatum/necrophorum (62%)- not present in normal cecal flora
Natural history
circumstantial evidence suggests that not all patients with appendicitis will progress to perforation and
that resolution may be a common event
Clinical Presentation
Symptoms
o periumbilical and diffuse pain that eventually localizes to the right lower quadrant
o pain in an atypical location or minimal pain
o GI symptoms: nausea, vomiting, anorexia, (GI symptoms before onset of pain suggest a different
etiology)
Signs
o body temperature and pulse rate may be normal or slightly elevated
o usually move slowly and prefer to lie supine due to the peritoneal irritation
o abdominal palpation: tenderness with a maximum at or near McBurney’s point
o deep palpation: often feel a muscular resistance (guarding) in the right iliac fossa
o (+) rebound tenderness
o Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness are strong indicators of
peritoneal irritation
o Psoas sign
o Obturator sign
Lab findings
Imaging Studies
Differential diagnosis
mesenteric adenitis, no organic pathologic condition, acute pelvic inflammatory disease, twisted ovarian
cyst or ruptured graafian follicle, and acute gastroenteritis
Pediatric Patient: Acute mesenteric adenitis
Elderly Patient: Diverticulitis or perforating carcinoma of the cecum or of a portion of the sigmoid that
overlies the right lower abdomen
Female Patient: pelvic inflammatory disease, ruptured graafian follicle, twisted ovarian cyst or tumor,
endometriosis, and ruptured ectopic pregnancy
Treatment
Uncomplicated appendicitis
o surgical treatment has been the standard of treatment
o concept of nonoperative treatment
when surgical treatment is not available treatment with antibiotics alone
was noted to be effective
patients with signs and symptoms consistent with appendicitis who did not pursue
medical treatment would occasionally have spontaneous resolution of their illness.
Complicated Appendicitis
o refers to perforated appendicitis commonly associated with an abscess or phlegmon
o Children <5 years of age and >65 years of age have the highest rates of perforation
o suspected in the presence of generalized peritonitis and a strong inflammatory response
o some: localized peritonitis
o 2% to 6% of cases, a palpable mass is detected on PE
could represent a phlegmon: matted loops of bowel adherent to the adjacent inflamed
appendix or a periappendiceal abscess.
symptoms for a longer duration, 5 to 7 days
o Patients who present with signs of sepsis and generalized peritonitis should be taken to the
operating room immediately with concurrent resuscitation
Open Appendectomy
Laparoscopic appendectomy