GROUP WORK ON ASSESSMENT OF ABDOMINAL PAIN

A.FELICIA CHITRA M.Sc(N);Ph.D PROFESSOR MTPG&RIHS 08 .10.2012

Acute Appendicitis

Epidemiology
The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis. Despite newer imaging techniques, acute appendicitis can be very difficult to diagnose.

Pathophysiology
Acute appendicitis is thought to begin with obstruction of the lumen Obstruction can result from food matter, adhesions, or lymphoid hyperplasia Mucosal secretions continue to increase intraluminal pressure

Pathophysiology
Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed. With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.

Pathophysiology
Increased pressure also leads to arterial stasis and tissue infarction End result is perforation and spillage of infected appendiceal contents into the peritoneum

Pathophysiology
Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10th thoracic vertebral level. This pain is generally vague and poorly localized. Pain is typically felt in the periumbilical or epigastric area.

Pathophysiology
As inflammation continues, the serosa and adjacent structures become inflamed This triggers somatic pain fibers, innervating the peritoneal structures. Typically causing pain in the RLQ

Pathophysiology
The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.

Pathophysiology
Exceptions exist in the classic presentation due to anatomic variability of the appendix Appendix can be retrocecal causing the pain to localize to the right flank In pregnancy, the appendix ca be shifted and patients can present with RUQ pain

Pathophysiology
In some males, retroileal appendicitis can irritate the ureter and cause testicular pain. Pelvic appendix may irritate the bladder or rectum causing suprapubic pain, pain with urination, or feeling the need to defecate Multiple anatomic variations explain the difficulty in diagnosing appendicitis

History
Primary symptom: abdominal pain to 2/3 of patients have the classical presentation Pain beginning in epigastrium or periumbilical area that is vague and hard to localize

History
Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting As the illness progresses RLQ localization typically occurs RLQ pain was 81 % sensitive and 53% specific for diagnosis

History
Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific Anorexia is the most common of associated symptoms Vomiting is more variable, occuring in about of patients

Physical Exam
Findings depend on duration of illness prior to exam. Early patients may not have localized tenderness With progression there is tenderness to deep palpation over McBurneys point

McBurneys point

Physical Exam
McBurneys Point: just below the middle of a line connecting the umbilicus and the ASIS Rovsings: pain in RLQ with palpation to LLQ Rectal exam: pain can be most pronounced if the patient has pelvic appendix

Physical Exam
Additional components that may be helpful in diagnosis: rebound tenderness, voluntary guarding, muscular rigidity, tenderness on rectal

Physical Exam
Psoas sign: place patient in L lateral decubitus and extend R leg at the hip. If there is pain with this movement, then the sign is positive.

Physical Exam
Obturator sign: passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positive

Physical Exam
Fever: another late finding. At the onset of pain, fever is usually not found. Temperatures >39 C are uncommon in first 24 h, but not uncommon after rupture

MANTRELS Score
Established in 1986

Migration of pain Anorexia Nausea / vomiting Tenderness RLQ Rebound Elevated temp. Leukocytosis Shift to left

MANTRELS Score, cont'd.

RLQ

tenderness and leukocytosis = 2 points each ; all others 1 point of 5 to 6 = possible appendicitis

Score

Score
Score

of 7 to 8 = probable appendicitis

of 9 to 10 = very probable appendicitis

Diagnosis
Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain who has not had an appendectomy

Diagnosis
Women of child bearing age need a pelvic exam and a pregnancy test. Additional studies: CBC, UA, imaging studies

Diagnosis
CBC: the WBC is of limited value. Sensitivity of an elevated WBC is 70-90%, but specificity is very low. But, +predictive value of high WBC is 92% and predictive value is 50% CRP and ESR have been studied with mixed results

Diagnosis
UA: abnormal UA results are found in 1940% Abnormalities include: pyuria, hematuria, bacteruria Presence of >20 wbc per field should increase consideration of Urinary tract pathology

Diagnosis
Imaging studies: include X-rays, US, CT Xrays of abd are abnormal in 24-95% Abnormal findings include: fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free air Abdominal xrays have limited use b/c the findings are seen in multiple other processes

Diagnosis
Graded Compression US: reported sensitivity 94.7% and specificity 88.9% Basis of this technique is that normal bowel and appendix can be compressed whereas an inflamed appendix can not be compressed DX: noncompressible >6mm appendix, appendicolith, periappendiceal abscess

Diagnosis
Limitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameter

Diagnosis
CT: best choice based on availability and alternative diagnoses. In one study, CT had greater sensitivity, accuracy, -predictive value Even if appendix is not visualized, diagnose can be made with localized fat stranding in RLQ.

Diagnosis
CT appears to change management decisions and decreases unnecessary appendectomies in women, but it is not as useful for changing management in men.

Differential Diagnosis
Gastroenteritis Mesenteric TOA Ectopic UTI Pyelonepritis

pregnancy

lymphadenitis
PID Crohn's

disease

Other

Diverticulitis

processes involving appendix

Endometriosis

Special Populations
Very young, very old, pregnant, and HIV patients present atypically and often have delayed diagnosis High index of suspicion is needed in the these groups to get an accurate diagnosis

Treatment
Appendectomy is the standard of care Patients should be NPO, given IVF, and preoperative antibiotics Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation

Treatment
There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage One sample monotherapy regimen is Zosyn 3.375g or Unasyn 3g Also, short acting narcotics should be used for pain management