This document provides information on acute appendicitis including epidemiology, anatomy, pathophysiology, clinical presentation, differential diagnosis, investigations, and complications. Some key points are: - Acute appendicitis is the most common cause of acute abdominal surgery. - The appendix is a blind pouch located off the cecum that can be found anywhere in the abdominal cavity. - Clinical presentation of appendicitis is often vague, though classical symptoms include RLQ pain, anorexia, nausea and vomiting. - Investigations like bloodwork, ultrasound and CT scans can help diagnose appendicitis but clinical evaluation remains most important.

1. A Presentation

2. Epidemiology
• Acute appendicitis is the most
common cause of ‘acute
surgical abdomen’
• 6% of the population will
suffer from acute appendicitis
during their lifetime.
• Nothing can be so easy or as
difficult as the diagnosis of
acute appendicitis

3. Anatomy
• Blind pouch off of cecum
• Contains lymphoid tissue which
peaks in adolescence, atrophies
with age
• Function still unclear
• Appendix can be anywhere within
peritoneal cavity
• One study showed 65 %
retrocecal, 31 % pelvic
• Review of 70,000 cases showed 4
% in RUQ, 0.06 % LUQ, 0.04 %
LLQ

4. Anatomy

5. Pathophysiology
• Lymphoid hyperplasia leads to
luminal obstruction
• Often follows viral illness
• Epithelial cells secrete mucus
• Appendix distends, bacteria
multiply
• Visceral pain begins an average of
17 hours after obstruction
• Increased pressure compromises
blood supply
• Somatic pain develops
• Average time to perforation = 34
hrs.

6. Clinical presentation
• Classical presentation seen in 60 %
Anorexia
Peri umbilical pain, nausea,
vomiting
• RLQ pain developing over 24 hrs.
• Anorexia and pain are most
frequent
• Usually nausea, sometimes
vomiting
• Diarrhoea, esp. with pelvic location
• Usually tender to palpation
• Rebound is a later finding

7. Symptoms

8. Signs

9. Migration of Pain

10. Examination

11. Tenderness

12. SPECIAL FEATURES, ACCORDING TO
POSITION OF THE
APPENDIX
.
RETROCAECAL
-Rigidity in often
absent
- Psoas spasm due to
inflamed appendix
in contact with the
muscle may cause
flexion of hip
PELVIC
-Early diarrhoea due
to contact with
rectum
-When inflamed
appendix is in
contact with
Bladder, may cause
frequency of
micturition.

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

14. MANTRELS Score
• RLQ tenderness and leukocytosis
= 2 points each ; all others 1 point
• Score of 5 to 6 = possible
appendicitis
• Score of 7 to 8 = probable
appendicitis
• Score of 9 to 10 = very probable
appendicitis

15. HIGH
RISK
PATIENTS
&
GROUPS

16. Ovulating women
• PID, TOA, ovarian cyst rupture can
mimic appendicitis
• Look for cervical motion
tenderness, adnexal tenderness,
history of STD’s
• Can have CMT with pelvic
appendix

17. Pregnancy
• Most common surgical emergency
in pregnancy
• Mortality rate if missed = 2 % for
mother, up to 35 % for fetus
• WBC elevated in pregnancy
• Appendix changes location

18. Pediatric Population
• Most common surgical disorder in kids
• Accounts for 5 % of abd. pain visits
• Up to 50 % initially misdiagnosed
• < 2 yrs. : perforation rate approaches
100 %
• 3 to 5 yrs. = 71 %
• 6 to 10 yrs. = 40 %
• Most common misdiagnosis is AGE
• Sequence of pain and vomiting may
be helpful
• Localized tenderness not a feature of
AGE

19. Elderly
• Vital signs and exam may not
reflect severity
• > age 60 : only 5 to 10 %
diagnosed without delay
• Perforation rate = 46 to 83 %
• RLQ tenderness absent in 23 %
• N/V, anorexia less common
• Leukocytosis less pronounced
• Only 20 % classic presentation

20. Immunocompromised
• HIV, chronic steroids, sickle cell,
chemotherapy, DM, dialysis
• Increased risk of complications
and misdiagnosis
• Inflammatory response decreased

21. Differential Diagnosis
• Gastroenteritis
• Mesenteric lymphadenitis
• PID
• Mittelschmertz
• Crohn's disease
• Diverticulitis
• Endometriosis
• TOA
• Ectopic pregnancy
• UTI
• Pyelonepritis
• Other processes involving appendix

22. INVESTIGATIONS

23. CBC
• 75 to 85 % have elevated WBC,
but it is nonspecific
• WBC normal in 80 % in the first
24 hrs.
• Can see elevated ANC in up to 89
%
• WBC usually 12 to 18,000 in
appendicitis
• Chemistry panel may help with
diagnosis of dehydration

24. OTHERS
• Urinalysis
Specific gravity, ketones
Can see WBC’s, RBC’s, bacteria if
inflamed appendix close to ureter
> 30 WBC’s = probable UTI
• HCG
Essential in women of child-bearing
age
• CRP
Acute phase reactant

25. PLAIN FILMS
• Low sensitivity and
specificity
• Appendicolith specific, but
seen in only 2 %
• May see local air-fluid levels,
psoas obliteration, soft
tissue mass, gas in appendix
• All nonspecific

26. ULTRASONOGRAM
• 75 to 90 % sensitive, 86 to 100 %
specific
• Non invasive, low cost, but
operator-dependent
• Good for diagnosing GYN
disorders
3 criteria for diagnosis
Tender, non compressible appendix
No peristalsis of appendix
Overall diameter > 6 mm

27. COMPUTED TOMOGRAM
• Early studies showed low yield,
but helical CT much more accurate
• Sensitivity 97 to 100 %,
specificity 95 % (similar no
matter what type or whether
contrast is used)
• Often shows alternative diagnosis
• More expensive, radiation
exposure

28. DO WE NEED IMAGING?
• Literature conflicting
• Imaging most useful in clinically
equivocal cases
• Costs of imaging minor compared
to cost of unnecessary surgery or
delayed diagnosis
• US and CT both specific enough to
rule in appendicitis, but only CT
sensitive enough to rule it out

29. NEJM CONSENSUS
• Patients with classic presentation
should go to O.R. Diagnostic
accuracy approaches 95 %
• If equivocal/suspect perforation : CT
• US reserved for pregnant women or
high suspicion of GYN disease
• If study indeterminate, observe with
repeated exams or laparoscopy

30. ANALGESIA?
Prospective studies (both
EM and Surgery literature)
now show appropriate use
of IV narcotics does not
decrease diagnostic
accuracy, and may improve
exam

31. 7 FEATURES OF MISSED
DIAGNOSIS
• No nausea / vomiting
• Lack of distress
• No rebound
• No guarding
• No rectal exam
(controversial)
• Narcotic pain meds given
• Diagnosis of acute
gastroenteritis

32. No single evaluation can
substitute for the
diagnostic accuracy of
the experienced
physician.

33. WHEN IN DOUBT
DO NOT DISCHARGE

34. COMPLICATIONS
OF
ACUTE APPENDICITIS

35. APPENDICULAR MASS
• Localization of
infection 3-5 days
after attack of acute
appendicitis
• Inflamed appendix
• Omentum
• Caecum
• Dilated ileum
• Tender
• Smooth
• Firm
• Not mobile

36. Treatment (Ochsner
sherren )
• Temp, BP, Pulse q 4h
• Marking the mass – (progression
or regression)
• Antibiotics
• Metronidazole
• Ampicillin
• Gentamycin
• IV fluids
• IV antibiotics
• Nasogastric aspiration q 4h

37. WHEN TO STOP?
• Toxic symptoms
• Increase in size of mass
• Abscess formation
• Features of peritonitis

38. APPENDICULAR ABSCESS
Suppuration in acute appendicitis
Sites:
Retrocaecal
Pelvic
Subphrenic
lumbar
C/F:
High fever
Features of peritonitis ( guarding /
rigidity)
Raised TC (>18,000)

39. MANAGEMENT
• Antibiotics
• Extra peritoneal drainage

40. GANGRENOUS APPENDIX

41. PERFORATED APPENDIX

42. LAP APPENDECTOMY

43. LAP APPENDECTOMY

45. COMPLICATIONS OF
APPENDECTOMY
Early complications:
1. Paralytic ileus
2. Sepsis – local wound abscess, pelvic
abscess.
3. Rupture of the stump or caecal wall.
4. Haemorrhage: At any time during the
first 72 hours after surgery means
either leakage from the stump or a
slipped arterial ligature.
Late complications
1. Intestinal obstruction due to local
adhesive bands.
2. Incisional hernia

46. KEY POINTS
Diagnosis of appendicitis is by
clinical evaluation
Definitive treatment is surgery
Lap has distinct advantages over
open surgery
If Left untreated complications are
dreaded