Appendicitis

1. Appendicitis
Hamzeh Halawani M.D.
American University of Beirut

2. Appendicitis
• 7% lifetime risk of developing appendicitis.
• Peak at 10 and 30 years of age, but may occur
in men and women of any age.
• Signs and Symptoms?
• Physical Exam?

3. Signs
• Dunphy sign: increased pain with any coughing or
movement
• Rovsing sign: is RLQ pain that is induced by palpation of the
left lower quadrant and is highly suggestive of a RLQ
inflammatory process.
• The obturator sign: is seen with inflammation of a pelvic
appendix and refers to pain on internal rotation of the right
hip.
• The iliopsoas sign: is most often seen with a retrocecal
appendix and refers to pain on extension of the right hip.
• Aure-Rozanova sign, Bartomier-Michelson's sign, Kocher's
(Kosher's) sign, Massouh sign, and Sitkovskiy (Rosenstein)'s
sign.

5. CT scan
• Enlarged appendix >6 mm in diameter
• Appendiceal wall thickness >2 mm
• Periappendiceal inflammation (fat stranding)
• The presence of a fecalith
• Wall enhancment
• The presence of the arrowhead sign (thickened
cecum funneling contrast toward the appendiceal
orifice)
– The risk of radiation-induced malignancy has been
recently estimated at 0.18% following exposure to
abdominal CT.

6. US
• Non compressable
• >6 mm in diameter
• Free fluid and abscess.
• fecalith

7. DDx
• inflammatory bowel disease
• Crohn's ileitis
• Gynecologic pathology (mittelschmerz, salpingitis, ectopic pregnancy,
tubo-ovarian abscess, and endometriosis ).
• gastroenteritis.
• diverticulitis
• Meckel's diverticulitis
• Renal Colic
• acute mesenteric adenitis.
• epiploic appendagitis, torsion, and thrombosis of a pedunculated adipose
structure off the serosal surface of the cecum may resemble appendicitis
but can be distinguished on CT scan.
• familial Mediterranean fever (FMF).
• Yersenia infection
• TB

9. Open Vs. Lap
– Laparoscopic appendectomy leads to a shortened
hospital stay for patients with uncomplicated acute
appendicitis, less postoperative pain, faster return to
work, and lower total cost of care.
– Laparoscopic appendectomy was associated with a
lower incidence of postoperative wound infection
than open appendectomy was (3.5% versus 6.7%), but
it was also associated with a higher incidence of
postoperative intra-abdominal abscess (2.5% versus
1.1%). The length of stay was slightly shorter after
laparoscopic appendectomy (1 to 4.9 days; average
2.7 days) than after open appendectomy (1.2 to 5.3
days; average 3.2 days)

10. • At present, however, the only patients for
whom laparoscopic appendectomy appears to
offer significant advantages are
– women of childbearing age
– Obese patients
– Patients with an unclear diagnosis.

17. Chronic appendicitis
• Pain last longer, same location, less intense.
• Much lower incidence of vomiting and
nausea.
• WBC normal, CT not diagnostic.
• Appendectomy is curative.