Appendicitis is the acute inflammation of the appendix.
Physical finding and Clinical presentation
- Abdominal pain: initially the pain may be epigastric or periumbilical in nearly 50% of patients; it subsequently localizes to the RLQ within 12 to 18 hours. Pain can be found in the back or right fl ank if appendix is retrocecal or in other abdominal locations if there is malrotation of the appendix.
- Pain with right thigh extension (psoas sign), low-grade fever: temperature may be 38° C if there is appendiceal perforation.
- Pain with internal rotation of the fl exed right thigh (obturator sign) is present.
- RLQ pain on palpation of the LLQ (Rovsing’s sign): physical examination may reveal right-sided tenderness in patients with pelvic appendix.
- Point of maximum tenderness is in the RLQ (McBurney’s point).
- Nausea, vomiting, tachycardia, cutaneous hyperesthesias at the level of T12 can be present.
Obstruction of the appendiceal lumen with subsequent vascular congestion, inflammation, and edema; common causes of obstruction are:
- Fecaliths: 30% to 35% of cases (most common in adults)
- Foreign body: 4% (fruit seeds, pinworms, tapeworms, roundworms, calculi)
- Inflammation: 50% to 60% of cases (submucosal lymphoid hyperplasia [most common etiology in children, teens])
- Neoplasms: 1% (carcinoids, metastatic disease, carcinoma)
- Intestinal: regional cecal enteritis, incarcerated hernia, cecal diverticulitis, intestinal
obstruction, perforated ulcer, perforated cecum, Meckel’s diverticulitis. - Reproductive: ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, salpingitis, tubo-ovarian abscess, Mittelschmerz endometriosis, seminal vesiculitis.
- Renal: renal and ureteral calculi, neoplasms, pyelonephritis
- Vascular: leaking aortic aneurysm
- Psoas abscess
- Trauma
- Cholecystitis
- Mesenteric adenitis
- CBC with differential reveals leukocytosis with a left shift in 90% of patients with appendicitis. Total WBC count is generally lower than 20,000/mm3. Higher counts may be indicative
of perforation. Less than 4% have a normal WBC and differential. A low Hgb and Hct in an older patient should raise suspicion for GI tract carcinoma. - Microscopic hematuria and pyuria may occur in 20% of patients.
- CT of the right lower quadrant of the abdomen has a sensitivity of 90% and an accuracy 94% for acute appendicitis. A distended appendix, periappendiceal inflammation, and a thickened appendiceal wall are indicative of appendicitis.
- Ultrasonography has a sensitivity of 75% to 90% for the diagnosis of acute appendicitis, although it is highly operator dependent and diffi cult in patients with large body habitus. Ultrasound is useful, especially in younger women when diagnosis is unclear. Normal ultrasonographic findings should not deter surgery if the history and physical examination are indicative of appendicitis.
- Urgent appendectomy (laparoscopic or open), correction of fluid and electrolyte imbalance with vigorous IV hydration and electrolyte replacement.
- IV antibiotic prophylaxis to cover gram-negative bacilli and anerobes.
