Acute Appendicitis

Muhammad S Niam, Digestive Surgery-General Surgery

Saiful Anwar General Hospital,
Faculty of Medicine-Brawijaya University

Learning Objective:
Student will be able to diagnose Acute
Appendicitis

Learning Outcomes:
Student will be able to:
explain its pathophysiology
take proper histories
perform good physical exam
compare differential dx
evaluate lab. and imaging result
give initial treatment and refer to
specialist

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
Obstruction of the lumen
Result from food matter,
adhesions, or lymphoid
hyperplasia, neoplasm, foreign
body
Result in vogue colicky pain
(visceral pain)

Mucosal secretions
accumulation
Increase intraluminal pressure

Pathophysiology

Pathophysiology

Pathophysiology
Exceeds capillary perfusion
pressure
Venous and lymphatic drainage
are obstructed
Vascular compromise
Epithelial mucosa breaks down
and bacterial invasion by bowel
flora

Pathophysiology
Increased pressure also leads
to arterial stasis and tissue
infarction
Parietal peritoneum inflamed
Shifted pain to RLQ (viceral pain
(periumbilical pain) somatic
pain)

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 retrocaecal
causing the pain to localize to
the right flank
In pregnancy, the appendix can
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

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

History
SYMPTOM
Abdominal Pain
Migration of Pain to
RLQ
Nausea
Vomiting
Anorexia
Fever
Diarrhea
Constipation

FREQUENCY (%)
97-100
49-61
67-78
49-74
70-92
10-20
4 -16
4 -16

Physical Exam

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

Physical Exam
McBurneys Point: just below
the middle of a line connecting
the umbilicus and the ASIS (1/3
lateral SIAS-Umbilicus)

Physical Exam
Rovsings: pain in RLQ with
palpation to LLQ

Physical Exam
Rectal exam: pain can be most
pronounced if the patient has
pelvic appendix
Additional components that may
be helpful in diagnosis: rebound
tenderness Blumbergs sign,
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

Differential Diagnosis
Based on History and Presentation

Systemic or infectious conditions

Influenza
Gastroenteritis
Hepatitis
Diaphragmatic pleurisy
Spinal disease
Typhoid
Tuberculosis
Acute porphyria
Diabetic ketoacidosis

Differential Diagnosis
(cont.)

Intra-abdominal conditions

Acute Appendicitis
Acute Cholecystitis
Diverticulitis (Meckels)
Inflammatory Bowel Disease (Crohns)
Duodenal Ulcer
Intestinal Obstruction
Carcinoma of the Cecum
Nonspecific adenitis Possible Yersinia
infection

Differential Diagnosis
(cont.)

Intra-pelvic conditions

Salpingitis
Pelvic Inflammatory Disease
Ectopic Pregnancy
Ruptured Corpus Luteum Cyst
Ruptured Follicular Cyst (Mittelschmerz)
Ruptured Ovarian Cyst
Ovarian Torsion
Pyelonephritis
Ureteral/Renal stone

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 19-40%
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 2495%
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.

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

Treatment

Treatment

Treatment

Treatment

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
with high dose broad spectrum
Also, short acting narcotics should
be used for pain management

Disposition
Abdominal pain patients can be
put in 4 groups
Group 1: classic presentation for
Acute appendicitis- prompt
surgical intervention, refer soon
Group 2: suspicious, but not
diagnosed appendicitis- benefit
from imaging and 4-6h
observation with surgical consult
if serial exam changes or
imaging studies confirm

Disposition
Group 3: remote possibility of
appendicitis- observe in ED for
serial exams; if no change and
course remains benign patient can
D/C with dx of nonspecific abd pain
Patients are given instructions to
return if worsening of symptoms,
and they should be seen by PCP in
12-24 h
Also advised to avoid strong
analgesia and antibiotic as initial tx

Disposition
Group 4: high risk
population(including elderly,
pediatric, pregnant and
immunocomprimised)- require
high index of suspicion and low
threshold for imaging and
surgical consultation
Advised tx for unclear diagnosis
in epigastric pain is only
antasida

Complication
Generalized Peritonitis
Localized Peritonitis
Appendiceal Abscess
(Periappendicular Abscess)
Appendiceal Mass
(Periappendicular Infiltrat)
Chronic Appendicitis

Treatment of Complication
Generalized Peritonitis
Localized Peritonitis
1. Resuscitation
2. Laparotomy Appendectomy

Treatment of Complication
Appendiceal Abscess
(Periappendicular Abscess)
1. Resuscitation
2. Laparotomy Appendectomy +
Drainage, or
3. Non Operative Drainage
(USG or CT guided)

Treatment of Complication
Appendiceal Mass
(Periappendicular Infiltrat)
1. Resuscitation
2. Medical Treatment for Gram (+)
and Gram (-) bacteria, anaerob
3. Some patients need Interval
Appendectomy

Treatment of Complication
Chronic Appendicitis
Appendectomy

Current Treatment Option

Single Incition Laparoscopy
Single Port Laparoscopy
Natural Orifice Transluminal
Endoscopic Surgery (NOTES)
Robotic Surgery

Thank you