Introduction:
The vermiform appendix is a part of Gut or intestine which is considered by most to be a vestigial organ(an organ of no use now), its importance in surgery is only to its propensity for inflammation (that causes pain, swelling and other complication of the organ) which results in the clinical syndrome or group of problems known as acute appendicitis.
Appendix is a tubular structure and a part of midgut. Its length varies from 2 to 20 cm, and the average length is 9 cm in an adults
Incidence:
Acute appendicitis is the most common cause of an ‘acute abdomen’ in young adults. About 8% of people in Western countries have appendicitis at some time during their life, with a peak incidence between 10 and 30 years of age. Acute appendicitis is the most common general surgical emergency, Appendectomy is the most common urgently performed surgical procedure as early surgical intervention improves outcomes.
Pathophysiology (How it initiate and progresses)
Bacteriology
Symptoms :include anorexia (90%), nausea and vomiting (70%), and diarrhea (10%) and finally localization of pain in right lower quadrant of abdomen.
Signs: Tenderness is often maximal at or near McBurney's point.Direct rebound tenderness is usually present.
Temperature elevation or pyrexia.
Muscular resistance to palpation of the abdominal wall roughly parallels the severity of the inflammatory process.
B. LAB TEST: Mild leukocytosis( or increased white blood cell counts) ranging from 10,000 to 18,000/mm3, is usually present in patients with acute, uncomplicated appendicitis and is often accompanied by a moderate polymorphonuclear predominance.
C. IMAGING STUDIES: Despite an increased use of ultrasonography, computed tomography (CT) scanning, and laparoscopy the rate of misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture.
X-rays are rarely helpful in diagnosing appendicitis. One study demonstrated an appendicolith on only 1.14% of the x-rays performed on patients.
ultrasonography has a sensitivity of about 85% and a specificity of more than 90% for the diagnosis of acute appendicitis. It is most useful in women of child-bearing age and in children because other causes of abdominal complaints can be demonstrated. Findings associated with acute appendicitis include an appendiceal diameter greater than 6 mm, lack of luminal compressibility, and presence of an appendicolith.
Treatment
The vermiform appendix is a part of Gut or intestine which is considered by most to be a vestigial organ(an organ of no use now), its importance in surgery is only to its propensity for inflammation (that causes pain, swelling and other complication of the organ) which results in the clinical syndrome or group of problems known as acute appendicitis.
Appendix is a tubular structure and a part of midgut. Its length varies from 2 to 20 cm, and the average length is 9 cm in an adults
Incidence:
Acute appendicitis is the most common cause of an ‘acute abdomen’ in young adults. About 8% of people in Western countries have appendicitis at some time during their life, with a peak incidence between 10 and 30 years of age. Acute appendicitis is the most common general surgical emergency, Appendectomy is the most common urgently performed surgical procedure as early surgical intervention improves outcomes.
- The lifetime rate of appendectomy is 12% for men and 25% for women.
- Lifetime risk of undergoing appendectomy is between 7% and 12%.
- The maximal incidence occurs in the second and third decades of life.
Pathophysiology (How it initiate and progresses)
A. Appendiceal obstruction
Appendiceal luminal obstruction is the most common initiating event of appendicitis.
- Hyperplasia of the submucosal lymphoid follicles of the appendix accounts for approximately 60% of obstructions (most common in teens).
- In older adults and children, the fecalith (hard part of stool or vegetable matter or seeds) is the most common etiology (35%).
B. Intraluminal pressure
Intraluminal pressure of the obstructed appendiceal lumen increases secondary to continued mucosal secretion and bacterial overgrowth; the appendiceal wall thins, and lymphatic and venous obstruction occurs.
C. Necrosis and perforation
This is the most dreaded complication of appendicitis. Necrosis and perforation develop when the arterial flow is compromised.
Bacteriology
The flora in the normal appendix is very similar to that in the colon or large gut, with a variety of facultative aerobic and anaerobic bacteria. The polymicrobial nature of perforated appendicitis is well established. Escherichia coli, Streptococcus viridans, and Bacteroides and Pseudomonas species are frequently isolated, and many other organisms may be cultured
Diagnosis (How to confirm patient has appendicitis)
A. HISTORY: Appendicitis typically begins with progressive, persistent midabdominal or pain around umblicus. The discomfort usually caused by obstruction and distention of the appendix, Anorexia (Lack of appetite) and a low-grade fever (<38.5°C) follow.Symptoms :include anorexia (90%), nausea and vomiting (70%), and diarrhea (10%) and finally localization of pain in right lower quadrant of abdomen.
Signs: Tenderness is often maximal at or near McBurney's point.Direct rebound tenderness is usually present.
Temperature elevation or pyrexia.
Muscular resistance to palpation of the abdominal wall roughly parallels the severity of the inflammatory process.
B. LAB TEST: Mild leukocytosis( or increased white blood cell counts) ranging from 10,000 to 18,000/mm3, is usually present in patients with acute, uncomplicated appendicitis and is often accompanied by a moderate polymorphonuclear predominance.
C. IMAGING STUDIES: Despite an increased use of ultrasonography, computed tomography (CT) scanning, and laparoscopy the rate of misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture.
X-rays are rarely helpful in diagnosing appendicitis. One study demonstrated an appendicolith on only 1.14% of the x-rays performed on patients.
ultrasonography has a sensitivity of about 85% and a specificity of more than 90% for the diagnosis of acute appendicitis. It is most useful in women of child-bearing age and in children because other causes of abdominal complaints can be demonstrated. Findings associated with acute appendicitis include an appendiceal diameter greater than 6 mm, lack of luminal compressibility, and presence of an appendicolith.
CT scan, originally recommended only in cases that were diagnostically uncertain, has emerged as the most commonly used radiographic diagnostic test. It is superior to US in diagnosing appendicitis, with a sensitivity of 94% and specificity of 95% CT findings of appendicitis include a distended, thick-walled appendix with inflammatory streaking of surrounding fat, a pericecal phlegmon or abscess, an appendicolith, or RLQ intra-abdominal free air that signals perforation. CT scan is particularly useful in distinguishing between periappendiceal abscesses and phlegmon.
Laparoscopic appendectomy is an accepted alternative to traditional open approaches. It is most useful when the diagnosis is uncertain or when the size of the patient would necessitate a large incision. Although recent studies suggest that postoperative lengths of stay may be marginally brieferDifferential Diagnosis
- Acute Mesenteric Adenitis: Acute mesenteric adenitis is the disease most often confused with acute appendicitis in children.
- Acute Gastroenteritis: Acute gastroenteritis is common in childhood but can usually be easily differentiated from appendicitis. Hyperperistaltic abdominal cramps precede the watery stools. Laboratory values are normal.
- Typhoid fever: Differentiation is usually possible because of prostration, maculopapular rash, inappropriate bradycardia, and leukopenia. Diagnosis is confirmed by culture of Salmonella typhosa from stool or blood. Intestinal perforation, usually in the lower ileum, develops in 1% of cases and requires immediate surgical therapy.
- Diseases of the Male Urogenital System: Includs torsion of the testis and acute epididymitis, because epigastric pain may overshadow local symptoms early in these diseases. Seminal vesiculitis may also mimic appendicitis, but can be diagnosed by palpating the enlarged, tender seminal vesicle on rectal examination.
- Meckel's Diverticulitis:Meckel's diverticulitis causes a clinical picture similar to that of acute appendicitis. The Meckel's diverticulum is located within the distal 2 feet of the ileum.
- Intussusception:Appendicitis is very uncommon in children younger than age 2 years, whereas nearly all idiopathic intussusceptions occur in children younger than age 2 years. Intussusception occurs typically in a well-nourished infant who is suddenly doubled up by apparent colicky pain. Between attacks of pain, the infant appears well. After several hours, the patient usually passes a bloody mucoid stool.
- Crohn's Enteritis: The manifestations of acute regional enteritis—fever, right lower quadrant pain and tenderness, and leukocytosis—often simulate acute appendicitis.
- Perforated Peptic Ulcer: Perforated peptic ulcer closely simulates appendicitis if the spilled gastroduodenal contents gravitate down the right gutter to the cecal area.
- Colonic Lesions: Diverticulitis or perforating carcinoma of the cecum, or of that portion of the sigmoid that lies on the right side.
- Epiploic Appendagitis: Epiploic appendagitis probably results from infarction of the colonic appendage(s) secondary to torsion.
- Gynecologic Disorders: The rate of false-negative appendectomies is highest in young adult females. The finding of a normal appendix is seen in 32 to 45% of appendectomies performed in women 15 to 45 years of age. Diseases of the female internal reproductive organs that may be erroneously diagnosed as appendicitis are, in approximate descending order of frequency, pelvic inflammatory disease, ruptured graafian follicle, twisted ovarian cyst or tumor, endometriosis, and ruptured ectopic pregnancy.
- Urinary Tract Infection: Acute pyelonephritis, on the right side particularly, may mimic a retroileal acute appendicitis. Chills, right costovertebral angle tenderness, pyuria, and bacteriuria are usually sufficient to make the diagnosis.
- Ureteral Stone: If the calculus is lodged near the appendix, it may simulate a retrocecal appendicitis. Pain referred to the labia, scrotum, or penis; hematuria; and/or absence of fever or leukocytosis suggest the presence of a ureteral stone.
- Primary Peritonitis: Primary peritonitis occurs most often in patients with nephrotic syndrome, cirrhosis, and endogenous or exogenous immunosuppression.
- Henoch-Schönlein Purpura: This syndrome usually occurs 2 to 3 weeks after a streptococcal infection. Abdominal pain may be prominent, but joint pains, purpura, and nephritis are also frequently present.
- Yersiniosis: Human infection with Yersinia enterocolitica or Y. pseudotuberculosis is transmitted through food contaminated by feces or urine.
- Campylobacter jejuni :causes diarrhea and pain that mimics that of appendicitis.
- Pelvic Inflammatory Disease: The infection is usually bilateral, but if confined to the right tube, may mimic acute appendicitis.
- Ruptured Graafian Follicle:Ovulation commonly results in the spillage of sufficient amounts of blood and follicular fluid to produce brief, mild, lower abdominal pain.
- Ruptured Ectopic Pregnancy: Pregnancies may implant in the fallopian tube (usually the ampullary portion), ovary, and, rarely, the peritoneum. Rupture of right tubal or ovarian pregnancies can mimic appendicitis.The presence of blood and particularly decidual tissue is pathognomonic. The treatment of ruptured ectopic pregnancy is emergency surgery.
- Twisted Ovarian Cyst: When right-sided cysts rupture or undergo torsion, the manifestations are similar to those of appendicitis. Patients develop right lower quadrant pain, tenderness, rebound, fever, and leukocytosis. If the mass is palpable on vaginal exam, the diagnosis can be made easily.Torsion requires emergent operative treatment.
- Other Diseases: Foreign-body perforations of the bowel, closed-loop intestinal obstruction, mesenteric vascular occlusion, pleuritis of the right lower chest, acute cholecystitis, acute pancreatitis, and hematoma of the abdominal wall.
Treatment
A. Preoperative preparation
Most patients with acute appendicitis are managed by prompt surgical removal of the appendix. A brief period of resuscitation is usually required to ensure the safe induction of general anesthesia. Intravenous isotonic fluid replacement should be initiated to achieve a brisk urinary output and to correct electrolyte abnormalities. Nasogastric suction is helpful, especially in patients with peritonitis. Temperature elevations are treated with acetaminophen and a cold fomentation.
B. Antibiotic therapy
Antibiotic prophylaxis is generally effective in the prevention of postoperative infectious complications (wound infection, intra-abdominal abscess). Antibiotic therapy in perforated or gangrenous appendicitis should be continued for 3 to 5 days.
C.Open Appendectomy
With very few exceptions, the treatment of appendicitis is appendectomy.Most surgeons employ either a McBurney (oblique) or Rocky-Davis (transverse) right lower quadrant muscle-splitting incision in patients with suspected appendicitis. The incision should be centered over either the point of maximal tenderness or a palpable mass. If an abscess is suspected, a laterally placed incision is imperative to allow retroperitoneal drainage and to avoid generalized contamination of the peritoneal cavity. If the diagnosis is in doubt, a lower midline incision is recommended to allow a more extensive examination of the peritoneal cavity. This is especially relevant in older patients with possible malignancy or diverticulitis.
The cecum, sigmoid colon, and ileum are carefully inspected for changes indicative of diverticular (including Meckel diverticulum), infectious, ischemic, or inflammatory bowel disease (e.g., Crohn's disease). Evidence of mesenteric lymphadenopathy is sought. In women, the ovaries and fallopian tubes are inspected for evidence of PID, ruptured follicular cysts, ectopic pregnancy, or other pathology. Bilious peritoneal fluid suggests peptic ulcer or gallbladder perforation.
D. Laparoscopic appendectomy
Laparoscopic appendectomy is an accepted alternative to traditional open approaches. It is most useful when the diagnosis is uncertain or when the size of the patient would necessitate a large incision.most patients undergoing routine appendectomy can be safely discharged from the hospital on the first postoperative day.
E. Drainage of periappendiceal abscess
Management of appendiceal abscesses remains controversial. Patients who have a well-localized periappendiceal abscess and are initially seen when symptoms are subsiding can be treated with systemic antibiotics and considered for percutaneous US- or CT-guided catheter drainage, followed by elective appendectomy 6 to 12 weeks later. This strategy is successful in more than 80% of patients. The appendix must be removed because the patient has a 60% risk of developing appendicitis again within 2 years. Systemic antibiotics are administered for at least 5 days or until the patient is afebrile and leukocytosis resolves.
F. Incidental appendectomy
Incidental appendectomy is removal of the normal appendix at laparotomy for another condition. The appendix must be easily accessible through the present abdominal incision, and the patient must be clinically stable enough to tolerate the extra time needed to complete the procedure. Because most cases of appendicitis occur early in life, the benefit of incidental appendectomy decreases substantially once a person is older than 30 years. Crohn's disease involving the cecum, radiation treatment to the cecum, immunosuppression, and vascular grafts or other bioprostheses are contraindications for incidental appendectomy because of the increased risk of infectious complications or appendiceal stump leak.
Complications of Acute Appendicitis
A. Perforation
Perforation is accompanied by severe pain and fever. It is present in 50% of appendicitis patients younger than 10 years and older than 50 years. Acute consequences of perforation include fever, tachycardia, generalized peritonitis, and abscess formation. Treatment is appendectomy, peritoneal irrigation, and broad-spectrum intravenous antibiotics for several days.
B. Postoperative wound infection risk
Postoperative wound infection risk can be decreased by appropriate intravenous antibiotics administered before skin incision. The incidence of wound infection increases from 3% in cases of nonperforated appendicitis to 4.7% in patients with a perforated or gangrenous appendix.
C. Intra-abdominal and pelvic abscesses
Intra-abdominal and pelvic abscesses occur most frequently with perforation of the appendix. Postoperative intra-abdominal and pelvic abscesses are best treated by percutaneous CT- or US-guided drainage. If the abscess is inaccessible or resistant to percutaneous drainage, operative drainage is indicated.
Prognosis
The mortality from appendicitis has steadily decreased . Among the factors responsible are advances in anesthesia, antibiotics, intravenous fluids, and blood products. Principal factors in mortality are whether rupture occurs before surgical treatment and the age of the patient.
Death is usually attributable to uncontrolled sepsis—peritonitis, intra-abdominal abscesses, or gram-negative septicemia. Pulmonary embolism continues to account for some deaths. Aspiration is a significant cause of death in the older patient group.
Morbidity rates parallel mortality rates, being significantly increased by rupture of the appendix and to a lesser extent by old age.
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