Acute Appendicitis

• Appendix


  An intraperitoneal hollow outpouching of the gut which arises from the caecum, suspended by the mesoappendix from the terminal portion of the ileum and commonly sits retrocaecally
• Function of the Appendix


  • It is a concentrate of lymphoid tissue resembling Peyer's patches and is the primary site for immunoglobulin A production which is crucial to regulate the density and quality of the intestinal flora
  • It is extremely rich in biofilms that continuously shed bacteria into the intestinal lumen and could replenish the large intestine with healthy flora after a diarrhea episode
• Acute Appendicitis


  Inflammation of the appendix and is one of the most common indication for emergency surgery in patients
• Appendicitis is one of the most common cause of acute abdominal pain
• Epidemiology & Demographics of Appendicitis

  • Occurs in 10% of the population, most commonly between the ages of 10 and 30 yr
  • Median age is 22 yr
  • Lifetime risk is 7% to 8%
  • Approximately 300,000 appendectomies are performed in the U.S. each yr
  • It is the most common abdominal surgical emergency
  • Incidence of appendicitis has declined over the past 30 yr
  • Male:female ratio is 3:2 until mid-20s; it equalizes after age 30 yr
• Causes of Appendiceal Lumen Obstruction

  • Inflammation: 50% to 60% of cases (submucosal lymphoid hyperplasia [most common etiology in children, teens])
  • Fecaliths: 30% to 35% of cases (most common in adults)
  • Foreign body: 4% (fruit seeds, pinworms, tapeworms, roundworms, calculi)
  • Neoplasms: 1% (carcinoids, metastatic disease, carcinoma)
• Pathophysiology of Acute Appendicitis


  1. Luminal obstruction, usually either secondary to a faecolith or lymphoid hyperplasia, or less commonly by a malignancy (such as a caecal adenocarcinoma or appendiceal neuroendocrine tumour)

  2. Commensal bacteria in the appendix can multiply, resulting in acute inflammation

  3. Reduced venous and lymphatic drainage and localised inflammation can result in increased pressure within the appendix, in turn resulting in ischaemia within the appendiceal wall

  4. If left untreated, ischaemia can result in necrosis, which in turn can cause the appendix to perforate, leading to perforation
• Physical Findings & Clinical Presentation


  • Abdominal pain: Initially the pain may be epigastric or periumbilical in nearly 50% of patients; it subsequently localizes to the right lower quadrant within 12 to 18 h
  • Migration of pain in appendicitis: Initial inflammation stimulates visceral afferent pain fibres which correspond to the T10 dermatome, producing umbilical pain. As the appendix becomes more inflamed, it irritates the parietal peritoneum which activates somatic nerve fibres and produces localised pain which is most often felt in the right iliac fossa
  • Pain with right thigh extension (psoas sign), low-grade fever: Temperature may be >38° if there is appendiceal perforation
  • Pain with internal rotation of the flexed right thigh (obturator sign) is present
  • Right lower quadrant (RLQ) pain on palpation of the left lower quadrant (LLQ) (Rovsing sign): Physical examination may reveal right-sided tenderness in patients with pelvic appendix
  • Point of maximum tenderness is in the RLQ (McBurney point)
  • Low grade fever, Nausea and vomiting can be present
• Murphy's triad


  A combination of clinical features often seen in appendicitis made up of: Nausea and vomiting, Low-grade fever, Right iliac fossa pain
• Differential Diagnosis


  • Gynaecological - ovarian cyst rupture, ectopic pregnancy, pelvic inflammatory disease
  • Renal - ureteric stones, urinary tract infection, pyelonephritis
  • Gastrointestinal - inflammatory bowel disease, Meckel's diverticulum, or diverticular disease
  • Urological - testicular torsion, epididymo-orchitis
  • In children: mesenteric adenitis, gastroenteritis, constipation, intussusception, or UTI
• Bedside Investigations


  • Urinalysis: to rule out urinary tract infection
  • Capillary blood glucose: nausea, vomiting and anorexia may have cause hypoglycaemia. Hyperglycaemia would be more suggestive of diabetic ketoacidosis and further investigation of this would be required
  • Pregnancy test for females of child bearing age
  • Baseline vital signs: a low-grade fever may be present
• Laboratory Investigations


  • Full blood count: raised white cell count
  • Urea & electrolytes: anorexia, nausea and vomiting may cause deranged renal function in severe cases
  • CRP: suggestive of inflammation
  • Blood Grouping: appendicitis management is typically operative and so this test is important as a transfusion may be required if there is a significant intraoperative blood loss
• Appendicitis Diagnosis


  Appendicitis is a clinical diagnosis, but imaging helps to determine the extent of appendix inflammation, as well as showing its exact anatomical location
• Imaging Modalities


  • Ultrasound: Accepted 1st-line imaging for appendicitis
  • CT: Cross-sectional imaging used for appendicitis
  • MRI: Used in cases where radiation and diagnostic difficulties preclude use of other modalities (e.g. pregnancy)
• Typical Ultrasound Findings


  • Non-compressible appendix (> 6mm in diameter)
  • Appendicolith presence within the appendix
  • Wall thickening (≥ 3mm)
• Diagnostic Criteria


  • Plain radiography: No role in diagnosis of acute appendicitis, although in some cases a faecolith may be shown
  • Ultrasonography: Aperistaltic and non-compressible structure with diameter >6 mm. Sensitivity of 86%; specificity of 81%
  • Computed tomography scanning: Abnormal appendix identified or calcified appendicolith seen in association with periappendiceal inflammation or diameter >6 mm. Sensitivity of 94% and specificity of 95% in diagnosis of acute appendicitis
  • Magnetic resonance imaging: Not confirmed. Restricted to cases in which radiation and diagnostic difficulties preclude use of other modalities (for example, pregnancy)
• Clinical Decision Tools


  • Appendicitis Inflammatory Response (AIR) score
  • Alvarado score
• Alvarado Score


  • Abdominal pain that migrates to the right iliac fossa: 1
  • Anorexia (loss of appetite) or ketones in the urine: 1
  • Nausea or vomiting: 1
  • Tenderness in the right iliac fossa: 2
  • Rebound tenderness: 1
  • Fever of 37.3 °C or more: 1
  • Leukocytosis > 10,000: 2
  • Neutrophilia > 70%: 1
• Alvarado Score Interpretation


  • Score of 5 or 6 = unlikely acute appendicitis
  • Score of 7 or 8 = probable appendicitis
  • Score of 9 or 10 = high probability of acute appendicitis
• Management of Appendicitis


  • The current definitive treatment is laparoscopic appendicectomy
  • In certain cases, a non-surgical conservative approach may be trialled with antibiotics alone, such as in high-risk surgical candidate with uncomplicated appendicitis. However, this has a failure rate of 25-30% at one year
  • If cases of an appendiceal mass, antibiotic therapy is favoured, with an interval appendectomy then performed approximately 6-8 weeks later
• Surgical Intervention


  • Laparoscopic appendicectomy remains the gold standard for treating an acute appendicitis. It provides a definitive treatment, is a relatively low-risk procedure, and allows direct visualisation of other organs
  • Open approach (via a Lanz incision) may still be used in certain cases and is routinely performed in some healthcare systems, however the laparoscopic approach has been shown to reduced hospital stay and permit earlier return to baseline activity
• The appendix should routinely be sent to histopathology once removed, to assess for any underlying malignancy
• Cochrane analysis found that appendicectomy should remain the standard treatment for acute appendicitis
• If cases of an appendiceal mass

  1. Antibiotic therapy is favoured

  2. Interval appendectomy performed approximately 6-8 weeks later
• Laparoscopic appendicectomy


  • Definitive treatment for appendicitis (compared to antibiotic therapy alone)
  • Relatively low-risk procedure
  • Allows direct visualisation of other organs
• Open appendectomy


  • May still be used in certain cases
  • Routinely performed in some healthcare systems
  • Laparoscopic approach has been shown to reduced hospital stay and permit earlier return to baseline activity
• The appendix should routinely be sent to histopathology once removed, to assess for any underlying malignancy, as this is identified in around 1% of cases
• NONPHARMACOLOGIC THERAPY


  1. Nothing by mouth

  2. Do not administer analgesics until the diagnosis is made
• ACUTE GENERAL Rx


  1. Urgent appendectomy (laparoscopic or open)

  2. Correction of fluid and electrolyte imbalance with intravenous (IV) hydration, and electrolyte replacement

  3. IV antibiotic prophylaxis to cover gram-negative bacilli and anaerobes (ampicillin)

  4. For patients who undergo appendectomy, antibiotics should be discontinued postoperatively
• If non-operative treatment is anticipated

  1. Administration of a long active parenteral antibiotic (ceftriaxone)

  2. High dose, once daily metronidazole can facilitate early discharge

  3. Parenteral antibiotics are followed by oral regimen of metronidazole plus advanced generation cephalosporin or fluoroquinolones for 7 to 10 days
• Laparoscopic appendectomy

  1. Visualization and upward retraction of appendix

  2. Division of the mesoappendix using harmonic scalpel

  3. Application of endoloops to the appendix

  4. Specimen is then divided between the endoloops
• Open appendectomy

  1. A larger incision was made in the lower right abdomen

  2. They opened the abdominal cavity and separated the abdominal muscles to locate the appendix beneath

  3. If the appendix has ruptured, there may be an abscess or fluid in the abdominal cavity to drain before they can perform the appendectomy

  4. Then they rinsed the abdominal cavity with a saline solution

  5. Then appendix was tied off with stitches, then detached from the intestine and removed
• Nonperforated appendicitis


  The gold standard treatment is appendectomy
• Preoperative care for nonperforated appendicitis

  1. IV Hydration

  2. Electrolyte replacement

  3. Bowel rest

  4. Pre operative Antibiotics (ampicillin–sulbactam, cefoxitin, and/or cefotetan)
• Laparoscopic appendectomy (LA)


  • Generally the procedure of choice
  • Advantages: less postoperative pain, lower rate of wound infection, shorter length of hospital stay, shorter recovery, and improved cosmesis
• Open appendectomy (OA)


  Certain patients are more suitable: those with significant intestinal dilatation, those with generalized peritonitis, and those that cannot tolerate pneumoperitoneum
• Perforated appendicitis


  Patients have a delayed or unusual presentation
• Management of perforated appendicitis


  1. Intravenous hydration and broad-spectrum antibiotics

  2. Early appendectomy within 24 hours of hospitalization with any intra abdominal abscesses identified drained intraoperatively

  3. Interval appendectomy 6 to 8 weeks after the initial diagnosis

  4. Presence of a periappendiceal abscess may warrant percutaneous, image-guided drainage
• Recent evidence may be in favor of routine use of early appendectomy in perforated appendicitis, but no consensus is yet reached between early and interval appendectomy
• If perforated appendicitis is diagnosed intraoperatively


  Antibiotics are continued until the patient is afebrile with resolution of leukocytosis