Surgery

Appendicitis symptoms

The partial inflammation of the peritoneum, in the iliac fossa, is sometimes set up by disease in Appendix caeci. The appendix having been perforated by ulcerations, occasioned by the lodgement of the faecal concretions in its cavity, extravasation takes place, and inflame-motion of a more severe and serious kind is originated. Nature sometimes succeeds in limiting the inflammation too part right side, but it is at other times diffused over the whole abdomen, and quickly proves fatal. The important appendicitis symptoms are discussed in the main article.

—Thomas Hodgkin, 1836

Aetiology

  • It is common in young males.
  • It is common in white races.
  • Fibre rich diet prevents appendicitis. Less fibre diet increases chance of appendicitis.
  • It is familiar in May, and August-seasonal variation-often called as epidemic appendicitis.
  • Active infection may cause mucosal oedema, inflammation, and that afters get contaminated by bacteria causing appendicitis.
  • The family records may be relevant in 30% of appendicitis in children with appendicitis occurring in first degree relatives.
  • Obstruction of the lumen of appendix resulting in obstructive appendicitis.
    1. Blockage occurs due to—faecoliths, stricture, foreign body, roundworm, or threadworm.
    2. Adhesions and kinking—carcinoma caecum near the base, ileocaecal Crohn’s disease.
  • Distal colonic obstruction.
  • Abuse of purgatives.
  • Faecolith is the most common cause.

Organisms:

  1. coli (85%), enterococci, (30%), streptococci, Anaerobic streptococci, Cl. welchii, bacteroides.

Pseudoappendicitis is appendicitis due to acute ileitis following Yersinia infection. It is often due to Crohn’s disease.

Symptoms of appendicitis

The common appendicitis symptoms are enlisted below:

  • Sudden pain that begins on the right side of the lower abdomen pain
  • Sudden pain that impels around your navel and repeatedly shifts to your lower right abdomen.
  • Pain that aggravates if you cough, walk or make any jarring movements.
  • Nausea and vomiting
  • Low-grade fever
  • Loss of appetite (anorexia)
  • Constipation or diarrhoea

The site of your pain may alter, depending on your age and the position of your appendix. When you’re pregnant, the pain may seem to begin from your upper abdomen because your appendix is superior to the normal position during pregnancy.

Clinical signs in appendicitis

  • Rovsing’s sign
  • Blumberg’s sign (Release sign)
  • Cope’s psoas test
  • Obturator test
  • Baldwing’s test
  • Bastede sign
  • Dumphy’s cough tenderness sign (Refer fascinating signs for detail)
  • Bapat bed shaking test
  • Heel Drop test
Acute appendicitis in infancy:

Even though it is rare when it occurs, it has got 80% chances of perforation with high mortality (50%).

Acute appendicitis in children:
    • Here localization is not present, and so peritonitis occurs early.
    • It requires early surgery. Dehydration, septicemia are common.
In elderly:

Gangrene and perforation are common. Because of the lax abdominal wall, localization is poor, and so peritonitis sets in early.

In pregnancy:
  • Incidence is 1 in 2,000 pregnancies. It is more common in 1st and 2nd trimesters.
  • Appendix shifts to the upper abdomen. So pain is higher and more lateral.
  • Rebound tenderness and guarding may not be evident.
  • TC will be very high with neutrophilia.
  • The risk of premature labour is 15%.
  • Fetal death in early appendicitis is 5% but becomes 29% once appendix perforates in pregnancy.
  • After six months, maternal mortality increases by ten times than usual and also leads to premature labour.
  • Appendicitis is the most common non-gynaecologic surgical emergency during pregnancy.
  • The incidence of perforation is highest in 3rd trimester.
  • Surgery is the treatment.

Pathogenesis

  • Acute inflammation of the mucous membrane with the secondary disease without obstruction causes acute nonobstructive appendicitis. It may lead to resolution, fibrosis, recurrent appendicitis, or eventual obstructive appendicitis.
  • Luminal obstruction by faecolith, lymphoid hyperplasia, pinworm (Oxyuris Vermicularis), other worms, foreign body, carcinoma/Crohn’s disease-mucus, and inflammatory fluid collects inside the lumen–increases intraluminal pressure—leads to blockage of lymphatic and venous drainage–resulting in increased oedema of mucosa and wall-causes mucosal ulceration and ischemia —bacterial translocation —bacterial spread through submucosa and muscularis Propria –acute obstructive appendicitis—thrombosis of appendicular artery–ischaemic necrosis of full thickness of the wall of the appendix–gangrene of the appendix—perforation at the tip or at the base–peritonitis.
  • After perforation– localization by greater omentum and dilated ileum occurs—with suppuration and pus inside forming an appendicular abscess.
  • In severe acute appendicitis,  —localization can occur by omentum and dilated ileum without pus inside—forming an appendicular mass.
  • Acute appendicitis with obstruction at the opening of the lumen—inflammation rarely subsides—mucus collects inside the lumen of the appendix resulting in its enlargement—Mucocele of the appendix.

Types

Acute nonobstructive appendicitis (catarrhal) (mucosal appendicitis):

Inflammation of mucous membrane occurs with redness, oedema, and haemorrhages which may go for following courses:

  • Resolution
  • Ulceration
  • Fibrosis
  • Suppuration
  • Recurrent appendicitis
  • Gangrene-rare initially in nonobstructive type but later can occur
  • Peritonitis. 
  1. Acute obstructive appendicitis: Here, pus collects in the blocked lumen of the appendix, which is blackish, gangrenous, oedematous, and rapidly progresses, leading to perforation either at the tip or at the base of the appendix. This leads to peritonitis, the formation of an appendicular abscess or pelvic abscess. Most often, there will be thrombosis of the appendicular artery.
  2. Recurrent appendicitis: Repeated attacks of nonobstructive appendicitis leads to fibrosis, adhesions causing recurrent appendicitis.
  3. Subacute appendicitis is a milder form of acute appendicitis.
  4. Stump appendicitis is retained long stump of the appendix after commonly laparoscopic appendicectomy.
  • It is rare before the age of two, common in children and other age groups.
  • Pain: It is the earliest symptom. Visceral pain starts around the umbilicus due to distension of appendix, and later after a few hours, somatic pain occurs in right iliac fossa due to irritation of parietal peritoneum due to inflamed appendix. The pain eventually becomes severe and diffuse, which signifies the spread of infection into the general peritoneal cavity.
  • Vomiting: Due to reflex pylorospasm.

Murphy's triad

• Pain—first • Vomiting—next • Temperature—last
  • Constipation is the usual hallmark, but diarrhoea can occur if the appendix is in post ileal or pelvic positions.
  • Fever, tachycardia, foetor oris are other features.
  • Urinary reiterations: Inflamed appendix may come in touch with bladder and can cause bladder irritation.
  • Tenderness and rebound tenderness at McBurney’s is the point in right iliac fossa (release sign-Blumberg ‘s sign) are typical.
  • Rovsing’s sign: On palpating left iliac fossa, pain occurs in the right iliac fossa, which is due to the shifting of bowel loops, which irritates the parietal peritoneum.
  • Hyperextension (in case of retrocausal appendix-Cope’s psoas test) or internal rotation (in case of the pelvic appendix-obturator test) of the right hip causes pain in right iliac fossa due to irritation of psoas muscle and obturator Internus muscle respectively.
  • Baldwing’s test is positive in Retrocaecal appendix-when legs are lifted off the bed with the knee extended, the patient complains of pain while pressing over the flanks.
  • P/R examination shows tenderness on the right side of the rectum
  • Hyperaesthesia in ‘Sherren’s triangle.’ This triangle is assembled by anterosuperior iliac spine, umbilicus, pubic symphysis.

 Differential Diagnosis for Acute Appendicitis

Many conditions mimic acute appendicitis. It differs in children, adults, elderly, and females.

  • They have a perforated duodenal ulcer. In duodenal ulcer perforation, fluid creeps to the bottom along the right paracolic gutter and mimics appendicitis. Upper abdominal pain, obliterated liver dullness, gas under the diaphragm in X-ray, and CT scan differentiate it from acute appendicitis.
  • Acute cholecystitis: Pain in the right upper abdomen, fever, jaundice, upper abdominal guarding are the features of acute cholecystitis. US; HIDA scan, LFT will differentiate it from acute appendicitis.
  • Acute pancreatitis: Pain in epigastrium, radiating to back, raised serum amylase and lipase, CT abdomen with a history of alcohol intake often are diagnostic.
  • Right ureteric colic: Pain is colicky in nature, which often refers to genitalia. Haematuria, urinary symptoms are common. It mimics Retrocaecal/pelvic acute appendicitis. Often in ureteric stone, the abdomen is soft and non-tender. CT is an important way to differentiate.
  • Acute typhlitis: Inflammation of caecum is called as typhlitis. Often it is difficult to differentiate it from acute appendicitis. Intravenous/oral metronidazole completely controls the disease.
  • Acute bacterial enterocolitis: It presents with pain abdomen, diarrhoea, toxaemia, dehydration. Often it is difficult to differentiate from acute appendicitis.
  • Right-sided acute pyelonephritis: Here, there will be pain and tenderness in loin. Urine analysis, US are diagnostic. Often DTPA scan may be needed.
  • Crohn ‘s disease presenting with acute symptoms will have similar features of acute appendicitis.
  • Pelvic inflammatory disease, like salpingo-oophoritis, mimics acute appendicitis. Twisted/haemorrhagic/ruptured ovarian cyst/ruptured ectopic gestation/endometriosis/Tubo-ovarian abscess mimics acute appendicitis. US laparoscopy helps to differentiate it from others. Mittelschmerz is lower abdominal pain due to the rupture of follicular cyst during midcycle. It subsides on its own. There are no systemic features.
  • Meckel’s diverticulitis presents clinically like acute appendicitis. It is not possible to differentiate between two clinically.
  • Intussusception mimics acute appendicitis in children. ISS is common before the age of 2 years. Acute appendicitis is rare before the age of 2 years. Palpable mass, features of intestinal obstruction, barium enema X-ray, US are useful methods to differentiate.
  • Worm infestation (roundworm bolus/ball): It often presents as pain in the right iliac fossa. Features of intestinal obstruction are common here.
  • Right-sided lobar pneumonia and pleurisy are often not easy to differentiate from acute appendicitis. Pleural rub, change in breath sounds, chest X-ray can identify pneumonia.
  • Testicular torsion/acute severe orchitis often look like acute appendicitis. Referred pain in the iliac fossa, and if scrotum is not palpated clinically these conditions are mistaken for acute appendicitis. These problems are much more obvious if the testis is undescended
  • Sigmoid diverticulitis in elderly with loop lying towards right side may present as pain in the right iliac fossa.
  • Carcinoma caecum may present with features of acute appendicitis without any earlier typical features.
  • Ruptured aortic aneurysm, acute intestinal obstruction, mesenteric ischaemia may present as acute appendicitis.
  • Rare conditions like preherpetic pain of the right 10th and 11th dorsal nerves may mimic acute appendicitis. Guarding and rigidity will not be present. There will be significant hyperaesthesia.
  • Tabetic crisis, tuberculosis of the spine, secondaries in the spine, multiple myeloma, osteoporotic pain often can mimic acute appendicitis.
  • Acute crisis of porphyria and diabetes mellitus mimic acute appendicitis with severe abdominal pain.

Differential diagnosis

  • Perforated peptic ulcer
  • Ruptured or twisted ovarian cyst
  • Acute cholecystitis
  • Right ureteric colic
  • Enterocolitis
  • Right acute pyelonephritis
  • Mesenteric lymphadenitis
  • Lobar pneumonia
  • Crohn’s disease
  • Acute pancreatitis
  • Meckel’s diverticulitis
  • Acute crisis of porphyria
  • Salpingitis
  • Diabetic abdomen
  • Ectopic gestation—ruptured
  • Typhlitis

Differential diagnosis in children

  • Meckel’s diverticulitis
  • Acute colitis
  • Acute iliac lymphadenitis
  • Intussusception
  • Roundworm colic
  • Lobar pneumonia

Differential diagnosis in females

  • Ruptured ectopic gestation
  • Mittelschmerz rupture of the ovarian follicle during the mid-menstrual period
  • Ovarian cyst torsion
  • Salpingo-oophoritis

Differential diagnosis in the elderly

  • Acute diverticulitis
  • Carcinoma caecum—acute features
  • Mesenteric ischaemia
  • Intestinal obstruction
  • Aortic aneurysm leak
  • Crohn’s disease

Sequelae of acute appendicitis

  • Resorption
  • Relapse and recurrent appendicitis
  • Appendicular mass
  • Appendicular abscess
  • Perforation—has got 20% mortality
  • Peritonitis, septicemia
  • Portal pyemia
  • Intestinal obstruction due to obstructive ileus, inflammatory adhesion, the formation of the band between appendix and omentum or between the appendix and small bowel 

Investigations

  • The total leucocyte count is increased.
  • Ultrasound is done to rule out other conditions like ureteric stone, pancreatitis, ovarian cyst, ectopic pregnancy, and also to confirm appendicular mass or abscess.
  • Laparoscopy is the most useful method.

Sonographic criteria for appendicitis (85% Specificity)

  • Noncompressible appendix of size > 6 mm AP diameter, hyperechoic thickened appendix wall > 2 mm—target sign.
  • Appendicolith.
  • Interruption of submucosal continuity.
  • Periappendicular fluid.
  • Kalam modified Alvarado scoring (1994), where the shift to the left is removed.
  • Tzamakis scoring system 2005-lower abdominal tenderness-4; rebound tenderness-3; total count> 12,000/cm-2; USG features-6.
  • RIPASA scoring system (2010)-with parameters.
  • Anderson scoring system-8 parameters.

 Treatment

Surgery-Appendectomy:

Read all the detail about Appendectomy

Also, read the prevention of appendicitis

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