appendicitis- a simplistic view for gps

APPENDICITISA Presentation

Epidemiology• Acute appendicitis is the

most common cause of ‘acute surgical abdomen’

• 6% of the population will suffer from acute appendicitis during their lifetime.

• Nothing can be so easy or as difficult as the diagnosis of acute appendicitis

Anatomy• Blind pouch off of cecum

• Contains lymphoid tissue which peaks in adolescence, atrophies with age

• Function still unclear

• Appendix can be anywhere within peritoneal cavity

• One study showed 65 % retrocecal, 31 % pelvic

• Review of 70,000 cases showed 4 % in RUQ, 0.06 % LUQ, 0.04 % LLQ

Anatomy

Pathophysiology• Lymphoid hyperplasia leads to

luminal obstruction

• Often follows viral illness

• Epithelial cells secrete mucus

• Appendix distends, bacteria multiply

• Visceral pain begins an average of 17 hours after obstruction

• Increased pressure compromises blood supply

• Somatic pain develops

• Average time to perforation = 34 hrs.

Clinical presentation

• Classical presentation seen in 60 %

AnorexiaPeri umbilical pain, nausea, vomiting

• RLQ pain developing over 24 hrs.

• Anorexia and pain are most frequent

• Usually nausea, sometimes vomiting

• Diarrhoea, esp. with pelvic location

• Usually tender to palpation

• Rebound is a later finding

Symptoms

Signs

Migration of Pain

Examination

Tenderness

SPECIAL FEATURES, ACCORDING TO POSITION

OF THEAPPENDIX

.

RETROCAECAL-Rigidity in often

absent

- Psoas spasm due to inflamed appendix in contact with the muscle may cause flexion of hip

PELVIC-Early diarrhoea

due to contact with rectum

-When inflamed

appendix is in contact with Bladder, may cause frequency of micturition.

MANTRELS Score

Migration of painAnorexiaNausea / vomitingTenderness RLQReboundElevated temp.LeukocytosisShift to left

MANTRELS Score

• RLQ tenderness and leukocytosis = 2 points each ; all others 1 point

• Score of 5 to 6 = possible appendicitis

• Score of 7 to 8 = probable appendicitis

• Score of 9 to 10 = very probable appendicitis

HIGHRISKPATIENTS&GROUPS

Ovulating women

• PID, TOA, ovarian cyst rupture can mimic appendicitis

• Look for cervical motion tenderness, adnexal tenderness, history of STD’s

• Can have CMT with pelvic appendix

Pregnancy

• Most common surgical emergency in pregnancy

• Mortality rate if missed = 2 % for mother, up to 35 % for fetus

• WBC elevated in pregnancy

• Appendix changes location

Pediatric Population

• Most common surgical disorder in kids

• Accounts for 5 % of abd. pain visits

• Up to 50 % initially misdiagnosed

• < 2 yrs. : perforation rate approaches 100 %

• 3 to 5 yrs. = 71 %

• 6 to 10 yrs. = 40 %

• Most common misdiagnosis is AGE

• Sequence of pain and vomiting may be helpful

• Localized tenderness not a feature of AGE

Elderly

• Vital signs and exam may not reflect severity

• > age 60 : only 5 to 10 % diagnosed without delay

• Perforation rate = 46 to 83 %

• RLQ tenderness absent in 23 %

• N/V, anorexia less common

• Leukocytosis less pronounced

• Only 20 % classic presentation

Immunocompromised

• HIV, chronic steroids, sickle cell, chemotherapy, DM, dialysis

• Increased risk of complications and misdiagnosis

• Inflammatory response decreased

Differential Diagnosis

• Gastroenteritis

• Mesenteric lymphadenitis

• PID

• Mittelschmertz

• Crohn's disease

• Diverticulitis

• Endometriosis

• TOA

• Ectopic pregnancy

• UTI

• Pyelonepritis

• Other processes involving appendix

INVESTIGATIONS

CBC

• 75 to 85 % have elevated WBC, but it is nonspecific

• WBC normal in 80 % in the first 24 hrs.

• Can see elevated ANC in up to 89 %

• WBC usually 12 to 18,000 in appendicitis

• Chemistry panel may help with diagnosis of dehydration

OTHERS• UrinalysisSpecific gravity, ketonesCan see WBC’s, RBC’s, bacteria

if inflamed appendix close to ureter

> 30 WBC’s = probable UTI

• HCG Essential in women of child-

bearing age

• CRPAcute phase reactant

PLAIN FILMS

• Low sensitivity and specificity

• Appendicolith specific, but seen in only 2 %

• May see local air-fluid levels, psoas obliteration, soft tissue mass, gas in appendix

• All nonspecific

ULTRASONOGRAM• 75 to 90 % sensitive, 86 to

100 % specific

• Non invasive, low cost, but operator-dependent

• Good for diagnosing GYN disorders

3 criteria for diagnosisTender, non compressible

appendixNo peristalsis of appendixOverall diameter > 6 mm

COMPUTED TOMOGRAM• Early studies showed low

yield, but helical CT much more accurate

• Sensitivity 97 to 100 %, specificity 95 % (similar no matter what type or whether contrast is used)

• Often shows alternative diagnosis

• More expensive, radiation exposure

DO WE NEED IMAGING?• Literature conflicting

• Imaging most useful in clinically equivocal cases

• Costs of imaging minor compared to cost of unnecessary surgery or delayed diagnosis

• US and CT both specific enough to rule in appendicitis, but only CT sensitive enough to rule it out

NEJM CONSENSUS• Patients with classic presentation

should go to O.R. Diagnostic accuracy approaches 95 %

• If equivocal/suspect perforation : CT

• US reserved for pregnant women or high suspicion of GYN disease

• If study indeterminate, observe with repeated exams or laparoscopy

ANALGESIA?

Prospective studies (both EM and Surgery literature) now show appropriate use of IV narcotics does not decrease diagnostic accuracy, and may improve exam

7 FEATURES OF MISSED DIAGNOSIS

• No nausea / vomiting

• Lack of distress

• No rebound

• No guarding

• No rectal exam (controversial)

• Narcotic pain meds given

• Diagnosis of acute gastroenteritis

No single evaluation can substitute for the diagnostic accuracy of the experienced physician.

WHEN IN DOUBTDO NOT DISCHARGE

COMPLICATIONSOF ACUTE APPENDICITIS

APPENDICULAR MASS• Localization of

infection 3-5 days after attack of acute appendicitis

• Inflamed appendix

• Omentum

• Caecum

• Dilated ileum

• Tender

• Smooth

• Firm

• Not mobile

Treatment (Ochsner sherren )• Temp, BP, Pulse q 4h

• Marking the mass – (progression or regression)

• Antibiotics

• Metronidazole

• Ampicillin

• Gentamycin

• IV fluids

• IV antibiotics

• Nasogastric aspiration q 4h

WHEN TO STOP?

• Toxic symptoms

• Increase in size of mass

• Abscess formation

• Features of peritonitis

APPENDICULAR ABSCESSSuppuration in acute

appendicitisSites:RetrocaecalPelvicSubphreniclumbarC/F:High feverFeatures of peritonitis

( guarding / rigidity) Raised TC (>18,000)

MANAGEMENT

• Antibiotics

• Extra peritoneal drainage

GANGRENOUS APPENDIX

PERFORATED APPENDIX

LAP APPENDECTOMY

LAP APPENDECTOMY

COMPLICATIONS OF APPENDECTOMYEarly complications:1. Paralytic ileus2. Sepsis – local wound abscess,

pelvic abscess.3. Rupture of the stump or caecal

wall.4. Haemorrhage: At any time during

the first 72 hours after surgery means either leakage from the stump or a slipped arterial ligature.

Late complications 1. Intestinal obstruction due to local

adhesive bands.2. Incisional hernia

KEY POINTSDiagnosis of appendicitis is by

clinical evaluation

Definitive treatment is surgery

Lap has distinct advantages over open surgery

If Left untreated complications are dreaded

THANK YOU