APPENDICITIS

Appendicitis is the most common abdominal surgical emergency, affecting approximately 10% of the population. It occurs most commonly between the ages of 10 and 30 years. It is initiated by obstruction of the appendix by a fecalith, inflammation, foreign body, or neoplasm. Obstruction leads to increased intraluminal pressure, venous congestion, infection, and thrombosis of intramu­ral vessels. If untreated, gangrene and perforation develop within 36 hours.

Appendicitis is a painful swelling of the appendix. The appendix is a small, thin pouch about 5 to 10cm (2 to 4 inches) long. It’s connected to the large intestine, where poo forms.

Signs and symptoms

Appendicitis usually begins with vague, often colicky peri­umbilical or epigastric pain. Within 12 hours the pain shifts to the right lower quadrant, manifested as a steady ache that is worsened by walking or coughing.

Almost all patients have nausea with one or two episodes of vomiting. Protracted vomiting or vomiting that begins before the onset of pain suggests another diagnosis.

A sense of consti­pation is typical, and some patients administer cathartics in an effort to relieve their symptoms—though some report diarrhea.

Low-grade fever (below 38°C) is typical; high fever or rigors suggest another diagnosis or appendiceal perforation.

On physical examination, localized tenderness with guarding in the right lower quadrant can be elicited with gentle palpation with one finger. When asked to cough, patients may be able to precisely localize the painful area, a sign of peritoneal irritation. Light percussion may also elicit pain. Although rebound tenderness is also present, it is unnecessary to elicit this finding if the above signs are present.

The psoas sign (pain on passive extension of the right hip) and the obturator sign (pain with passive flexion and internal rotation of the right hip) are indicative of adjacent inflammation and strongly suggestive of appendicitis.

Diagnosis

Both abdominal ultrasound and CT scanning are useful in diagnosing appendicitis as well as excluding other diseases presenting with similar symptoms, including adnexal dis­ease in younger women. However, CT scanning appears to be more accurate (sensitivity 94%, specificity 95%, positive likelihood ratio 13.3, negative likelihood ratio 0.09). Abdominal CT scanning is also useful in cases of suspected appendiceal perforation to diagnose a periappendiceal abscess. In patients in whom there is a clinically high sus­picion of appendicitis, some surgeons feel that preoperative diagnostic imaging is unnecessary. However, studies sug­gest that even in this group, imaging studies suggest an alternative diagnosis in up to 15%.

Treatment

The treatment of early, uncomplicated appendicitis is surgi­cal appendectomy in most patients. When possible, a lapa­roscopic approach is preferred to open laparotomy. Prior to surgery, patients should be given broad-spectrum antibiot­ics with gram-negative and anaerobic coverage to reduce the incidence of postoperative infections. Recommended preoperative intravenous regimens include cefoxitin or cefotetan 1–2 g every 8 hours; ampicillin-sulfabactam 3 g every 6 hours; or ertapenem 1 g as a single dose. Up to 80–90% of patients with uncomplicated appendicitis treated with antibiotics alone for 7 days have resolution of symp­toms and signs. Therefore, conservative management with antibiotics alone may be considered in patients with a non­perforated appendicitis with surgical contraindications or with a strong preference to avoid surgery; however, appen­dectomy generally still is recommended in most patients to prevent recurrent appendicitis (20–35% within 1 year).

Emergency appendectomy is required in patients with perforated appendicitis with generalized peritonitis. The optimal treatment of stable patients with perforated appen­dicitis and a contained abscess is controversial. Surgery in this setting can be difficult. Many recommend percutane­ous CT-guided drainage of the abscess with intravenous fluids and antibiotics to allow the inflammation to subside. An interval appendectomy may be performed after 6 weeks to prevent recurrent appendicitis.