APPENDICITIS

Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laporatomyr or laporoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginal fitz first described acute and chronic appendicitis in 1886,and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".

Signs

Location of the appendix in the digestive system

These include localized findings in the right illiac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there isrebound tenderness.

Causes

On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen.Once this obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis oflyphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. Asbacteria begin to leak out through the dying walls,pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicimia and eventually death.

Diagnosis

Ultrasound

Ultrasound image of an acute appendicitis.

 

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children.
In some cases (15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis.

Computed tomography

A cat scan demonstrating acute appendicitis (note the appendix has a diameter of 17.1mm and there is surrounding fat stranding.)

A fecalith marked by the arrow which has resulted in acute appendicitis.

 

In places where it is readily available, has be CT scancome frequently used, especially in adults whose diagnosis is not obvious on history and physical. Concerns about radiation, however, tend to limit use of CT in pregnant women and children.

Ultrasound and CT compared

According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents.

Management

Inflamed appendix removal by open surgery

Before surgery

The treatment begins by keeping the patient fronm eating and drinking in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metrodinazole may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.
Once the decision to perform an appendectomy has been made, the preparation procedure takes more or less one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. With all surgeries there are certain risks that must be evaluated before performing the procedures. However, the risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%.The most usual complications that can occur are pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesion.
The surgeon will also explain how long the recovery process should take. Abdomen hair is usually removed in order to avoid complications that may appear regarding the incision. In most of the cases patients experience nausea or vomiting which requires specific medication before surgery. Antibiotics along with pain medication may also be administrated prior to appendectomies.

Pain management

Pain from appendicitis can be severe. Strong pain medications (i.e. narcotic pain medications) are recommended for pain management prior to surgery. Morphine is generally the standard of care in adults and children in the treatment of pain from appendicitis prior to surgery.
In the past (and in some medical textbooks that are still published today), it has been commonly accepted that pain medication not be given until the surgeon has the chance to evaluate the patient, so as to not "corrupt" the findings of the physical examination. This line of practice, combined with the fact that surgeons may sometimes take hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to drive in from home, often leads to a situation that is ethically questionable at best. More recently, due to better understanding of the importance of pain control in patients, it has been shown that the physical examination is actually not that dramatically disturbed when pain medication is given prior to medical evaluation. Individual hospitals and clinics have adapted to this new approach of pain management of appendicitis by developing a compromise of allowing the surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain management is initiated. Many surgeons also advocate this new approach of providing pain management immediately rather than only after surgical evaluation.

Surgery

Laparoscopic appendectomy.

 

The surgical procedure for the removal of the appendix is called an appendicectomy (also known as an appendectomy). Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to visualize the area of interest in the abdomen. If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy incision if required most often centers on the area of maximum tenderness,  in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly.