Appendicitis - Clinicals, Diagnosis, and Management

Colorectal

Clinicals - History

Fact Explanation
Colicky abdominal pain Colicky pain arises due to the inflammation and obstruction of the appendix. During the initial stages patient complains of peri-umbilical pain which later localizes to the right iliac fossa. The embryological origin of the appendix is the mid-gut. So the initial visceral pain is referred to the peri-umbilical region. Once the inflammation progresses and involves the parietal peritoneum pain becomes more localized to the right iliac fossa. Coughing and sneezing exacerbates the pain. However in elders pain may rarely be localized to the right iliac fossa.
When the inflamed appendix perforates it causes peritonitis. The patient lies still on the bed because even a slight movement aggravates the pain.
Colicky abdominal pain
Colicky pain arises due to the inflammation and obstruction of the appendix. During the initial stages patient complains of peri-umbilical pain which later localizes to the right iliac fossa. The embryological origin of the appendix is the mid-gut. So the initial visceral pain is referred to the peri-umbilical region. Once the inflammation progresses and involves the parietal peritoneum pain becomes more localized to the right iliac fossa. Coughing and sneezing exacerbates the pain. However in elders pain may rarely be localized to the right iliac fossa.
When the inflamed appendix perforates it causes peritonitis. The patient lies still on the bed because even a slight movement aggravates the pain.
Anorexia This occurs prior to the onset of abdominal pain and relatively constant symptom. Anorexia
This occurs prior to the onset of abdominal pain and relatively constant symptom.
Nausea and or vomiting Nausea and vomiting results due to the sympathetic activation secondary to visceral pain. Nausea and or vomiting
Nausea and vomiting results due to the sympathetic activation secondary to visceral pain.
Fever Fever occurs after the first 6 hours. Fever occurs due to the inflammation and release of pyrogens. Fever
Fever occurs after the first 6 hours. Fever occurs due to the inflammation and release of pyrogens.
Diarrhea In pelvic appendix this is a relatively early feature. Diarrhea also occurs in post ileal appendix as well. Inflamed appendix irritates the adjacent bowel loops and causes diarrhea. Diarrhea
In pelvic appendix this is a relatively early feature. Diarrhea also occurs in post ileal appendix as well. Inflamed appendix irritates the adjacent bowel loops and causes diarrhea.
Increased frequency of micturition In pelvic appendix which lies over the bladder causes irritation of the bladder and results in increased frequency of micturition. Increased frequency of micturition
In pelvic appendix which lies over the bladder causes irritation of the bladder and results in increased frequency of micturition.
Excessive retching This occurs with post ileal appendix. Excessive retching
This occurs with post ileal appendix.

Clinicals - Examination

Fact Explanation
Fever Patient is febrile after the first 6 hours. This is usually a low-grade fever. Fever
Patient is febrile after the first 6 hours. This is usually a low-grade fever.
Tachycardia Fever occurs with the onset of fever. Tachycardia
Fever occurs with the onset of fever.
Reduced respiratory movements in the lower abdomen. When the inflamed parietal peritoneum and the visceral peritoneum touches each other during the respiratory movements pain arises. This results in reduced respiratory movements in the lower abdomen. Reduced respiratory movements in the lower abdomen.
When the inflamed parietal peritoneum and the visceral peritoneum touches each other during the respiratory movements pain arises. This results in reduced respiratory movements in the lower abdomen.
Abdominal tenderness Tenderness is localized to the right iliac fossa. There is associated muscle guarding and rebound tenderness. This is maximum over the McBurney’s point. Tenderness may be absent even with deep palpation if the appendix is retro cecal (silent appendix) or pelvic in location. It is due to the poor transmission of the pressure due to the gas filled cecum. Retrocecal appendix causes spasm of the psoas muscle and the patient may keep the muscle in a flexed position. The hyper-extension of the hip joint may elicit abdominal pain in retrocecal appendix. Pelvic appendix often produces tenderness on palpation of the suprapubic area slightly more towards to the right side. Abdominal tenderness
Tenderness is localized to the right iliac fossa. There is associated muscle guarding and rebound tenderness. This is maximum over the McBurney’s point. Tenderness may be absent even with deep palpation if the appendix is retro cecal (silent appendix) or pelvic in location. It is due to the poor transmission of the pressure due to the gas filled cecum. Retrocecal appendix causes spasm of the psoas muscle and the patient may keep the muscle in a flexed position. The hyper-extension of the hip joint may elicit abdominal pain in retrocecal appendix. Pelvic appendix often produces tenderness on palpation of the suprapubic area slightly more towards to the right side.
Pointing sign When the patient is asked to point the place where the maximum pain is felt, patient points to the right iliac fossa. Pointing sign
When the patient is asked to point the place where the maximum pain is felt, patient points to the right iliac fossa.
Rovsing’s sign Deep palpation of the left iliac fossa causes pain in the right iliac fossa. Rovsing’s sign
Deep palpation of the left iliac fossa causes pain in the right iliac fossa.
Psoas sign When the inflamed appendix lies over the psoas muscle flexion of the thigh elicits pain. Psoas sign
When the inflamed appendix lies over the psoas muscle flexion of the thigh elicits pain.
Obturator test When the hip is flexed and internally rotated it causes spasm of the obturator muscle. Obturator test
When the hip is flexed and internally rotated it causes spasm of the obturator muscle.
Cutaneous hyperaesthesia over the right iliac fossa Occurs due to the underlying inflammation in the right iliac fossa. Cutaneous hyperaesthesia over the right iliac fossa
Occurs due to the underlying inflammation in the right iliac fossa.
Tenderness over the pouch of Douglas On digital rectal examination a pelvic appendix causes pain in the pouch of Douglas. Obturator spasm may also be felt. Tenderness over the pouch of Douglas
On digital rectal examination a pelvic appendix causes pain in the pouch of Douglas. Obturator spasm may also be felt.
Markle sign Patient is asked to stand on toes and to shift the weight to the heels quickly. This will elicit abdominal pain. Markle sign
Patient is asked to stand on toes and to shift the weight to the heels quickly. This will elicit abdominal pain.

Investigations - Diagnosis

Fact Explanation
None Appendicitis is usually a clinical diagnosis. None
Appendicitis is usually a clinical diagnosis.
Full blood count Leukocytosis and left shift favor the diagnosis of appendicitis according to the Alvarado score. (score of 7 or more is strongly suggestive of acute appendicitis) Full blood count
Leukocytosis and left shift favor the diagnosis of appendicitis according to the Alvarado score. (score of 7 or more is strongly suggestive of acute appendicitis)
Contrast-enhanced CT This aids in diagnosis and reduces the incidence of unnecessary appendectomy. It is considered the best investigation to confirm or to exclude the diagnosis of appendicitis. Contrast-enhanced CT
This aids in diagnosis and reduces the incidence of unnecessary appendectomy. It is considered the best investigation to confirm or to exclude the diagnosis of appendicitis.
MRI MRI is useful imaging modality in diagnosing appendicitis if the clinical diagnosis is uncertain. MRI
MRI is useful imaging modality in diagnosing appendicitis if the clinical diagnosis is uncertain.
Abdominal X-ray This will help in excluding intestinal obstruction and also may find clues to the etiology of appendicitis (Eg: Fecolith)
An erect abdominal X-ray will help in excluding perforated peptic ulcer.
Abdominal X-ray
This will help in excluding intestinal obstruction and also may find clues to the etiology of appendicitis (Eg: Fecolith)
An erect abdominal X-ray will help in excluding perforated peptic ulcer.
Diagnostic laparoscopy This is not routinely done and useful when the diagnosis is uncertain. Diagnostic laparoscopy
This is not routinely done and useful when the diagnosis is uncertain.
Abdominal ultrasound Not routinely used. When the diagnosis is in doubt ultrasound investigation will help in the diagnosis. Abdominal ultrasound
Not routinely used. When the diagnosis is in doubt ultrasound investigation will help in the diagnosis.
C-Reactive Protein (CRP) CRP is an inflammatory marker and elevated in appendicitis. C-Reactive Protein (CRP)
CRP is an inflammatory marker and elevated in appendicitis.
Urinalysis Urinalysis has limited value in excluding the diagnosis of appendicitis. Urinalysis
Urinalysis has limited value in excluding the diagnosis of appendicitis.
Urine pregnancy test Excludes pregnancy and makes the ruptured ectopic less likely. Urine pregnancy test
Excludes pregnancy and makes the ruptured ectopic less likely.

Investigations - Management

Fact Explanation
Urea and electrolytes Asses the renal function before the induction of general anesthesia. Urea and electrolytes
Asses the renal function before the induction of general anesthesia.
Chest X-ray It is indicated if there is a history of lung disease. Chest X-ray
It is indicated if there is a history of lung disease.
ECG Asses the cardiovascular fitness of the patient. ECG
Asses the cardiovascular fitness of the patient.

Management - Supportive

Fact Explanation
Intravenous fluids Patient might be dehydrated due to recurrent vomiting and poor oral intake. Intravenous fluids
Patient might be dehydrated due to recurrent vomiting and poor oral intake.
Antibiotics Single dose of intravenous antibiotics at the time of induction will reduce the risk of wound infection. Third-generation cephalosporin is the drug of choice. However if peritonitis is present antibiotics should cover gram negative and anerobic organisms as well. Antibiotics
Single dose of intravenous antibiotics at the time of induction will reduce the risk of wound infection. Third-generation cephalosporin is the drug of choice. However if peritonitis is present antibiotics should cover gram negative and anerobic organisms as well.
Anelgesics Pain may relieve with diclofenac sodium suppository. Anelgesics
Pain may relieve with diclofenac sodium suppository.

Management - Specific

Fact Explanation
Open appendectomy Open appendectomy and laparoscopic appendectomy both are considered as equally beneficial and have fewer complications. If an appendicular mass is felt the conservative approach is practiced and interval appendectomy is performed. However if the conservative management is successful surgery may not be indicated since appendicitis has low risk of recurrences. Open appendectomy
Open appendectomy and laparoscopic appendectomy both are considered as equally beneficial and have fewer complications. If an appendicular mass is felt the conservative approach is practiced and interval appendectomy is performed. However if the conservative management is successful surgery may not be indicated since appendicitis has low risk of recurrences.
Laparoscopic appendectomy This is the suitable mode of treatment in pregnant females , children and in uncomplicated appendicitis and it is preferred in perforated appendicitis, in obese and in elderly patients. Recurrent appendicitis is treated with interval appendectomy and laparoscopic approach is preferred. Laparoscopic appendectomy
This is the suitable mode of treatment in pregnant females , children and in uncomplicated appendicitis and it is preferred in perforated appendicitis, in obese and in elderly patients. Recurrent appendicitis is treated with interval appendectomy and laparoscopic approach is preferred.

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