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Appendictis, originally uploaded by www.hemovac.com.

Appendicitis is acute inflammation of the vermiform appendix,

typically resulting in abdominal pain, anorexia, and abdominal

tenderness. Diagnosis is clinical, often supplemented by CT or

ultrasound. Treatment is surgical removal.



In the US, acute appendicitis is the most common cause of acute

abdominal pain requiring surgery. Over 5% of the population develops

appendicitis at some point. It most commonly occurs in the teens and

20s but may occur at any age.



Other conditions affecting the appendix include carcinoids, cancer,

villous adenomas, and diverticula. The appendix may also be affected

by Crohn's disease or ulcerative colitis with pancolitis.



Etiology

Appendicitis is thought to result from obstruction of the appendiceal

lumen, typically by lymphoid hyperplasia, but occasionally by a

fecalith, foreign body, or even worms. The obstruction leads to

distention, bacterial overgrowth, ischemia, and inflammation. If

untreated, necrosis, gangrene, and perforation occur. If the

perforation is contained by the omentum, an appendiceal abscess results.



Symptoms and Signs

The classic symptoms of acute appendicitis are epigastric or

periumbilical pain followed by brief nausea, vomiting, and anorexia;

after a few hours, the pain shifts to the right lower quadrant. Pain

increases with cough and motion. Classic signs are right lower

quadrant direct and rebound tenderness located at McBurney's point

(junction of the middle and outer thirds of the line joining the

umbilicus to the anterior superior spine). Additional signs are pain

felt in the right lower quadrant with palpation of the left lower

quadrant (Rovsing sign), an increase in pain from passive extension of

the right hip joint that stretches the iliopsoas muscle (psoas sign),

or pain caused by passive internal rotation of the flexed thigh

(obturator sign). Low-grade fever (rectal temperature 37.7 to 38.3° C

[100 to 101° F]) is common.



Unfortunately, these classic findings appear in 50%.



With early surgery, the mortality rate is < 1%, and convalescence is

normally rapid and complete. With complications (rupture and

development of an abscess or peritonitis), the prognosis is worse:

Repeat operations and a long convalescence may follow.



Treatment

Surgical removal

IV fluids and antibiotics

Treatment of acute appendicitis is open or laparoscopic appendectomy;

because treatment delay increases mortality, a negative appendectomy

rate of 15% is considered acceptable. The surgeon can usually remove

the appendix even if perforated. Occasionally, the appendix is

difficult to locate: In these cases, it usually lies behind the cecum

or the ileum and mesentery of the right colon. A contraindication to

appendectomy is inflammatory bowel disease involving the cecum.

However, in cases of terminal ileitis and a normal cecum, the appendix

should be removed.



Appendectomy should be preceded by IV antibiotics. Third-generation

cephalosporins are preferred. For nonperforated appendicitis, no

further antibiotics are required. If the appendix is perforated,

antibiotics should be continued until the patient's temperature and

WBC count have normalized or continued for a fixed course, according

to the surgeon's preference. If surgery is impossible, antibiotics—

although not curative—markedly improve the survival rate. When a

large inflammatory mass is found involving the appendix, terminal

ileum, and cecum, resection of the entire mass and ileocolostomy are

preferable. In late cases in which a pericolic abscess has already

formed, the abscess is drained either by an ultrasound-guided

percutaneous catheter or by open operation (with appendectomy to

follow at a later date). A Meckel's diverticulum in a patient under

the age of 40 should be removed concomitantly with the appendectomy

unless extensive inflammation around the appendix prevents the

procedure.