Appendicitis

review acute appendicitis

1. Appendicitis Dr. SALAH Z aki

2. Appendicitis is an emergency condition that requires prompt surgery Today recognized as one of the most common cause of severe acute abdominal pain worldwide It is one of the most frequent diagnoses for emergency department visits resulting in hospitalization among age 5–17 years one in 15 people will get appendicitis. Although it can strike at any age, appendicitis is rare under age 2 and most common between ages 10 and 30.

3. Etiology Appendicitis occurs when the appendix becomes blocked, often by stool, a foreign body, or cancer . Blockage may also occur from infection.

4. The classic symptoms of appendicitis include: * Dull pain near the umbilicus or the upper abdomen that becomes sharp as it moves to the lower right abdomen. This is usually the first sign. * Loss of appetite *Nausea and/or vomiting soon after abdominal pain begins *Abdominal distention *Fever 37.5 -38 degrees

5. ** Other symptoms of appendicitis including: Dull or sharp pain anywhere in the upper or lower abdomen, back, or rectum Painful urination Vomiting that precedes the abdominal pain Severe cramps Constipation or diarrhea with gas

6. Signs include localized findings in the right iliac fossa . ( McBurney's point ). *The abdominal wall becomes very sensitive to ( palpation and percussion )& Coughing( Dunphy's sign) causes point tenderness in this area * ( rebound tenderness ).

7. O bturator sign spasm of the muscle can be demonstrated by flexing and internal rotation of the hip cause pain in the hypogastrium Psoas sign is right lower-quadrant pain that is produced with the passive extension of the patient's right hip * Rectal examination elicits tenderness in the rectovesical pouch. In cases of Silent appendix

8. Silent appendix In case of a retrocecal appendix (appendix localized behind the cecum ), however, even deep pressure in the right lower quadrant may fail to elicit tenderness because the cecum , distended with gas, protects the inflamed appendix from pressure. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity.

9. Appendicitis in Pregnancy Although a rare presentation, appendicitis is one of the most common causes of an acute abdomen in pregnancy, occurring in approximately 1 in 1500 pregnancies. The most common presenting symptoms anorexia, nausea, vomiting, and right lower quadrant pain. However Fever and tachycardia may not be present during pregnancy. Right upper quadrant pain, uterine contractions, dysuria , and diarrhea

10. It is believed that the appendix changes its location during pregnancy with an upward displacement toward the costal margin in the later stages of pregnancy Patients may then present with right upper quadrant pain or entire right-sided pain, A presentation with right upper quadrant pain can be highly variable with an incidence as high as 55%

11. Blood and urine test *complete blood count (CBC) is done to check for signs of infection * urinalysis is important for determining the pregnancy status, especially the possibility of an ectopic pregnancy in childbearing females, However, there is a possibility of a microscopic pyuria , the condition of urine containing pus, or hematuria , urine containing red blood cells, caused by the proximity of the appendix to the ureter and bladder in acute appendicitis

12. Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children, and shows free fluid collection in the right iliac fossa, along with a visible appendix without blood flow in color Doppler.

13. It can often distinguish between appendicitis and other diseases with similar symptoms, such as mesenteric adenitis or other pelvic organs such as the ovaries or fallopian tube. In some cases (15% approximately), ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis.

14. Differential diagnosis * In children : Gastroenteritis , mesenteric adenitis , Meckel's diverticulitis , intussusception , Henoch-Schönlein purpura , pneumonia , urinary tract infection ( abdominal pain in the absence of other symptoms can occur in children with UTI), * In women : A pregnancy test is important in all women of child bearing age, as ectopic pregnancies and appendicitis present similar symptoms.Other causes ovarian torsion , menarche , dysmenorrhea,, Mittelschmerz

15. * In men : testicular torsion ; * In adults : new-onset Crohn's disease , ulcerative colitis , regional enteritis, renal colic , perforated peptic ulcer , pancreatitis , rectus sheath hematoma ; * In elderly : diverticulitis , intestinal obstruction, colonic carcinoma , mesenteric ischemia , leaking aortic aneurysm .

16. Treatment

17. Appendectomy was the treatment for over than 120 years. Antibiotic treatment has occasionally been used in small uncontrolled studies, instead of operation, but this alternative has never before been tried in a multicenter . But six different hospitals in Swed between 1996 and 1999 were enrolled in a study

18. During the study period 252 men participated, 124 in the surgery group and 128 in the antibiotic group. in the surgery group The frequency of appendicitis was 97% and 5% had a perforated appendix. The complication rate was 14% in the surgery group. In the antibiotic group 86% improved without surgery; 18 patients were operated on within 24 hours, and the diagnosis of acute appendicitis was confirmed in all but one patient, and he was suffering from ileitis.. Conclusions Acute non perforated non obstructed appendicitis can be treated successfully with antibiotics. However , there is a risk of recurrence in cases of acute appendicitis, and this risk should be compared with the risk of complications after appendectomy.

19. But about 80 percent of patients with an inflamed appendix, commonly called appendicitis , don't need to have their appendix surgically removed, and those who ultimately do need the surgery aren't hurt by waiting, according to Salminen . She thinks that this and other studies will change how appendicitis is treated. "Now we know that only a small proportion of appendicitis patients need an emergency operation," Salminen said. However, there are two types of appendicitis -- one that always requires surgery and a milder form that can be treated with antibiotics, Salminen explained. "The majority of appendicitis is the milder form, making up almost 80 percent of the cases of appendicitis," she said. The more serious type of appendicitis can cause the appendix to rupture. Treating this type of appendicitis requires that the appendix be removed, she said. A CT scan can accurately detect which type of appendicitis someone has, Salminen added. The study's findings were published June 16 in the Journal of the American Medical Association . For the study, Salminen and colleagues randomly assigned 530 patients with acute appendicitis to appendectomy or a 10-day course of antibiotics. The researchers found that appendectomies were 99.6 percent successful. Among patients treated with antibiotics and followed for a year, 73 percent did not need surgery. However, 27 percent of the patients treated with antibiotics had to have their appendix removed within a year after treatment. But there were no major complications associated with delaying surgery, the researchers said.

20. Dr. Edward Livingston, deputy editor of JAMA and coauthor of an accompanying editorial, said, "It's kind of lost to history why people started doing appendectomies, but it has become so routine that when someone comes in with appendicitis they get whisked into the operating room." However, a lot has changed in 130 years, he said. For example, the ability to diagnose appendicitis has improved. "It's almost perfect with CT scans," Livingston said. In addition, the antibiotics available are very powerful and can kill anything in the appendix that can cause infection, he said. "These changes have made us rethink how we approach appendicitis," Livingston said. More than 300,000 appendectomies are done each year in the United States. However, most patients can be treated with antibiotics alone, he said. "Appendicitis of this type is not an emergency. You can always give somebody antibiotics and see how they do, and if the appendicitis comes back you can take out their appendix and not have complications related to the delay," Livingston said. He added that even though an appendectomy is usually well tolerated, there are risks and pain. And, having an operation is expensive. "I am a surgeon and I hope to get through life without ever having an operation," he said. "So if I were given the option of taking antibiotics and not have surgery, I would take antibiotics in a heartbeat." More information For more about appendicitis, visit the U.S. National Institutes of Health

21. Appendicectom y It is the traditional type of surgery used for treating appendicitis Laparoscopic removal (via three small incisions with a camera to visualize the area of interest in the abdomen) seem to have some advantages over an open procedures especially in young females and the obeset y .

22. The self-appendectomy It happened on April 30, 1961 at Novolazarevskaya Station. The patient was the only physician on station , Dr. Leonid Rogozov ... The operation took 2 hours. He positioned himself so that he could see his own body using a mirror - he made a 12 cm cut through which he found the appendix. After 5 days the doctor felt good, and after 7 days he removed the wires which had been used to sew up the body.