Appendicitis is a condition characterized by inflammation of the appendix

Signs and symptoms

Location of the appendix in the digestive system

Pain first, vomiting next and fever last has been described as the classic presentation of acute appendicitis. Since the innervation of the appendix enters the spinal cord at T12, the same level as the umbilicus, the pain begins mid-abdomen. Later, as the appendix becomes more inflamed and irritates the adjoining abdominal wall, it tends to localize over several hours into the right lower quadrant, except in children under three years. This pain can be elicited through various signs and can be severe. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is severe pain on sudden release of deep pressure in the lower abdomen (rebound tenderness). In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis, requiring urgent surgical intervention.

Causes
On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen (the inside space of a tubular structure). 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 of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria 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 tosepticemia and eventually death.

Diagnosis

Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Histories fall into two categories, typical and atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant, where tenderness develops. Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. [24] Atypical histories often require imaging with ultrasound and/or CT scanning. A pregnancy test is vital in all women of child bearing age, as ectopic pregnancies and appendicitis present similar symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men) should be appreciated. Blood test Most patients suspected of having appendicitis would be asked to do a blood test. Half of the time, the blood test is normal, so it is not foolproof in diagnosing appendicitis. Urine test A urine test in appendicitis is usually normal. It may, however, show blood if the appendix is rubbing on the bladder, causing irritation. A urine test or urinalysis is compulsory in women, to rule out pregnancy in appendicitis, as well to help ensure that the abdominal pain felt and thought to be acute appendicitis is not in fact, due to ectopic pregnancy. XRay In 10% of patients with appendicitis, plain abdominal x-ray may demonstrate hard formed feces in the lumen of the appendix (Fecolith). It is agreed that the finding of Fecolith in the appendix on X ray alone is a reason to operate to remove the appendix, because of the potential to cause worsening symptoms. Ultrasound

Ultrasound image of an acute appendicitis

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. In some cases (15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make Computed tomography

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

Where it is readily available, CT scan has become frequently used, especially in adults whose diagnosis is not obvious on history and physical examination.

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 Alvarado score Alvarado score

Migratory right iliac fossa pain

1 point

Anorexia

1 point

Nausea and vomiting

1 point

Right iliac fossa tenderness

2 points

Rebound tenderness

1 point

Fever

1 point

Leukocytosis

2 points

Shift to left (segmented neutrophils)

1 point

Total score

10 points

Other data
Tzanakis scoring
Tzanakis and colleagues, in 2005 published a simplified system, now called the Tzanakis scoring system for appendicitis, to aid the diagnosis of appendicitis

Pathologic diagnosis

Micrograph of appendicitis and periappendicitis. H&E stain.

The definitive diagnosis is based on pathology. The histologic findings of appendicits are neutrophils in the muscularis propria.

Differential diagnosis
In children Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, HenochSchnlein purpura, lobar pneumonia, urinary tract infection(abdominal pain in the absence of other symptoms can occur in children with UTI), new-onset Crohn's disease or ulcerative colitis, pancreatitis, and abdominal trauma from child abuse; distal intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in children with leukemia; In women menarche, dysmenorrhea, severe menstrual cramps, Mittelschmerz, pelvic inflammatory disease, ectopic pregnancy. The most common mimic of appendicitis is the ruptured ovarian cyst in young women. In adults

regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma; in men: testicular torsion, new-onset Crohn's disease or ulcerative colitis; in women: pelvic inflammatory disease, ectopic pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle) In elderly diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.

Management
Largely surgical, any conservative management is done at the threshold of operation theater as the acutely inflamed appendix is liable to rupture during such treatment.

Inflamed appendix removal by open surgery

The treatment begins by keeping the patient from eating or

drinking in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole 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. 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 [28] complication rate rises to almost 59%. The most usual complications that can occur are pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesions. Recent evidence indicates that a delay in

Pain management
Pain from appendicitis can be severe. Strong (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

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 openlaparotomy incision if required most often centers on the area of maximum tenderness, McBurney's point, in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly.

Laparoscopic surgery
The newer method to treat appendicitis is the laparoscopic surgery. This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inch (6.3 to 13 mm) long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the patient's body and it is designed to help the surgeon to inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using surgical instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two hours. The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there [34] is no incision on the external skin and SILS( Single incision laparoscopic Surgery)where a single 2.5 cm incision is made to perform the surgery.

After surgery

The stitches the day after having his appendix removed by laparoscopic surgery

Hospital lengths of stay typically range from a few hours to a few days, but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition, if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally a [35] lot faster if the appendix did not rupture. It is important that patients respect their doctor's advice and limit their physical activity so the tissues can heal faster. Recovery after an appendectomy may not require diet changes or a lifestyle change. After surgery occurs, the patient will be transferred to an postanesthesia care unit so his or her vital signs can be closely monitored to detect anesthesia- and/or surgery-related complications. Pain medication may also be administered if necessary. After patients are completely awake, they are moved into a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular diet when the intestines start to function properly. Patients are recommended to sit up on the edge of the bed and walk short distances for several times a day. Moving is mandatory and pain medication may be given if necessary. Full recovery from appendectomies takes about four to six weeks, but can be prolonged to up to eight weeks if the appendix had ruptured.

Prognosis
Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks.