Acute appendicitis
• Acute abdominal pain is defined as previously undiagnosed pain of <72
hours duration
• Accounts for about 2% of hospital admissions
• In only 50% of patients is the preoperative diagnosis correct
• Right iliac fossa pain accounts for about half of all cases of acute abdominal
pain
Causes of right iliac fossa pain
• Appendicitis
• Urinary tract infection
• Non-specific abdominal pain
• Pelvic inflammatory disease
• Renal colic
• Ectopic pregnancy
• Constipation
Causes of right iliac fossa mass
• Appendix mass
• Crohn's disease
• Caecal carcinoma
• Mucocele of the gallbladder
• Psoas abscess
• Pelvic kidney
• Ovarian cyst
Appendicitis
• About 10% of the population will develop acute appendicitis
• The incidence is falling
• 70,000 appendicectomies are performed each year in the UK
• Appendicitis is more common in men
• Appendicectomy is performed more often in women
• At 10-20% appendicectomies a normal appendix is removed
• The risk of perforation is:
o Less than 10 years old = 50%
o 10-50 years old = 10%
o Over 50 years old = 30%
• A women is more likely to have a 'normal' appendix removed
Clinical features of appendicitis
• Central abdominal pain moving to right iliac fossa
• Nausea, vomiting, anorexia
• Low-grade pyrexia
• Localised tenderness in right iliac fossa
• Right iliac fossa peritonism
• Percussion tenderness is a kinder sign of peritonism than rebound
• Rovsing's sign = pain in right iliac fossa on palpation of the left iliac fossa
Investigations
• Appendicitis is essentially a clinical diagnosis
• The following may be useful:
• Urinalysis may exclude urinary tract infection
• Pregnancy test to exclude ectopic pregnancy
• Abdominal x-ray is of little value
• A normal white cell count does not exclude appendicitis
• Ultrasound may be helpful in the assessment of an appendix mass or abscess
• Ultrasound adds little to the clinical diagnosis of acute appendicitis
• Scoring systems and computer-aided diagnosis my be helpful
• Meta-analysis suggest the following to be useful predictors of appendicitis in
patients with abdominal pain
o Raised inflammatory markers
o Clinical signs of peritoneal irritation
o Migration of abdominal pain
Picture provided by Fahid Abu-Zant, Neblus Speciality Hospital, Neblus, Palestine
Management
• In cases of diagnostic doubt a period of 'active observation' is useful
• Active observation reduces negative appendicectomy rate without increased
risk of perforation
• Intravenous fluids and analgesia should be given
• Opiate analgesia does not mask the signs of peritonism
• Antibiotics should not be given until a decision to operate has been made
• Diagnostic laparoscopy should be considered particularly in young women
• Whether a 'normal' appendix should be removed following laparoscopy is
unclear
Appendicectomy
• Early appendicectomy for non-perforated appendicitis was first performed in
1880s
• Open appendicectomy is usually performed via a Lanz incision and muscle
splitting approach
• No evidence that burying the stump reduces the infection rate
• Consider a midline incision in elderly patients
• If normal appendix removed need to look for:
o Meckel's diverticulum
o Acute salpingitis
o Crohn's disease
• Laparoscopic appendicectomy may be associated with:
o reduced hospital stay
o rapid return to normal activity
• Overall benefits of laparoscopic approach not as great as for
cholecystectomy
Appendix mass
• Usually presents with a several day history
• Inflammation localised to the right iliac fossa by the omentum
• Patient is usually pyrexial with a palpable mass
• Initial treatment should be conservative
• Fluids, analgesia and antibiotics
• Observe the patient and mass
• Continue conservative whilst there is clinical improvement
Appendix abscess
• Results from localised perforation
• Abscess should be surgically or percutaneously drained
• Appendicectomy at initial operation can be difficult
• Need for appendicectomy after abscess drainage is unclear
Picture provided by Dr Florencia Castro, Hospital Juan de San Martin, Buenos Aires, Argentina
. Acute appendicitis
• Acute abdominal pain is defined as previously undiagnosed pain of. Psoas abscess
• Pelvic kidney
• Ovarian cyst
Appendicitis
• About 10% of the population will develop acute appendicitis
• The incidence is falling
• 70,000