Appendicitis
Introduction
Inflammation of the vestigial vermiform appendix.
Clinical assessment
History
Abdominal pain – in all confirmed cases of appendicitis
Classic symptoms
o Right lower quadrant/ right anterior iliac fossa abdominal pain
o Anorexia
o Nausea and vomiting
Pain in periumbilical migrating to the right lower quadrant - only in 50 to 60 %. Nausea and vomiting
follow the pain. Fever related symptoms occur later.
50% patient have atypical presentation
o Retrocecal appendix produces right flank or pelvic pain
o Malrotation of colon results in transposition of appendix and causes left upper quadrant
pain
o In pregnant mothers due to gravid uterus causes right upper quadrant pain. But most
common site of pain in pregnancy due to appendicitis is right lower quadrant pain.
Non-specific symptoms
o Indigestion
o Flatulence
o Bowel irregularity
o Diarrhea
o Generalized malaise
Location of the appendix tip produce different pain
o Anterior appendix – marked localized pain in right lower quadrant
o Retrocecal appendix – dull abdominal ache.
o Pelvic appendix – tenderness below McBurney’s point
Sudden improvement of release of pain – perforation
Physical examination
Early signs are subtle – low grade fever – 38.30 C may be present.
Later localized tenderness in the lower quadrant.
Rectal examination – no addition information. In women right adnexal tenderness.
Pt with retrocecal appendix – no marked localized tenderness elicited.
Rectal and pelvic examination more likely to elicit positive signs than abdominal examination.
No physical finding alone definitively confirms appendicitis.
Common physical signs
McBurney’s point tenderness – maximal tenderness at 1.5 to 2 inches from anterior superior iliac
spine on strait line from the ASIS to umbilicus.
Rovsings’s sign – pain in right lower quadrant with palpation of the left lower quadrant. - indirect
tenderness and indicative of right sided local peritoneal irritation.
The psoas sign – due to retrocecal appendix. – right lower quadrant pain with passive hip extension.
The obturator sign – due to pelvic appendix. When flexing the patients right hip and knee, followed
by internal rotation of the right hip – elicits right lower quadrant pain. Sensitivity is low and clinicians
no longer perform.
Investigations strategies
Urine analysis, Urine hCG
FBC, CRP
o WBC does not distinguish between simple and perforated appendicitis.
o CRP > 10 mg/l in children < 6 yrs old may of value in predicting appendicitis.
Abdominal x-ray – to exclude obstruction, appendicolith can be seen in 50% of cases
Migration of pain, RIF rigidity and guarding with raised inflammatory markers – combination strongly
suggest appendicitis.
Additional imaging investigations
USS
o Graded compression US is the investigation of choice in both pregnant and children. Should
be considered in young and non-obese patient
o Should be thickened non-compressible with a maximum diameter > 6mm.
o Doppler US – illustrate hyperemia.
o Normal small bowel differentiated by absence of peristalsis and the lack of change in
configuration over time.
o Overall accuracy of 90% - sensitivity 86% and specificity 95%
o USS rule in appendicitis, but cannot rule it out.
o Perforation will disappear the specific imaging hallmarks and difficult visualization of the
appendix.
CT
o Dilated appendix > 6 mm with thickened wall, peri appendiceal inflammation with
appendicolith or abscess.
o Luminal obstruction and dilatation may be relieved in perforation
o Greater overall accuracy of 94%. In > 2 yrs of age, sensitivity 94% and specificity 95%
o Appendiceal CT – use rectally administered contrast only with acquisition of thin cuts
through the right iliac fossa. But less frequently used protocol.
o Similar to USS, CT can rule in but not rule out appendicitis.
o Non-contrast CT should be considered an acceptable imaging modality in the workup of
acute appendicitis. – sensitivity 93% and sensitivity/ positive predictive value - > 92%
MRI
o In pregnant women and applicable to pediatric patients >5 yrs.
o IV gadolinium cross the placenta and not given in pregnancy and also in renal insufficiency
which can cause fibrosing dermopathy.
If patient have a likelihood of appendicitis then unnecessary imaging should not delay surgery. Mortality
and morbidity are higher if the appendix is perforated.
ALVARADO SCORE
MANTRELS (TL = 2)
M Migration of pain to RIF 1
A Anorexia (urinary acetone) 1
N Nausea and vomiting 1
T Tenderness in RIF 2
R Rebound pain 1
E Elevated temperature 1
L Leukocytosis (> 10,000/mm2) 2
S Shift of WBC to left 1
Total 10
Interpretation
o For ruling in and ruling out appendicitis
Alvarado < 3 - 4: Studies ruling out appendicitis (sensitivity of 72%)
Alvarado > 5 – 7: Studies ruling in appendicitis (sensitivity of 58 – 88%)
The McKay study recommends:
o Alvarado ≥ 7: Surgical consultation
o Alvarado 4 – 6: CT scan
o Alvarado ≤ 3: no CT for diagnosing appendicitis, as appendicitis is
unlikely.
Management
Nil by mouth
IV fluids with antiemetics and analgesia
Perioperative antibiotics
o Ampicillin / sulbactam 3g IV (pediatric – 75mg/KG)
o Piperacillin/tazobactam 4.5g IV (100mg/kg)
o Cefoxitin 2g IV (40mg/kg)
o Metronidazole 500mg IV + ciprofloxacin 400mg IV
Surgical management
Non-operative approach in high risk patient (occasionally) – Older, sicker who are high risk for
surgery
