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Appendicitis is inflammation of the appendix. Appendicitis is caused by a blockage of the hollow portion of the appendix. The diagnosis of appendicitis is largely based on the person's signs and symptoms. The standard treatment for acute appendicitis is surgical removal of the appendix. Surgery decreases the risk of side effects or death associated with rupture of the appendix.

In about The presentation of acute appendicitis includes acute abdominal pain, nausea, vomiting, and fever. As the appendix becomes more swollen and inflamed, it begins to irritate the adjoining abdominal wall. This leads to the localization of the pain to the right lower quadrant. This classic migration of pain may not be seen in children under three years. This pain can be elicited through signs, which can feel sharp. Pain from appendicitis may begin as dull pain around the navel.

After several hours, pain will usually transition towards the right lower quadrant, where it becomes localized. Symptoms include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure palpation.

There is pain in the sudden release of deep tension in the lower abdomen Blumberg sign. If the appendix is retrocecal localized behind the cecum , even deep pressure in the right lower quadrant may fail to elicit tenderness silent appendix. This is because the cecum , distended with gas, protects the inflamed appendix from pressure. Similarly, if the appendix lies entirely within the pelvis, there is typically a 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 , historically called Dunphy's sign. Acute appendicitis seems to be the result of a primary obstruction of the appendix. This continued production of mucus leads to increased pressures within the lumen and the walls of the appendix. The increased pressure results in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow.

At this point, spontaneous recovery rarely occurs. As the occlusion of blood vessels 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 result is appendiceal rupture a 'burst appendix' causing peritonitis , which may lead to sepsis and in rare cases, death.

These events are responsible for the slowly evolving abdominal pain and other commonly associated symptoms. The causative agents include bezoars , foreign bodies, trauma , intestinal worms , lymphadenitis and, most commonly, calcified fecal deposits that are known as appendicoliths or fecaliths. The occurrence of a fecalith in the appendix was thought to be attributed to a right-sided fecal retention reservoir in the colon and a prolonged transit time.

However, a prolonged transit time was not observed in subsequent studies. Studies have implicated a transition to a Western diet lower in fibre in rising frequencies of appendicitis as well as the other aforementioned colonic diseases in these communities. Diagnosis is based on a medical history symptoms and physical examination, which can be supported by an elevation of neutrophilic white blood cells and imaging studies if needed.

Histories fall into two categories, typical and atypical. Typical appendicitis includes several hours of generalized abdominal pain that begins in the region of the umbilicus with associated anorexia , nausea, or vomiting. The pain then "localizes" into the right lower quadrant where the tenderness increases in intensity. It is possible the pain could localize to the left lower quadrant in people with situs inversus totalis. The combination of pain, anorexia, leukocytosis, and fever is classic.

Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Irritation of the peritoneum inside lining of the abdominal wall can lead to increased pain on movement, or jolting, for example going over speed bumps. While there is no laboratory test specific for appendicitis, a complete blood count CBC is done to check for signs of infection. Although 70—90 percent of people with appendicitis may have an elevated white blood cell WBC count, there are many other abdominal and pelvic conditions that can cause the WBC count to be elevated.

A urinalysis generally does not show infection, but it is important for determining pregnancy status, especially the possibility of an ectopic pregnancy in women of childbearing age. The urinalysis is also important for ruling out a urinary tract infection as the cause of abdominal pain.

The presence of more than 20 WBC per high-power field in the urine is more suggestive of a urinary tract disorder. In children the clinical examination is important to determine which children with abdominal pain should receive immediate surgical consultation and which should receive diagnostic imaging. Abdominal ultrasonography , preferably with doppler sonography , is useful to detect appendicitis, especially in children. Ultrasound can show the free fluid collection in the right iliac fossa, along with a visible appendix with increased blood flow when using color Doppler, and noncompressibility of the appendix, as it is essentially walled-off abscess.

Other secondary sonographic signs of acute appendicitis include the presence of echogenic mesenteric fat surrounding the appendix and the acoustic shadowing of an appendicolith. This false-negative finding is especially true of early appendicitis before the appendix has become significantly distended.

Also, false-negative findings are more common in adults where larger amounts of fat and bowel gas make visualizing the appendix technically difficult. Despite these limitations, sonographic imaging with experienced hands can often distinguish between appendicitis and other diseases with similar symptoms.

Some of these conditions include inflammation of lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or Fallopian tubes. Ultrasounds may be either done by the radiology department or by the emergency physician.

Ultrasound showing appendicitis and an appendicolith [50]. A normal appendix without and with compression. Absence of compressibility indicates appendicitis. Where it is readily available, computed tomography CT has become frequently used, especially in people whose diagnosis is not obvious on history and physical examination. Although some concerns about interpretation are identified, a Cochrane review found that sensitivity and specificity of CT for the diagnosis of acute appendicitis in adults was high.

The accurate diagnosis of appendicitis is multi-tiered, with the size of the appendix having the strongest positive predictive value , while indirect features can either increase or decrease sensitivity and specificity. However, because the appendix can be filled with fecal material, causing intraluminal distention, this criterion has shown limited utility in more recent meta-analyses.

In such scenarios, ancillary features such as increased wall enhancement as compared to adjacent bowel and inflammation of the surrounding fat, or fat stranding, can be supportive of the diagnosis. However, their absence does not preclude it.

In severe cases with perforation, an adjacent phlegmon or abscess can be seen. Dense fluid layering in the pelvis can also result, related to either pus or enteric spillage. When patients are thin or younger, the relative absence of fat can make the appendix and surrounding fat stranding difficult to see.

Magnetic resonance imaging MRI use has become increasingly common for diagnosis of appendicitis in children and pregnant patients due to the radiation dosage that, while of nearly negligible risk in healthy adults, can be harmful to children or the developing baby. In pregnancy, it is more useful during the second and third trimester, particularly as the enlargening uterus displaces the appendix, making it difficult to find by ultrasound. The periappendiceal stranding that is reflected on CT by fat stranding on MRI appears as an increased fluid signal on T2 weighted sequences.

First trimester pregnancies are usually not candidates for MRI, as the fetus is still undergoing organogenesis, and there are no long-term studies to date regarding its potential risks or side effects. In general, plain abdominal radiography PAR is not useful in making the diagnosis of appendicitis and should not be routinely obtained from a person being evaluated for appendicitis.

Several scoring systems have been developed to try to identify people who are likely to have appendicitis. The performance of scores such as the Alvarado score and the Pediatric Appendicitis Score, however, are variable. The Alvarado score is the most known scoring system. A score below 5 suggests against a diagnosis of appendicitis, whereas a score of 7 or more is predictive of acute appendicitis.

In a person with an equivocal score of 5 or 6, a CT scan or ultrasound exam may be used to reduce the rate of negative appendectomy. Even for clinically certain appendicitis, routine histopathology examination of appendectomy specimens is of value for identifying unsuspected pathologies requiring further postoperative management. Pathology diagnosis of appendicitis can be made by detecting a neutrophilic infiltrate of the muscularis propria.

Periappendicitis, inflammation of tissues around the appendix, is often found in conjunction with other abdominal pathology. Micrograph of appendicitis and periappendicitis. Micrograph of appendicitis showing neutrophils in the muscularis propria. Women: A pregnancy test is important for all women of childbearing age since an ectopic pregnancy can have signs and symptoms similar to those of appendicitis.

Adults: new-onset Crohn disease , ulcerative colitis , regional enteritis, cholecystitis , renal colic , perforated peptic ulcer , pancreatitis , rectus sheath hematoma and epiploic appendagitis. Elderly: diverticulitis , intestinal obstruction, colonic carcinoma , mesenteric ischemia , leaking aortic aneurysm. The term " pseudoappendicitis " is used to describe a condition mimicking appendicitis. Acute appendicitis [68] is typically managed by surgery. Using antibiotics to prevent potential postoperative complications in emergency appendectomy procedures is recommended, and the antibiotics are effective when given to a person before, during, or after surgery.

Pain medications such as morphine do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given early in the patient's care. The surgical procedure for the removal of the appendix is called an appendectomy.

Appendectomy can be performed through open or laparoscopic surgery. Laparoscopic appendectomy has several advantages over open appendectomy as an intervention for acute appendicitis. For over a century, laparotomy open appendectomy was the standard treatment for acute appendicitis. During an open appendectomy, the person with suspected appendicitis is placed under general anesthesia to keep the muscles completely relaxed and to keep the person unconscious.

The incision is two to three inches 76 mm long, and it is made in the right lower abdomen, several inches above the hip bone. Once the incision opens the abdomen cavity, and the appendix is identified, the surgeon removes the infected tissue and cuts the appendix from the surrounding tissue. After careful and close inspection of the infected area, and ensuring there are no signs that surrounding tissues are damaged or infected.

In case of complicated appendicitis managed by an emergency open appendectomy, abdominal drainage a temporary tube from the abdomen to the outside to avoid abscess formation may be inserted, but this may increase the hospital stay. This means sewing the muscles and using surgical staples or stitches to close the skin up. To prevent infections, the incision is covered with a sterile bandage or surgical adhesive.

Laparoscopic appendectomy was introduced in and has become an increasingly prevalent intervention for acute appendicitis. This type of appendectomy is made by inserting a special surgical tool called a laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the person'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 requires general anesthesia , and it can last up to two hours. Laparoscopic appendectomy has several advantages over open appendectomy, including a shorter post-operative recovery, less post-operative pain, and lower superficial surgical site infection rate.

However, the occurrence of an intra-abdominal abscess is almost three times more prevalent in laparoscopic appendectomy than open appendectomy. The treatment begins by keeping the person who will be having surgery from eating or drinking for a given period, usually overnight. An intravenous drip is used to hydrate the person who will be having surgery.

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. Once the decision to perform an appendectomy has been made, the preparation procedure takes approximately one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. With all surgeries there are risks that must be evaluated before performing the procedures. The risks are different depending on the state of the appendix. Evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in outcomes to the person with appendicitis.

The surgeon will explain how long the recovery process should take. Abdomen hair is usually removed to avoid complications that may appear regarding the incision. In most cases, patients going in for surgery experience nausea or vomiting that require medication before surgery. Antibiotics, along with pain medication, may be administered before appendectomies. 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 lot faster if the appendix did not rupture. Recovery after an appendectomy may not require diet changes or a lifestyle change. The length of hospital stays for appendicitis varies on the severity of the condition. A study from the United States found that in , the average appendicitis hospital stay was 1. For stays where the person's appendix had ruptured, the average length of stay was 5.

After surgery, the patient will be transferred to a postanesthesia care unit , so his or her vital signs can be closely monitored to detect anesthesia- or surgery-related complications. Pain medication may be administered if necessary. After patients are completely awake, they are moved to 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 correctly.

Patients are recommended to sit upon the edge of the bed and walk short distances 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.

Most people with appendicitis recover quickly after 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 ten years old , the recovery takes three weeks. The possibility of peritonitis is the reason why acute appendicitis warrants rapid evaluation and treatment. Article in PDF. The aim of the study is to identify risk factors for the development of perforation of the appendix in elderly patients with acute appendicitis. The medical records of patients over 60 years of age with acute appendicitis were analyzed.

The patients were divided into 2 groups: with perforated appendicitis and with non-perforated appendicitis. A comparison was made between both groups in terms of demography, clinical presentation, preoperative delay time, diagnosis, hospital stay, and postoperative complications.

Clinical evaluation, ultrasound and CT were used for diagnosis.

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