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Appendicitis

Appendicitis is a condition characterised by inflammation of the appendix. While mild cases may resolve without treatment, most require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly due to peritonitis and shock. more...

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Causes

The cause of appendicitis is generally unknown, but the leading theory is that obstruction of the appendiceal orifice is the inciting factor. Obstruction may come from fecal matter lodged in the appendix, impaction of mucous, a small tumor (such as a carcinoid), or even a small blood clot. Viral infections, which can cause ulceration of the lining, can also lead to obstruction of the appendix through enlargement of lymph nodes in its walls, a possible explanation for seasonal variations in rates of appendicitis and clustering of cases. Regardless of the cause, obstruction of the appendix may lead to progressive appendiceal distension. This distension increases the pressure within the appendix, which in turn impairs its blood supply. Deprived of blood, the appendix loses the ability to fight infection and fecal bacteria begin to grow out of control. Although spontaneous recovery can rarely occur, with time and lack of treatment the walls of the appendix eventually become gangrenous from the infection and lack of blood flow. 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 causing peritonitis, which may lead to septicemia and eventually death.

Although the model described above is traditionally taught in medical schools, histories of patients operated for appendicitis do not often correlate well with such a single disease progression. Specifically, those with atypical histories have findings at surgery that are consistent with a suppurative process that starts at the onset of symptoms and then smolders. Patients with typical histories may have findings suggesting resolution. Histories to suggest rupture of the appendix while patients are being diagnostically observed are exceedingly rare.

Thus appendicitis is now considered by some to behave as two distinct disease processes, typical and atypical (or suppurative). Approximately 2/3 of patients with appendicitis have typical histories, and findings suggest a virus or mild obstruction as a cause. In the 1/3 with atypical histories, an early suppurative process begins at the clinical onset, and severe unremitting obstruction is the likely cause. In any case, early operation is the best treatment for either type of appendicitis.

Signs, symptoms and findings

Appendicitis can be classified into two types, typical and atypical. The pain of typical acute appendicitis usually starts centrally (periumbilical) before localising to the right iliac fossa (the lower right side of the abdomen). There is usually associated loss of appetite and fever. Nausea, or vomiting may or may not occur. These classic signs and symptoms are more likely the younger the patient. Older patients (beyond their teenage years) may present with only one or two. Diagnosis is easier in typical acute appendicitis and surgery removes a swollen, inflamed appendix with little or no suppuration (pus) if operated early (within 24 hours of onset).

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Diagnosis of appendicitis in emergency departments - Tips from Other Journals - Author Abstract
From American Family Physician, 6/1/03 by Bill Zepf

Among patients presenting to emergency departments with abdominal pain, the underlying causes of the pain range from benign processes to acute, life-threatening disease. The most common abdominal operation performed on an emergency basis is the appendectomy, which is performed more than 250,000 times annually in the United States. Using a hypothetic illustrative case, Paulson and colleagues review the management of patients with suspected appendicitis.

A previously healthy 22-year-old woman presents to the emergency department with acute abdominal pain in the right lower quadrant of 18 hours' duration. She has no fever, and her examination is remarkable only for right lower quadrant tenderness without peritoneal signs.

The authors first discuss the aspects of the history and physical examination that may be used to develop a clinical suspicion of acute appendicitis. The sensitivity and specificity of various signs and symptoms relating to appendicitis are reviewed in the accompanying table. The three factors with the highest predictive value for acute appendicitis are right lower quadrant pain, abdominal rigidity, and migration of pain from the periumbilical region to the right lower quadrant. A shorter duration of pain also supports the diagnosis of appendicitis, whereas other causes of abdominal pain may have a shorter course of pain.

Laboratory studies in patients with abdominal pain share the limited sensitivity and specificity of the history and physical examination. Pregnancy must always be ruled out in women of reproductive age. An elevated leukocyte count is usually noted in cases of acute appendicitis, but it has poor specificity. While urinalysis will often show some pyuria, hematuria, or bacteriuria in patients with appendicitis, more than 20 leukocytes per high-power field or more than 30 red cells per high-power field is suggestive of a urinary tract disorder.

In equivocal cases, the authors note that observation of patients for six to 10 hours has been shown to decrease the number of unnecessary surgeries without increasing the rate of appendiceal perforation.

Imaging is also commonly involved in cases with an unclear diagnosis. In the authors' opinion, plain abdominal radiographs and contrast barium-enema examinations have little clinical utility. Abdominal ultrasonography may be useful in ruling out appendicitis; however, because the appendix is usually not well visualized, the physician is left uncertain of the diagnosis. Computed tomographic (CT) scanning has improved with the advent of rapid-scanning spiral CT machines, which decrease image artifact caused by movement. A retrospective review of 650 patients with suspected appendicitis showed a sensitivity of 97 percent and a specificity of 98 percent with spiral CT. In patients in which the clinical suspicion was uncertain, sensitivity was 92 percent and specificity was 85 percent.

Two prospective studies comparing ultrasonography with spiral CT have favored the latter modality. Cost-effectiveness studies have also supported the utility of CT scans, especially in female patients, because of the decreased accuracy of the clinical examination in correctly predicting appendicitis.

BILL ZEPF, M.D.

Paulson EK, et al. Suspected appendicitis. N Engl J Med January 16, 2003;348:236-42.

COPYRIGHT 2003 American Academy of Family Physicians
COPYRIGHT 2003 Gale Group

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