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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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CT does not improve ability to diagnose appendicitis - Tips from Other Journals
From American Family Physician, 10/15/03 by Anne D. Walling

Approximately 290,000 patients in the United States underwent urgent appendectomy in 1999. A normal appendix is removed in up to 40 percent of patients who undergo surgery because of a preoperative diagnosis of appendicitis. Several studies have reported improved diagnostic accuracy with the incorporation of computed tomography (CT) into clinical decision-making, but other studies have failed to replicate these results. Perez and colleagues studied the contribution of CT scanning to the accuracy of preoperative diagnosis of appendicitis at a community hospital.

The study included all 118 patients who underwent nonincidental appendectomy between April 1999 and June 2000 at a 300-bed community hospital. The impact of increasing the use of CT scanning in the diagnosis of appendicitis was studied by comparing data from these patients with data from 100 patients who underwent nonincidental appendectomy at the same hospital during 1994. Data included patient demographics, diagnostic tests, pathologic diagnoses, antibiotic usage, complications, duration of emergency department treatment, and length of hospital stay.

The two groups of patients were comparable in all important respects. Preoperative CT scanning was performed in 11 percent of patients in the 1994 cohort and 48.3 percent of those in the 1999-2000 cohort. In spite of the more than fourfold increase in preoperative CT scans, the percentage of normal appendixes removed increased (nonsignificantly) from 12 percent to 17.8 percent. Furthermore, the diagnostic accuracy of the CT scans did not improve significantly between the two study periods. In the 1994 study, CT accuracy was 81.8 percent, compared with 80.7 percent in the 1999-2000 study. The authors calculate that CT scanning did not add to the post-test probability of correctly diagnosing appendicitis or accurately ruling out appendicitis. The patients who underwent CT scanning spent a significantly longer time in the emergency department and had a longer hospital stay than the patients who did not undergo CT scanning. The authors conclude that widespread use of CT scanning has not improved the accuracy of diagnosing appendicitis and has contributed to longer emergency department and hospital stays. These results confirm the findings of several previous studies but contradict the findings of other studies in which CT scanning reduced the number of normal appendixes that were removed. The authors of the present study speculate that the differences may be explained by the technique of CT used. Investigations using oral, rectal, or intravenous contrast media may have greater accuracy but may be more difficult to conduct successfully in an emergency situation.

Perez J, et al. Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis. Am J Surg March 2003;185:194-7.

COPYRIGHT 2003 American Academy of Family Physicians
COPYRIGHT 2003 Gale Group

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