Appendicitis is the comments surgical emergency. It is common in ages between 10 to 20 years, but it can occur at any age. In babies less than 2 yeas of age, the appendicitis is less common as they have large lumen in their appendix.
Anatomy of the appendix
The appendix is a finger like, blind ended tube which is connects to the cecum. The cecum is located at the junction of the small and large intestines. The cecum is a pouch like structure of the colon.
Pathogenesis of appendicitis
The lumen of the appendix can be obstructed by lymphoid hyperplasia, faecolith, or filarial worms. So the appendix can get swollen and because of the pressure due to oedema it can get necroses. At the end it can be perforated.
Sings and symptoms of appendicitis
Patients with acute appendicitis, their usual presentation is periumbilical pain that moves to the right iliac fossa. Patient is having fever, anorexia and vomiting. Some patients get constipation and some develop diarrhoea.
On examination there is tachycardia, peritonism, with guarding and rebound or percussion tenderness in RIF. Rovsing’s sign positive, the pain in RIF is high than LIF when the LIF is pressed. Psoas sign, patient feel pain on extending hip if retrocaecal appendix. If the appendix in close relation to obturator internus, patient feel pain on flexion and internal rotation of the right hip, the sign is called Cope sign. On PR examination, if the patient feel pain on right suggests an inflammed, low lying pelvic appendix.
- Full Blood Count- Neutrophil leucocytosis.
- CRP – Elevated
- Ultrasound Scan of the Abdomen – May help, but the appendix is not always visualized.
- CT Abdomen – Can confirm the diagnosis and the accuracy is very high.
- Appendicectomy – Usually performed under general anaesthesia. The operation usually takes between half an hour and an hour. The procedure can be performed by laparoscopic technique or by an open cut in the abdomen.
- Antibiotics – IV antibiotics can be used to reduce wound infections, piperacillin tazobactam 4.5 g/8hourly, 1 to 3 doses IV started 1hour pre-op. If the appendix is perforated can give a longer course.
- Laparoscopic procedure – This technique is used specially for women and obese patients. It has diagnostic as well as therapeutic advantages. This procedure is not recommended if suspects a gangrenous perforation as it has high chance of abscess formation.
Complications of Appendicitis
The commonest complication is perforation, if faecolith is present and in young children as the diagnosis is more often delayed. The inflamed appendix become covered by omentum, and it will result in the formation of appendicular mass. In this condition performing an US or CT scan may be useful when making diagnosis. If the mass is formed, some perform an interval appendicectomy. If the appendix mass fail to resolve, an appendix abscess will result. It can be treated with IV antibiotics alone or drainage with US or CT guide.