Acute appendicitis

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Appendicitis, the most common cause of acute abdomen, is the acute inflammation of the appendix which requires emergency surgery. Diagnosis is made principally on clinical grounds. The most crucial aspect of treatment is timely intervention.

Causes

Appendicitis is caused by a blockage of the hollow portion of the appendix by:

  • Lymphoid tissue
  • Faecal matter
  • Foreign bodies
  • Worm infestations
  • Intestinal infections
  • Tumours

Signs and symptoms

Nonspecific symptoms

  • Progressive fever 
  • Anorexia 
  • Nausea and vomiting
  • Diarrhoea and/or constipation 
  • Abdominal pain - sharp right lower quadrant (RLQ) pain
  • Male infants and children occasionally present with an inflamed hemiscrotum
  • Urinary frequency from a long appendix irritating the bladder

Physical examination

  • Rebound tenderness, pain on percussion, rigidity, and guarding (most specific)
  • RLQ tenderness (96% of patients, but nonspecific)
  • Left lower quadrant (LLQ) tenderness: May be the major manifestation in patients with situs inversus or in patients with a lengthy appendix that extends into the LLQ
  • Male infants and children occasionally present with an inflamed hemiscrotum
  • In pregnant women, RLQ pain and tenderness dominate in the first trimester, but in the latter half of pregnancy, right upper quadrant (RUQ) or right flank pain may occur

Differential diagnosis

  • See acute abdomen

Complications

  • Gangrenous perforation 
  • Abscess
  • Peritonitis

Investigations

  • Full blood count showing - leucocytosis
  • Urinalysis - pyuria
  • Abdominal X-ray to assess perforation
  • Abdominal ultrasound scan

Treatment

  • Establish IV access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration
  • Initiate appropriate antibiotic therapy for septicaemia
  • Do not give oral medication
  • Supportive care e.g. administer parenteral analgesic, antiemetic as appropriate

Antibiotics

Broad-spectrum antibiotic prophylaxis provides both gram-negative and positive coverage before every appendectomy

Ceftriaxone IV

Adult:

2 g intravenously once daily

Child: 80 mg/kg intravenously once daily

PLUS

Metronidazole

Adult: 500 mg intravenously every 8 hours

Child: 10 mg/kg intravenously every 8 hours

Referral

  • Refer for specialist attention
  • Appendectomy remains the only curative treatment of appendicitis