Acute Appendicitis

This is the commonest acute abdominal surgical emergency. Typical symptoms are shifting abdominal pain (starting as vague periumbilical pain then shifting to the right iliac fossa) associated with nausea and occasional vomiting. On evaluation, uncomplicated appendicitis has right iliac tenderness elicited maximally at McBurney's point with possible positive Roving sign. The white blood count may be elevated.

The diagnosis of appendicitis should be made on clinical grounds but other investigations especially ultrasound scan and CT scan might be necessary in females and where the history is not typical. The other tests are especially useful to exclude other pathologies that might mimic appendicitis. Straightforward appendicitis needs emergency surgery as delays are associated with complications and poor outcome. The treatment of appendicitis is surgical. Laparoscopic appendicectomy is now popular among surgeons with special interest and is particularly useful in females where the advantage of visualising pelvic viscera is important. The cosmetic advantages are additional to the less pain, reduced hospital stay and earlier recovery noted with laparoscopic surgery.

The use of antibiotics in appendicitis and its complications can be summarized as below:

Condition Treatment

Acute appendicitis:

Emergency appendicectomy and prophylaxis:

	Medicine	Dose	Frequency	Duration
	ceftriaxone iv	1g	Once only	-
and	metronidazole iv	500mg	Once only	-

Appendiceal Mass

Clinical assessment of size of mass and institution of IV antibiotics and analgesia

	Medicine	Dose	Frequency	Duration
	benzyl penicillin iv	2.5MU	4 times a day
and	gentamicin iv	120mg	once a day
and	metronidazole iv	500mg	3 times a day
	Alternatively:
	ceftriaxone iv	1g	2 times a day
and	metronidazole iv	500mg	3 times a day

This can be done while serial examinations (daily) for clinical improvement of size of mass. are instituted. Serial FBC and USS monitoring for improvement is also important. Failure to improve or deterioration in condition might warrant surgical intervention. If the patient improves elective surgery (six weeks after initial presentation) is advised as operating early is fraught with higher risk of complications.

Appendiceal Abscess:

Emergency incision and drainage (with or without appendicectomy) or USS guided pus drainage plus antibiotics as follows:

	Medicine	Dose	Frequency	Duration
	benzyl penicillin iv	2.5MU	4 times a day
and	gentamicin iv	120mg	once a day
	Alternatively:
	ceftriaxone iv	1g	2 times a day
and	metronidazole iv	500mg	3 times a day

These treatments are continued till clinical improvement is satisfactory. Interval elective appendicectomy might or might not be necessary.

Appendiceal rupture/perforation.

Generalised peritonitis is typical and prognosis is poor. Aggressive fluid resuscitation, IV antibiotics and urgent laparotomy are all necessary. The IV antibiotic regime is as for appendiceal abscess above.