Acute Appendicitis Tintinalli Ch 84

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Acute AppendicitisTintinalli Ch 84
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Pathophysiology

• Obstruction of appendiceal lumen
• Food matter, Adhesions, Lymphoid hyperplasia,
  Mucosal secretion
• Causes increased intraluminal pressure
• Vascular compromise
• Causes breakdown of epithelial mucosa and
  bacterial invasion
• Inflammatory response
• Eventually leads to arterial stasis and tissue
  infarction

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Innervation

• Luminal distention triggers visceral afferent
  fibers entering at T10 ? Vague, poorly localized
  periumbilical or epigastric
• Inflammation of serosa localized to RLQ
• Anatomic Variability
• Retrocecal (26) ? Flank Pain
• Pregnant Women ? RUQ Pain
• Retroileal ? Testicular Pain
• Pelvic ? Irritate bladder/rectum, suprapubic
  pain/pain with urination/defecation

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Symptoms

• Vague abdominal pain with localization -64
  sensitive, 82 specific
• Anorexia - 68 sensitive, 36 specific
• N/V - 50 sensitive, 45 specific
• Rebound tenderness - 63 sensitive, 69 specific
• Guarding - 74 sensitive, 57 specific
• Rigidity - 27 sensitive, 83 specific
• Fever - 67 sensitive, 79 specific

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Physical Exam

• McBurneys point
• May have rectal or flank tenderness if pelvic or
  retrocecal
• Rovsing sign - Palpation of LLQ produces RLQ pain
• Psoas sign - Patient in left lateral decubitus,
  Extend right leg at hip
• Obturator sign - Passive flexion of hip knee
  with internal rotation of hip

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Diagnostics

• CBC 70-90 sensitive, low specificity
• Urinalysis - Abnormal in 19-40
• Plain Radiographs - Limited diagnostic value
• Abnormal in 24-95
• Look for appendiceal gas, fecalith, localized
  paralytic ileus, blurred right psoas muscle, free
  air

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Diagnostics

• Graded Compression Ultrasound Test of choice in
  children and pregnant women
• 94.7 sensitive, 88.9 specific
• Inflamed appendix cannot be compressed
• Findings
• Diameter gt 6mm
• Presence of appendicolith
• Periappendiceal abscess
• Doppler may show hyperemia
• Limitations
• Retrocecal
• Ruptured appendix normal diameter

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Diagnostics

• CT Contrast may not be necessary, depends on
  your radiologist
• Findings
• Pericecal inflammation
• Abscess
• Periappendiceal phlegmon
• Fluid collections
• Localized fat stranding

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Special Populations

• Very young, High misdiagnosis rate, High
  perforation rate, Communication difficulty
• Atypical symptoms
• Concurrent respiratory symptoms
• Gastroenteritis
• Lethargy, inactivity, hypothermia
• Elderly, Late presentation with an advanced
  course, Misdiagnosis can exceed 50, Incidence of
  perforation 40-70, Mortality rate in patients gt
  70 30
• Pregnant
• Most common extrauterine surgical emergency
• Fetal mortality rate increases up to four times
  if complicated by perforation and peritonitis

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Management

• NPO
• IV fluids
• Preoperative antibiotics cover for anaerobes,
  enterococci, and gram-negatives
• Zosyn or Unasyn
• Analgesics
• Surgical consult