-IBIS-1.5.0-
tx
digestive system
appendicitis
diagnoses

definition and etiology

definition:
infection and inflammation of the vermiform appendix

etiology:
luminal obstruction (fecalith, tumor, parasites, or lymphoid hyperplasia) that leads to bacterial overgrowth, or ulceration of the mucosa. Most patients are in their teens through their twenties.

signs and symptoms

signs and symptoms:
• pain: epigastric at first, then moving to the right iliac fossa, often with a sense of a "downward urge", that if stool or flatus was passed there would be relief (though neither affords relief). The pain is steady and worse with movement, breathing, coughing or sneezing.
• vomiting/nausea/anorexia: most patients experience one or all of the three. The vomiting does not usually become severe. Hunger in a patient is almost considered to rule out appendicitis.
• deep tenderness: local deep tenderness is often missing at the onset of the illness, when the generalized abdominal discomfort is most marked. Once that subsides, then deep tenderness may be elicited, particularly at McBurney's point. Tenderness in some location must be demonstrated before the diagnosis of appendicitis can be made.
• guarding: over the abdomen, especially the RLQ
• rebound tenderness: peritoneal inflammation.
• (+) psoas and/or obturator sign
• hyperesthesia of the skin over the RLQ
• constipation.
• absence of bowel sounds (late sign)
• fever
• other possible presentations based on where the appendix might lay in the abdomen: dysuria, hematuria, pain with rectal exam, pain with vaginal exam, testicular symptoms

lab findings:
• moderate leukocytosis: 10,000-18,000 cells/mm, with a shift to the left; more WBCs suggest perforation
• UA: to rule out urinary problem
• increased ESR
• (+) blood culture with perforation
• gynecological exam must be performed
• rectal exam must be performed

course and prognosis

Complications include: adhesions, abscess, peritonitis, gangrene or perforation. Perforation is most commonly seen in infants under 2 years old. With an early operation, the mortality is very low (0.1%); in cases of perforation the mortality rises to 3%. Cathartics and enemas/colonics are contraindicated, as well as antibiotics when the cause of pain is not clear.

differential diagnosis

• influenza
• diaphragmatic pleurisy
• spinal disease
• typhoid
• gastroenteritis
• mesenteric adenitis, esp. in kids
• hepatitis
• other GI tract problems
• gynecological conditions: ectopic pregnancy, salpingitis, etc.


footnotes