Appendicitis Early Signs Symptoms, Causes, Surgery

Appendicitis Early Signs Symptoms, Causes, Surgery/Appendicitis is an inflammation of the appendix that may lead to an abscess, ileus, peritonitis, or death if untreated. Appendicitis is the most common abdominal surgical emergency. The current standard treatment of uncomplicated appendicitis is usually surgery, but there has been increasing evidence published on the use of antibiotics.

Appendicitis is inflammation of the vermiform appendix. This is a hollow organ located at the tip of the cecum, usually in the right lower quadrant of the abdomen. The appendix develops embryonically at the fifth week. During this time there is a movement of the midgut to the external umbilical cord with the eventual return to the abdomen and rotation of the cecum. This results in the usual retrocecal location of the appendix. It is most often a disease of acute presentation, usually within 24 hours, but it can also present as a more chronic condition. If there has been a perforation with a contained abscess, then the presenting symptoms can be more indolent. The exact function of the appendix has been a debated topic. Today it is accepted that this organ may have an immunoprotective function and acts as a lymphoid organ especially in the younger person. Other theories contend that the appendix acts as a storage vessel for “good” colonic bacteria. Still, others argue that it is a mear developmental remnant and has no real function.[rx][rx][rx]

Anatomy of Appendicitis

The vermiform appendix is a tubular structure attached to the base of the caecum at the confluence of the taeniae coli. It is approximately 8-10 cm long in adults and represents the underdeveloped distal end of the large caecum seen in other animals. In humans it is regarded as a vestigial organ, and acute inflammation of this structure is called acute appendicitis

• Retrocaecal/retrocolic (75%)—Right loin pain is often present, with tenderness on examination. Muscular rigidity and tenderness to deep palpation are often absent because of protection from the overlying caecum. The psoas muscle may be irritated in this position, leading to hip flexion and exacerbation of the pain on hip extension (psoas stretch sign)
• Subcaecal and pelvis (20%)—Suprapubic pain and urinary frequency may predominate. Diarrhea may be present as a result of irritation of the rectum. Abdominal tenderness may be lacking, but rectal or vaginal tenderness may be present on the right. Microscopic haematuria and leucocytes may be present on urine analysis
• Pre-ileal and post-ileal (5%)—Signs and symptoms may be lacking. Vomiting may be more prominent, and diarrhea may result from irritation of the distal ileum

Appendicitis Early Signs Symptoms

A blockage in the lining of the appendix that results in infection is the likely cause of appendicitis. The bacteria multiply rapidly, causing the appendix to become inflamed, swollen and filled with pus. If not treated promptly, the appendix can rupture.

There are numerous issues that can cause appendix luminal blockage, including:

• Appendicoliths or fecaliths, which are calcified fecal deposits, also known as “appendix stones” (this is more common in children than adults) (rx)
  
• Intestinal worms or parasites, including pinworm (Enterobius vermicularis)
• Irritation and ulcers in the gastrointestinal (GI) tract resulting from long-lasting disorders, such as Crohn’s disease or ulcerative colitis
• Abdominal injury or trauma
• Enlarged lymph tissue of the wall of the appendix, which is typically the result of infections in the GI tract
• Benign or malignant tumors
• Various foreign objects, such as stones, bullets, air gun pellets, and pins (rx)
• Sometimes appendicitis is due to a viral, bacterial, or fungal infection that has spread to the appendix. (rx) Possible causes of infection include, but are not limited to:
• E. coli, which are bacteria found in the environment, foods, and intestines of animals. Most strains of E. coli are harmless, but others can cause illness. (rx)
  
• Pseudomonas bacteria, which are found in soil and water and moist areas such as sinks and toilets (rx)
  
• Bacteroides, bacteria that already inhabit the digestive tract of humans (rx)
  
• Adenovirus, a very common virus spread through contact or through the air that can cause cold-like symptoms as well as bladder and other infections. (rx)
• Salmonella, a foodborne bacteria that typically causes gastrointestinal upset (diarrhea, nausea, and vomiting) but can have serious complications
• Shigella bacteria, germs that are very contagious and typically result in diarrheal illness that usually lasts no more than a week. (rx)
  
• Measles, a highly contagious virus spread through the air and contact. Vaccination protects most of the population, but there are outbreaks in which unvaccinated people are susceptible (rx)
  
• The fungal infections mucormycosis (a rare but serious mold infection caused by environmental molds) (rx) and histoplasmosis; most people who breathe in these spores won’t get sick or will have mild symptoms, but infection can become severe in people with weakened immune systems (11

Appendicitis can have more than one cause, and in many cases, the cause is not clear. Possible causes include

• Blockage of the opening inside the appendix
• enlarged tissue in the wall of your appendix, caused by an infection in the gastrointestinal (GI) tract or elsewhere in your body
• inflammatory bowel disease
• stool, parasites, or growths that can clog your appendiceal lumen
• trauma to your abdomen

Appendicitis can cause serious complications, such as:

• A ruptured appendix. A rupture spreads infection throughout your abdomen (peritonitis). Possibly life-threatening, this condition requires immediate surgery to remove the appendix and clean your abdominal cavity.
• A pocket of pus that forms in the abdomen. If your appendix bursts, you may develop a pocket of infection (abscess). In most cases, a surgeon drains the abscess by placing a tube through your abdominal wall into the abscess. The tube is left in place for two weeks, and you’re given antibiotics to clear the infection.

Symptoms of Appendicitis

Classically, appendicitis presents as an initial generalized or periumbilical abdominal pain that then localizes to the right lower quadrant. Initially, as the visceral afferent nerve fibers at T8 through T10 are stimulated, and this leads to vague centralized pain. As the appendix becomes more inflamed and the adjacent parietal peritoneum is irritated, the pain becomes more localized to the right lower quadrant. Pain may or may not be accompanied by any of the following symptoms:

• Sudden pain that begins on the right side of the lower abdomen
• Sudden pain that begins around your navel and often shifts to your lower right abdomen
• Pain that worsens if you cough, walk or make other jarring movements
• Nausea and vomiting
• Loss of appetite
• Low-grade fever that may worsen as the illness progresses
• Constipation or diarrhea
• Abdominal bloating
• Anorexia
• Nausea/vomiting
• Fever (40% of patients)
• Diarrhea
• Generalize malaise
• Urinary frequency or urgency
• begins near your belly button and then moves lower and to your right
• Gets worse in a matter of hours
• Gets worse when you move around, take deep breaths, cough, or sneeze
• Is severe and often described as different from any pain you’ve felt before
• Occurs suddenly and may even wake you up if you’re sleeping
• An inability to pass gas
• A low-grade fever
• Swelling in your abdomen
• The feeling that having a bowel movement will relieve discomfort

Symptoms can be different for each person and can seem like the following conditions that also cause pain in the abdomen:

• Abdominal adhesions
• Constipation
• Inflammatory bowel disease, which includes Crohn’s disease and ulcerative colitis, long-lasting disorders that cause irritation and ulcers in the GI tract
• Intestinal obstruction
• Pelvic inflammatory disease

As inflammation progresses, signs of peritoneal inflammation develop. Signs include:

• Right lower quadrant guarding and rebound tenderness over McBurney’s point (1.5 to 2 inches from the anterior superior iliac spine on a straight line from the ASIS to the umbilicus)
• Rovsing’s sign (right lower quadrant pain elicited by palpation of the left lower quadrant)
• Dunphy’s sign (increased abdominal pain with coughing)

Other associated signs such as psoas sign (pain on external rotation or passive extension of the right hip suggesting retrocecal appendicitis) or obturator sign (pain on internal rotation of the right hip suggesting pelvic appendicitis) are rare.

Diagnosis of Appendicitis

Clinical

• Aure-Rozanova’s sign – Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg’s).^[rx]
• Bartomier-Michelson’s sign – Increased pain on palpation at the right iliac region as the person being examined lies on his or her left side compared to when he/she lies on the back.^[rx]
• Dunphy’s sign – Increased pain in the right lower quadrant with coughing.^[rx]
• Hamburger sign -The patient refuses to eat (anorexia is 80% specific for appendicitis)^[rx]
• Kocher’s (Kosher’s) sign – From the person’s medical history, the start of pain in the umbilical region with a subsequent shift to the right iliac region.^[rx]
• Massouh sign – Developed in and popular in southwest England, the examiner performs a firm swish with his or her index and middle finger across the abdomen from the xiphoid process to the left and the right iliac fossa. A positive Massouh sign is a grimace of the person being examined upon a right sided (and not left) sweep.^[rx]
• Obturator sign – The person being evaluated lies on her or his back with the hip and knee both flexed at ninety degrees. The examiner holds the person’s ankle with one hand and knee with the other hand. The examiner rotates the hip by moving the person’s ankle away from his or her body while allowing the knee to move only inward. A positive test is pain with internal rotation of the hip.^[rx]
• Psoas sign, also known as Obraztsova’s sign –  is right lower-quadrant pain that is produced with either the passive extension of the right hip or by the active flexion of the person’s right hip while supine. The pain that is elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles while flexing the hip activates the iliopsoas and causes pain.^[rx]
• Rovsing’s sign – Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon). The thought is there will be increased pressure around the appendix by pushing bowel contents and air toward the ileocaecal valve provoking right-sided abdominal pain.^[rx]
• Sitkovskiy (Rosenstein)’s sign – Increased pain in the right iliac region as the person is being examined lies on his/her left side.^[rx]

Investigation of acute appendicitis

• Urine analysis—up to 40% can have abnormalities
• Pregnancy test—to exclude pregnancy
• Full blood count—neutrophil (> 75%) predominant leucocytosis is present in 80-90%
• C reactive protein—raised concentration may be present, but its absence should not exclude a diagnosis of appendicitis
• White Blood Cell Count (WBC) –Although an increase in peripheral WBC with a left shift may be the earliest marker of inflammation, its presence or absence is not significant enough to diagnose or exclude acute appendicitis. Many patients with gastroenteritis, mesenteric adenitis, pelvic inflammatory disease, and many other conditions have an elevated WBC. A normal WBC is also not uncommon in patients with appendicitis.
• Urinalysis – Urinalysis is usually normal but may not be due to the inflamed appendix sitting on the ureter or bladder.

Differential diagnosis of acute appendicitis

Surgical

• Intestinal obstruction
• Intussusception
• Acute cholecystitis
• Perforated peptic ulcer
• Mesenteric adenitis
• Meckel’s diverticulitis
• Colonic/appendicular diverticulitis
• Pancreatitis
• Rectus sheath haematoma

Urological

• Right ureteric colic
• Right pyelonephritis
• Urinary tract infection

Gynaecological

• Ectopic pregnancy
• Ruptured ovarian follicle
• Torted ovarian cyst
• Salpingitis/pelvic inflammatory disease

Medical

• Gastroenteritis
• Pneumonia
• Terminal ileitis
• Diabetic ketoacidosis
• Preherpetic pain on the right 10th and 11th dorsal nerves
• Porphyria

Ultrasound (US)

Use of ultrasound is increasing, particularly in children in whom the risks of ionizing radiation are greatest. The advantages include decreased cost relative to other imaging modalities and lack of ionizing radiation exposure. However, it is operator-dependent.

The visualization of a thickened, non-compressible appendix greater than 6 mm in diameter is diagnostic. If the US is non-diagnostic, further imaging with CT or MRI, particularly in pregnancy, is required. In practice, a positive ultrasound can be used to reduce CT scan utilization. However, a negative or non-diagnostic result is not sufficient to rule out appendicitis. During childbearing age, it can be helpful to exclude a tubo-ovarian abscess.

CT Scan

CT of the abdomen and pelvis is considered the modality of choice for definitive assessment of patients being evaluated for possible appendicitis. However, a major concern with CT scan is radiation exposure, particularly in children. Practitioners should, therefore, use these scans judiciously. Limited-range CT scans have been proposed in children to reduce the radiation dose. The following findings may be seen:

• Dilated appendix greater than 6 mm with a thickened wall (greater than 2 mm)
• Peri-appendiceal inflammation (peri-appendiceal fat stranding)
• Appendicolith
• Appendiceal or abscess
• Free fluid

If the practitioner does not visualize the appendix, appendicitis is not ruled out.

MRI

MRI is a reliable modality which is particularly useful for pregnant women and children when ultrasound is inconclusive. Since intravenous (IV) gadolinium can cross the placenta, it should not be used during pregnancy. Also, patients with renal insufficiency should not receive IV gadolinium.

The following factors limit MRI use:

• Higher cost
• More time required to acquire images
• Skilled radiologist required to interpret MRI
• Not widely available

Also, MRI is not a test of choice for unstable patients and young children in whom sedation may be required. In recent years, the utility of rapid MRI without contrast agents or sedation has been assessed for a diagnosis of pediatric appendicitis.

Treatment of Appendicitis

If practitioners are evaluating the patient for appendicitis, they should also obtain an early surgical consultation.[rx][rx] Intravenously administer isotonic crystalloid fluid.

• Antibiotic prophylaxis, which is coverage for gram-negative and gram-positive aerobic and anaerobic bacteria, and anaerobes (Bacteroides fragilis and Escherichia coli), is recommended. However, its administration should be timed in consultation with the surgical service to ensure that high antibiotic levels coincide with the operative procedure. Treat nonperforated appendicitis with cefoxitin or cefotetan.

In perforated appendicitis consider the following choices:

• Carbapenem
• Ticarcillin-clavulanate
• Piperacillin-tazobactam
• Ampicillin-sulbactam
• Provide adequate analgesia
• The primary treatment for appendicitis is surgery. Doctors should make operative decisions in con
• Antibiotics are less effective if an appendicolith is present.^[rx] Surgery is the standard management approach for acute appendicitis.^[rx] The cost-effectiveness of surgery versus antibiotics is unclear.^[rx]
• Using antibiotics to prevent potential postoperative complications in emergency appendectomy procedures is recommended, and the antibiotics are effective when given to a person before, during, or after surgery.^[rx]
• Pain medications (such as morphine) do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given early in the patient’s care.^[rx] Historically there were concerns among some general surgeons that analgesics would affect the clinical exam in children, and some recommended that they not be given until the surgeon was able to examine the person.^[rx]

Surgery of Appendicitis

Health care professionals call the surgery to remove the appendix an appendectomy. A surgeon performs the surgery using one of the following methods:

• Laparoscopic surgery – During laparoscopic surgery, surgeons use several smaller incisions and special surgical tools that they feed through the incisions to remove your appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.
• Laparotomy – Surgeons use laparotomy to remove the appendix through a single incision in the lower right area of your abdomen.

Surgery versus antibiotics

We found three systematic reviews (each with a search date of 2011). The three reviews reported many of the same RCTs, but in different combinations (see Further information on studies). Each review reported a synthesis of different outcome measures and came to different conclusions; therefore, we have reported all three reviews here to cover the full spectrum of evidence.

References