Acute Appendicitis

Introduction

Acute Appendicitis is the inflammation of the appendix and is a surgical emergency. Early recognition and prompt surgical management are essential to preventing serious consequences of appendicitis, especially perforation and peritonitis.

1. Pathophysiology

   1. Initial inflammation of the appendiceal wall is followed by localized ischemia, perforation, and the development of a contained abscess or generalized peritonitis.

   2. Obstruction of the appendiceal lumen is the most commonly accepted cause of appendicitis. Fecoliths are the most common cause of obstruction, however parasites and calculi can also cause obstruction.

   3. In young children, appendiceal inflammation most likely occurs after an infection. The inflammation of the lymphoid tissue causes the distension of the appendix with associated congestion of the venuous outflow.

2. Presenting symptoms

   1. Vague Peri-umbilical pain that migrates to the right lower quadrant

   2. Nausea, Vomiting, Fever and Anorexia

   3. Note: McBurney’s Sign develops after 24 hours of appendicitis onset.

3. Clinical Signs

   1. Blumberg’s Sign

      1. Rebound tenderness, the pain is worsened after palpatory pressure is removed.

   2. McBurney’s Sign

      1. Pain on palpation over the McBurney’s Point.

   3. Dunphy’s Sign

      1. Abdominal tenderness worsened by coughing. It is caused by peritonitis.

   4. Rovsing’s Sign

      1. Also called the “Indirect Sign”. Right lower quadrant with palpation of the left lower quadrant

   5. Pain followed by vomiting. These patients will experience abdominal pain first, which is followed by vomiting.

4. Diagnostic Workup

   1. Labs:

      1. CBC

         1. White Blood Cell elevation is highly sensitive for Appendicitis, especially in the absence of other elevations.

      2. Electrolytes

      3. Creatinine

      4. CRP

   2. Abdominal Ultrasound

      1. To assess the HPB system and to rule out other causes of abdominal pain

      2. To assess the renal system to rule out renal stones

      3. To assess for free abdominal fluids

      4. In some literature a “Target Sign” can be seen, when the ultrasound probe is used to assess the point of maximal pain. The target sign occurs due to the visualization of the fecolith within the appendix.

      5. The most accurate սltrаѕoսnd finding for acute арреոԁiсitiѕ is an appendiceal diameter of >6 mm

   3. CT Scan

   4. MRI

      1. Indicated in pregnant women

5. Surgical/Medical Management

   1. Open Appendectomy

   2. Laparoscopic Appendectomy

6. Relevant Surgical Anatomy

   1. Location of Appendix

      

   2. Difference between McBurney’s Point and Mid-Inguinal Point

      1. McBurney’s Point → A point on the right side of the abdomen, one third of the distance from the Anterior Superior Iliac Spine to the Umbilicus.

      2. Mid-Inguinal Point → Half-way between the Anterior Superior Iliac Spine and the Pubic Symphysis. This is the point where the Femoral Artery can be palpated below the inguinal ligament.

   3. McBurney’s Incision (Layers)

      1. Gridiron Incision

         • Location → Centered along the McBurney’s Point

         • Layers Involved in Gridiron Incision:

           1. Skin

           2. Subcutaneous Fat

           3. Fascia

           4. External Oblique

           5. Internal Oblique

           6. Transversus Abdominis

           7. Transversalis Fascia

           8. Peritoneum

         • Performed for Appendectomies

         • The Gridiron Incision can be extended Cephalad to create a Rutherford Morrison Incision

           • This Incision helps to access the Ascending colon

   4. Blood Supply of the Appendix

      1. Appendicular Artery → Originates most commonly from the Ileocolic Artery