Acute Appendicitis, AA

Notes

## Basic introduction

  • AA is the disease entity resulting from sudden inflammation of the vermiform appendix

## Pathogenesis

  • It results from closed loop obstruction usually by a faecolith (hard discreet mass of thick and hardened faeces) followed by infection
  • The appendix may undergo gangrene with subsequent perforation, abscess formation, and peritonitis

## Statistics

  • It is the most common cause of an acute abdomen globally.
  • It is most common between 5 and 40 years old (median age is 28 years)
  • It is more prevalent in males than females (mainly poor people)
  • Its global annual mortality in 2013 was 72,000 deaths
  • At Kenyatta National Hospital(KNH), appendectomy contributes 16.3% of abdominal emergencies in female and it is the most common overall indication at 37.5% of emergency laparotomy
  • At KNH, young patients under 30 years account for 64% while the elderly over 60 years account for 1.6% of cases of AA
  • The male to female ratio of AA in Kenya is 1.2-1.8:1
  • The rate of perforated AA in Kenya is 20 - 22%, while that of combined gangrene non-perforated and perforated AA is 29.7%

## Grading of AA (according to Disease Severity Score, DSS)

  • Grade 1, inflamed
  • Grade 2, gangrenous
  • Grade 3, perforated with localized free fluid
  • Grade 4, perforated with a regional abscess
  • Grade 5, perforated with diffuse peritonitis.
Symptoms
  • The first manifestation is usually diffuse abdominal pain – mostly in the periumbilical area. This pain then moves in the right lower quadrant of the abdomen and remains at McBurney’s point
  • Sometimes, the intensity of pain can be reduced at a time that corresponds to perforation of appendix and later worsens after peritonitis has developed.
  • Lack of appetite (anorexia)
  • Nausea
  • Vomiting
  • Elevated temperature
  • Localized tenderness in the right lower quadrant of the abdomen
  • Blumberg's sign (rebound tenderness or pain upon removal of pressure) in the right lower quadrant of the abdomen (it is mainly a sign of peritonitis)
  • Sometimes positive Rovsing’s sign (where palpation of the left lower quadrant of abdomen increases the pain felt in the right lower quadrant)
  • Muscle guarding i.e. tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them)
  • Cutaneous hyperesthesia (where the skin reacts overtly to any type of stimuli causing an increase in pain and tenderness).
  • Pelvic tenderness in the right iliac fossa on rectal examination
  • Sitkovskiy (Rosenstein)'s sign
  • Psoas sign
  • Obturator sign
  • Massouh sign
  • Hamburger sign
  • Bartomier-Michelson's sign
  • Aure-Rozanova's sign
Diagnosis
  • Clinical evaluation
  • Ultrasonography is useful to detect AA (especially in children)
  • CT scan is frequently used, apart from children and in pregnancy
Differential
  • Abdominal trauma from child abuse
  • Colonic carcinoma
  • Distal intestinal obstruction syndrome
  • Dysmenorrhea
  • Ectopic pregnancy
  • Endometriosis
  • Gastroenteritis
  • Henoch–Schönlein purpura
  • Intussusception
  • Leaking aortic aneurysm
  • Meckel's diverticulitis
  • Mesenteric adenitis
  • Mesenteric ischemia
  • New-onset Crohn's disease
  • Ovarian torsion
  • Pancreatitis
  • Pelvic inflammatory disease in women
  • Perforated peptic ulcer
  • Renal colic
  • Testicular torsion
  • Ulcerative colitis
  • UTIs
Prevention
  • None is currently known
Reference

a. Awori M N, Jani P.G. Surgical implications of abdominal pains in patients presenting to Kenyatta National hospital casualty department with abdominal pain. East Africa medical journal, 2005; 85(6):307-310. 13.

b. Chavda SK, Hassan S, Magoha GA. Appendicitis at Kenyatta National Hospital, Nairobi. East Afr Med J.2005 Oct; 82(10):526-30 15.

c. Dennis C. Physiologic behavior of the human appendix and the problem of appendicitis. Arch.Surg.1941; 43:1021-60 11.

d. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

e. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

f. Mwangi P.M, Ngugi P M, Oliech JS, Ndaguatha PLW. Diagnostic accuracy in acute appendicitis: a protocol based on modified Alvarado score and ultrasonofigurey at Kenyatta National Hospital. M.med thesis 2012. 16.

g. Ngugi PM. Pattern of indications for laparotomy at Kenyatta National Hospital. M.med thesis 1991. 27 14.

h. Prystowsky JB, Pugh CM, Nagle AP. Current problems in surgery. Appendicitis. CurrProbl Surg. 2005; 42(10):688-742. 12.

i. Wangensteen OH, Dennis C. Experimental proof of the obstructive origin of appendicitis in the genesis of appendicitis in man. Ann surg 1939; 119:629-647.

j. Wilmore W.S, Hill A. G. Acute appendicitis in a rural Kenyan hospital. East African Medical Journal 2001; 78 (7):355-357.

Management
  • Appendectomy (gold standard)
  • Percutaneous drainage and antibiotics
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