Signs and symptoms
The presentation of acute appendicitis includes acute abdominal pain, nausea, vomiting, and fever. As the appendix becomes more swollen and inflamed, it begins to irritate the adjoining abdominal wall. This leads to the localization of the pain to the right lower quadrant. This classic migration of pain may not be seen in children under three years. This pain can be elicited through signs, which can feel sharp. Pain from appendicitis may begin as dull pain around the navel. After several hours, pain will usually transition towards the right lower quadrant, where it becomes localized. Symptoms include localized findings in the rightCauses
Acute appendicitis seems to be the result of a primary obstruction of the appendix. Once this obstruction occurs, the appendix becomes filled withDiagnosis
Diagnosis is based on a medical history (symptoms) and physical examination, which can be supported by an elevation ofClinical
* Aure-Rozanova's sign: Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg's). * Bartomier-Michelson's sign: Increased pain on palpation at the right iliac region as the person being examined lies on their left side compared to when they lie on their back. * Dunphy's sign: Increased pain in the right lower quadrant with coughing. * Hamburger sign: The patient refuses to eat (Blood and urine test
While there is no laboratory test specific for appendicitis, aImaging
In children the clinical examination is important to determine which children with abdominal pain should receive immediate surgical consultation and which should receive diagnostic imaging. Because of the health risks of exposing children to radiation, ultrasound is the preferred first choice with CT scan being a legitimate follow-up if the ultrasound is inconclusive. CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of 94%, specificity of 95%. Ultrasonography had an overall sensitivity of 86%, a specificity of 81%.Ultrasound
Computed tomography
Where it is readily available, computed tomography (CT) has become frequently used, especially in people whose diagnosis is not obvious on history and physical examination. Although some concerns about interpretation are identified, a 2019 Cochrane review found that sensitivity and specificity of CT for the diagnosis of acute appendicitis in adults was high. Concerns about radiation tend to limit use of CT in pregnant women and children, especially with the increasingly widespread usage of MRI. The accurate diagnosis of appendicitis is multi-tiered, with the size of the appendix having the strongest positive predictive value, while indirect features can either increase or decrease sensitivity and specificity. A size of over 6 mm is both 95% sensitive and specific for appendicitis. However, because the appendix can be filled with fecal material, causing intraluminal distention, this criterion has shown limited utility in more recent meta-analyses. This is as opposed to ultrasound, in which the wall of the appendix can be more easily distinguished from intraluminal feces. In such scenarios, ancillary features such as increased wall enhancement as compared to adjacent bowel and inflammation of the surrounding fat, or fat stranding, can be supportive of the diagnosis. However, their absence does not preclude it. In severe cases with perforation, an adjacent phlegmon or abscess can be seen. Dense fluid layering in the pelvis can also result, related to either pus or enteric spillage. When patients are thin or younger, the relative absence of fat can make the appendix and surrounding fat stranding difficult to see.Magnetic resonance imaging
Magnetic resonance imaging (MRI) use has become increasingly common for diagnosis of appendicitis in children and pregnant patients due to the radiation dosage that, while of nearly negligible risk in healthy adults, can be harmful to children or the developing baby. In pregnancy, it is more useful during the second and third trimester, particularly as the enlargening uterus displaces the appendix, making it difficult to find by ultrasound. The periappendiceal stranding that is reflected on CT by fat stranding on MRI appears as an increased fluid signal on T2 weighted sequences. First trimester pregnancies are usually not candidates for MRI, as the fetus is still undergoing organogenesis, and there are no long-term studies to date regarding its potential risks or side effects.X-ray
In general, plain abdominal radiography (PAR) is not useful in making the diagnosis of appendicitis and should not be routinely obtained from a person being evaluated for appendicitis. Plain abdominal films may be useful for the detection ofScoring systems
Several scoring systems have been developed to try to identify people who are likely to have appendicitis. The performance of scores such as the Alvarado score and the Pediatric Appendicitis Score, however, are variable. The Alvarado score is the most known scoring system. A score below 5 suggests against a diagnosis of appendicitis, whereas a score of 7 or more is predictive of acute appendicitis. In a person with an equivocal score of 5 or 6, a CT scan or ultrasound exam may be used to reduce the rate of negative appendectomy.Pathology
Even for clinically certain appendicitis, routine histopathology examination of appendectomy specimens is of value for identifying unsuspected pathologies requiring further postoperative management. Notably, appendix cancer is found incidentally in about 1% of appendectomy specimens. Pathology diagnosis of appendicitis can be made by detecting aDifferential diagnosis
Children: Gastroenteritis,Management
Acute appendicitis is typically managed by surgery. While antibiotics are safe and effective for treating uncomplicated appendicitis, 26% of people had a recurrence within a year and required an eventual appendectomy. Antibiotics are less effective if an appendicolith is present. Surgery is the standard management approach for acute appendicitis, however, the 2011 Cochrane review comparing appendectomy with antibiotics treatments has not been updated and has been withdrawn. The cost effectiveness of surgery versus antibiotics is unclear. 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.Pain
Pain medications (such asSurgery
TheOpen appendectomy
For over a century, laparotomy (open appendectomy) was the standard treatment for acute appendicitis. This procedure consists of the removal of the infected appendix through a single large incision in the lower right area of the abdomen. The incision in a laparotomy is usually long. During an open appendectomy, the person with suspected appendicitis is placed under general anesthesia to keep the muscles completely relaxed and to keep the person unconscious. The incision is two to three inches (76 mm) long, and it is made in the right lower abdomen, several inches above theLaparoscopic appendectomy
Laparoscopic appendectomy was introduced in 1983 and has become an increasingly prevalent intervention for acute appendicitis. This surgical procedure consists of making three to four incisions in the abdomen, each long. This type of appendectomy is made by inserting a special surgical tool called a laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the person's body, and it is designed to help the surgeon to inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by usingLaparoscopic-assisted transumbilical appendectomy
In pediatric patients, the high mobility of the cecum allows externalization of the appendix through the umbilicus, and the entire procedure can be performed with a single incision. Laparoscopic-assisted transumbilical appendectomy is a relatively recent technique but with long published series and very good surgical and aesthetic results.Pre-surgery
The treatment begins by keeping the person who will be having surgery from eating or drinking for a given period, usually overnight. AnAfter surgery
Hospital lengths of stay typically range from a few hours to a few days but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition: if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally a lot faster if the appendix did not rupture. It is important that people undergoing surgery respect their doctor's advice and limit their physical activity so the tissues can heal faster. Recovery after an appendectomy may not require diet changes or a lifestyle change. The length of hospital stays for appendicitis varies on the severity of the condition. A study from the United States found that in 2010, the average appendicitis hospital stay was 1.8 days. For stays where the person's appendix had ruptured, the average length of stay was 5.2 days. After surgery, the patient will be transferred to a postanesthesia care unit, so his or her vital signs can be closely monitored to detect anesthesia- or surgery-related complications. Pain medication may be administered if necessary. After patients are completely awake, they are moved to a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular diet when the intestines start to function correctly. Patients are recommended to sit upon the edge of the bed and walk short distances several times a day. Moving is mandatory, and pain medication may be given if necessary. Full recovery from appendectomies takes about four to six weeks but can be prolonged to up to eight weeks if the appendix had ruptured.Prognosis
Most people with appendicitis recover quickly after surgical treatment, but complications can occur if treatment is delayed or ifEpidemiology
Appendicitis is most common between the ages of 5 and 40. In 2013, it resulted in 72,000 deaths globally, down from 88,000 in 1990. In the United States, there were nearly 293,000 hospitalizations involving appendicitis in 2010. Appendicitis is one of the most frequent diagnoses for emergency department visits resulting in hospitalization among children ages 5–17 years in the United States.See also
* Deaths from appendicitis * Evan O'Neill Kane *References
External links
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