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Clinical picture according to the position:
I. Retrocecal appendicitis:
· Rigidity is often absent in the RIF.
· Deep tenderness is often found in the loin not in the RIF.
· Rigidity of the quadratus lumborum muscle may present.
· Flexion of the right hip.
· Positive psoas sign
II. Pelvic appendicitis:
· Early diarrhea may be the presenting complaint, because the inflamed
appendix comes in contact with the rectum.
· Absent tenderness and rigidity at Mc Burney`s point
· Deep suprapubic tenderness mainly in the right side
· Per rectum examination reveals tender pelvis more mainly the right
side
· Psoas and obturator signs may be positive
· Patient may have frequency of micturation
III. Postileal appendicitis:
· It is rare, diarrhea is a feature, there is no pain shifting, and the
tenderness is ill defined.
IV. Maldescend:
In cases of subhepatic appendicitis the tenderness is in the right
hypochondrium, and it should be differentiated from acute cholecystitis
Clinical picture of special situations:
I. Infants:
· Acute appendicitis is relatively rare below 2 years of age, but
when it occur it has a higher incidence of perforation (80%) and
morbidity because of delayed diagnosis and underdeveloped greater
omentum.
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II. Children:
· Vomiting,anorexia and interference with sleep are common
complaints. Bowel sounds are often absent
III. Elderly patient:
· Gangrene and perforation are much more common because of
atheroscloretic appendicular artery and atrophic greater omentum
· The clinical finding do not represent the underlying pathology
because of laxity of the abdomen and obesity
· It can mimic sub acute intestinal obstruction
IV. Obese patient:
· The local findings are usually obscured and misleading
· Midline abdominal incision is preferred because of delayed diagnosis
and technical difficulties
V. Pregnancy:
· Acute appendicitis is the most common extra uterine acute abdominal
condition in pregnancy
· Delayed diagnosis because of early non specific symptoms and
change position of the appendix
· If patient present with flank pain, pyelonephritis should be excluded
and when patient present with lower abdominal pain other gynecological
problems like torsion of ovarian cyst should be excluded
· Fetal loss occurs in 2-3% of cases, the risk increases to 20% in
cases of perforated appendicitis
· In doubtful cases it is better to perform early appendicectomy
Diagnosis
A. Clinical evaluation.
B. Ultrasound and if needed CT
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When classic symptoms and signs are present, the diagnosis is linical.
In such patients, delaying laparotomy to perform imaging tests only
increases the likelihood of perforation and subsequent complications.
In patients with atypical or equivocal findings, imaging studies should
be done without delay. Abdominal ultrasound is diagnostic in 90% of
cases especially in Children, the finding will be edematous appendix
or faecolith in the lumen, it is helpful to exclude other pathology like
kidney problems ; however, it is occasionally limited by the presence
of bowel gas and is less useful for recognizing nonappendiceal causes
of pain. Pelvic ultrasound is helpful to exclude pelvic pathology.
Contrast-enhanced CT has reasonable accuracy in diagnosing appendicitis
and can also reveal other causes of an acute abdomen. Appendicitis
remains primarily a clinical diagnosis. Selective and judicious use of
radiographic studies may reduce the rate of negative laparotomy.
Laparoscopy can be used for diagnosis as well as definitive treatment;
it may be especially helpful in women with lower abdominal pain of
unclear etiology. Laboratory studies typically show leukocytosis
(12,000 to 15,000/μL), but this finding is highly variable; a normal
WBC count should not be used to exclude appendicitis.
DIFFRENTIAL DIAGNOSIS
I. IN CHILDREN:
1. Acute gastroenteritis:
a. Intestinal colic, diarrhea, vomiting are common feature.
b. Localized tenderness usually absent.
c. History of other family member affected.
d. Postileal appendicitis mimic the same condition.
e. If doubt persists patient should be explored-
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2.Mesenteric lymphadenitis:
· Colicky abdominal pain for few minutes, between the attacks
patient is free of pain, the cervical lymph nodes may be enlarged.
· Shifting tenderness is convincing evidence of appendicitis and if
doubt exists, patient should be explored.
3. Meckle`s diverticulitis:
· It is impossible to distinguish it from appendicitis clinically and it
is usually an intraoperative diagnosis.
4- Intussusceptions:
· Common before 2 years of age and a mass in the right lower
abdomen may be felt and patient usually pass red current jelly stool
5- Henoch – Schonlein purpura:
· Patient had history of sore throat or upper respiratory tract infection
and present with ecchymotic rash in the extensor surfaces of the
limbs and buttocks, but the face is spared. Platelets count and
bleeding time are normal.
6- Lobar pneumonia:
· Patient will be toxic with marked pyrexia, minimal abdominal
finding and chest finding are obvious.
· Chest x ray is diagnostic and should be done.
II. ADULTS:
1- Terminal ileitis:
· History of abdominal cramps, weight loss, and diarrhea. Occasionally
doughy mass felt in the right iliac fossa
2- Ureteric colic.
· Nature and radiation of pain are different.
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· Urine analysis will reveal haematuria.
· Ultrasound and intravenous pyelogram (IVP) is diagnostic
3- Right acute pyelonephritis:
· The patient will present with right loin pain, high fever (39ْ C)
rigors, pyuria, and frequency of micturation
4- Perforated peptic ulcer:
· The duodenal content pass along the paracolic gutter to the right
iliac fossa will result in sudden onset epigastric pain pass down to
the right iliac fossa with tenderness and rigidity.
· Erect chest X ray may show gas under diaphragm
5- Testicular torsion:
· It occurs in teenager and young adults, the testicular pain referred
to the right iliac fossa and scrotal examination reveals tender swollen
right testis
6- Acute pancreatitis:
· In adults in early cases of acute pancreatitis the diffuse abdominal
pain may be confused with that of appendicitis
7- Rectus sheath haematoma:
· is rare and present clinically with acute pain, localized tenderness,
occasionally mass in the right iliac fossa, usually after sever exercise
III. ADULT FEMALE:
Careful gynecological history should be taken to exclude any
gynecological pathology
1- Salpingitis:
· The patient usually young female, with lower bilateral abdominal
pain, history of vaginal discharge, dysmenorrhoea and dysuria.
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· Gynecologist opinion and diagnostic laparoscopy should be considered
in case of uncertainty
2- Midcycle pain (Mittelschmerz):
· It is due to rupture of follicular cyst with bleeding, rarely it has
systemic effects and it usually subside within few hours. Occasionally
diagnostic laparoscopy needed
3- Torsion/haemorrhage of ovarian cyst:
The clinical presentation is severe lower abdominal pain referred to
the loin, tachycardia with normal body temperature, ultrasound
examination is helpful in diagnosis.Intraoperatively the other ovary
should be visualized.
Huge haemorrhagic ovarian cyst.
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4- Ectopic pregnancy:
· Right side tubal pregnancy mimic acute appendicitis, the patient
present with missed period, severe constant lower abdominal pain,
soft tender cervix, and signs of intraperitoneal bleeding.
· Positive urinary pregnancy test and vaginal ultrasound is diagnostic
IV. Elderly Patients
1- Sigmoid diverticulitis:
· In patient with long sigmoid loop crossing to the right side sigmoid
diverticulitis may present with right lower abdominal pain
2- Intestinal obstruction:
· Persistent colicky abdominal pain, vomiting, and exaggerated
bowel sound. Standing x ray abdomen will reveal air fluid levels
3- Carcinoma of the caecum:
· When obstructed or perforated may present with symptoms and
signs of acute appendicitis but usually patient has history of weight
loss, alternative bowel habit, anemia and right iliac fossa mass.
· Barium enema and colonoscopy is diagnostic
RARE DIFFERNTIAL DIAGNOSIS:
1- Preherpetic pain of 10th and 11th dorsal nerves:. Pain in the right iliac
fossa, does not shift, associated with marked hyperaesthesia, patient
has no abdominal finding. After 3-8 hrs herpetic eruption appear
2- Tabetic crises: sever abdominal pain and vomiting
3- Spinal conditions:
· Tuberculosis of the spine, metastatic carcinoma, multiple myeloma,
osteoporotic vertebral collapse. The pain due to nerve root
compression, patient has no intestinal symptoms
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4- Complication of diabetes mellitus like diabetic ketoacidosis (DKA)
The patient has high blood sugar and acetone in the urine
5- Porphyria: associated with mental and neurological symptoms and
signs.
6- Cyclic vomiting: occur in infants and young children, usually there
is history of previous similar attacks, patient has no abdominal finding.
Prognosis
Without surgery or antibiotics, mortality is > 50%. With early surgery,
the mortality rate is < 1%, and convalescence is normally rapid and
complete. With complications (rupture and development of an abscess
or peritonitis), the prognosis is worse: Repeat operations and a long
convalescence may follow.
Treatment
A. Surgical removal
B. IV fluids and antibiotics
Treatment of acute appendicitis is open or laparoscopic appendectomy;
because treatment delay increases mortality, a negative appendectomy
rate of 15% is considered acceptable. The surgeon can usually remove
the appendix even if perforated. Occasionally, the appendix is difficult
to locate: In these cases, it usually lies behind the cecum or the ileum
and mesentery of the right colon. A contraindication to appendectomy
is inflammatory bowel disease involving the cecum. However, in cases
of terminal ileitis and a normal cecum, the appendix should be removed.
Appendectomy should be preceded by IV antibiotics. Third-generation
cephalosporins are preferred. For nonperforated appendicitis, no
further antibiotics are required. If the appendix is perforated, antibiotics
should be continued until the patient's temperature and WBC count
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have normalized or continued for a fixed course, according to the
surgeon's preference. If surgery is impossible, antibiotics - although
not curative - markedly improve the survival rate. When a large
inflammatory mass is found involving the appendix, terminal ileum,
and cecum, resection of the entire mass and ileocolostomy are preferable.
In late cases in which a pericolic abscess has already formed, the abscess
is drained either by an ultrasound-guided percutaneous catheter or by
open operation (with appendectomy to follow at a later date if needed).
A Meckel's diverticulum in a patient under the age of 40 should be
removed concomitantly with the appendectomy unless extensive
inflammation around the appendix prevents the procedure.
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Intestinal Obstruction
Intestinal obstruction is significant mechanical impairment or complete
arrest of the passage of contents through the intestine. Symptoms include
cramping pain, vomiting, constipation, and lack of flatus. Diagnosis is
clinical, confirmed by abdominal x-rays. Treatment is fluid resuscitation,
nasogastric suction, and, in most cases of complete obstruction,
surgery. Mechanical obstruction is divided into obstruction of the small
bowel (including the duodenum) and obstruction of the large bowel.
Obstruction may be partial or complete. About 85% of partial smallbowel obstructions resolve with nonoperative treatment, whereas about
85% of complete small-bowel obstructions require operation.
Different clinical pictures:
1- High small bowel obstruction:
a. Vomiting: early and profuse
b. Rapid dehydration
c. Minimal abdominal distention
d. Little or no fluid levels on standing abdominal x ray
2- Low small bowel obstruction:
a. Severe colicky abdominal pain
b. Central abdominal distention
c. Vomiting is delayed
d. Multiple air fluid levels on standing abdominal x ray
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