Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy.
Your appendix is a finger-shaped pouch that projects out from your colon on the lower right side of your abdomen. This small structure has no known essential purpose, but that doesn't mean it can't cause problems.
CAUSES
On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen (the inside space of a tubular structure).Once this obstruction occurs, the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death.
The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis, and, most commonly, calcified fecal deposits known as appendicoliths or fecaliths. The occurrence of obstructing fecaliths has attracted attention since their presence in patients with appendicitis is significantly higher in developed than in developing countries,and an appendiceal fecalith is commonly associated with complicated appendicitis.Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls.The occurrence of a fecalith in the appendix seems to be attributed to a right-sided fecal retention reservoir in the colon and a prolonged transit time.From epidemiological data, it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt from appendicitis. Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis. This is in accordance with the occurrence of a right-sided fecal reservoir and the fact that dietary fiber reduces transit time.
SYMPTOMS
Signs and symptoms of appendicitis may include:
-Aching pain that begins around your navel and often shifts to your lower right abdomen
-Pain that becomes sharper over several hours
-Tenderness that occurs when you apply pressure to your lower right abdomen
-Sharp pain in your lower right abdomen that occurs when the area is pressed on and then the pressure is -quickly released (rebound tenderness)-Pain that worsens if you cough, walk or make other jarring movements
-Nausea
-Vomiting
-Loss of appetite
-Low-grade fever
-Constipation
-Inability to pass gas
-Diarrhea
-Abdominal swelling
The location of your pain may vary, depending on your age and the position of your appendix. Young children or pregnant women, especially, may have appendicitis pain in different places.
Make an appointment with a doctor if you or your child experiences signs or symptoms that worry you. Abdominal pain so severe that you are unable to sit still or find a comfortable position requires immediate medical attention.
DIAGNOSIS
Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Histories fall into two categories, typical and atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant (or the left lower quadrant in patients with situs inversus totalis), where tenderness develops. A commonly used acronym for diagnosis is PALF: pain, anorexia, leukocytosis, and fever. Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Atypical histories often require imaging with ultrasound and/or CT scanning. A pregnancy test is vital in all women of child bearing age, as ectopic pregnancies and appendicitis present similar symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men) should be appreciated.
IMAGING
*X–Ray
In 10% of patients with appendicitis, plain abdominal X-ray may demonstrate hard formed feces in the lumen of the appendix (fecolith).
*Ultrasound
Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children, and shows free fluid collection in the right iliac fossa, along with a visible appendix without blood flow in color Doppler.This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult.
*Computed tomography
Concerns about radiation, however, tend to limit use of CT in pregnant women and children. A properly performed CT scan with modern equipment has a detection rate (sensitivity) of over 95%, and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in cross-sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye). The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. .
DIFERIENTIAL DIAGNOSIS
In children
Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, Henoch-Schönlein purpura, lobar pneumonia, urinary tract infection (abdominal pain in the absence of other symptoms can occur in children with UTI), new-onset Crohn's disease or ulcerative colitis, pancreatitis, and abdominal trauma from child abuse; distal intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in children with leukemia;
In women
menarche, dysmenorrhea, severe menstrual cramps, Mittelschmerz, pelvic inflammatory disease, ectopic pregnancy, pelvic inflammatory disease, ectopic pregnancy, endometriosis, Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle). The most common mimic of appendicitis is the ruptured ovarian cyst in young women.
In men
testicular torsion, new-onset Crohn's disease or ulcerative colitis;
In adults
regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma;
In elderly
diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.
TREATMENT/MANAGEMENT
Acute appendicitis is typically managed by surgery however in uncomplicated cases antibiotics are both effective and safe.While antibiotics are effective for treating uncomplicated appendicitis 20% of people had a recurrence within a year and required eventual appendectomy.
-SURGERY
Laparotomy
Laparotomy is the traditional type of surgery used for treating appendicitis. This procedure consists in the removal of the infected appendix through a single larger incision in the lower right area of the abdomen.[35] The incision in a laparotomy is usually 2-3 inches long. This type of surgery is used also for visualizing and examining structures inside the abdominal cavity and it is called exploratory laparotomy.
During a traditional appendectomy procedure, the patient is placed under general anesthesia to keep the muscles completely relaxed and to keep the patient unconscious. The incision is two to three inches (76 mm) long and it is made in the right lower abdomen, several inches above the hip bone.[36] Once the incision opens the abdomen cavity and the appendix is identified, the surgeon removes the infected tissue and cuts the appendix from the surrounding tissue. After the surgeon inspects carefully and closely the infected area and there are no signs that surrounding tissues are damaged or infected, he will start closing the incision. This means sewing the muscles and using surgical staples or stitches to close the skin up. In order to prevent infections the incision is covered with a sterile bandage.
The entire procedure does not last longer than an hour if complications do not occur.
Laparoscopic surgery
The newer method to treat appendicitis is the laparoscopic surgery. This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inches (6.3 to 13 mm) long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the patient'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 using surgical instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two hours. The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there is no incision on the external skin and SILS (Single incision laparoscopic Surgery) where a single 2.5 cm incision is made to perform the surgery.
-AFTER SURGERY (POST OP).
The stitches the day after having his appendix removed by laparoscopic 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 patients engages in limit their physical activity so the tissues can heal faster. Recovery after an appendectomy may not require diet changes or a lifestyle change.
. 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 appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks.An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior incomplete appendectomy.
