Appendicitis

- is a condition characterized by inflammation of

the appendix.
- is an inflammation of the appendix, a fingershaped pouch that projects from your colon on
the lower right side of your abdomen. The
appendix doesn't seem to have a specific
purpose
- most cases require removal of the inflammed
appendix, either by laparotomy or laparoscopy
- if untreate, mortality is high, mainly due to
peritonitis and shock.

Incidence

Acute appendicitis is one of the most common acute surgical abdominal emergencies.
More than 34,600 cases were treated in UK hospitals in 2006 to 2007. Most cases were
in male subjects (30,120) and occurred predominantly in the 15 to 59 year age group. A
large majority presented (29,576) as medical emergencies. More than 250,000
appendectomies are performed each year in the US; however, the incidence is lower in
populations where a high-fibre diet is consumed. The overall lifetime risk of developing
acute appendicitis is 8.6% for males and 6.7% for females; lifetime risk of
appendectomy is around 12% in males and 23% in females. The rate of appendectomy
is around 10 per 10,000 cases per year in the US. This condition is most commonly
seen in patients aged between early teens and late 40s.

Causes:
-trauma
-obstructing fecalith

-lymphadenitis
-intestinal worm

Manifestations

1.Pain
-Caused initially by the distention of the wal of the appendix
-Later due to the grossly inflamed appendix rubbing on the overlying inner
wall of the abdomen
-then with the spillage of the content of the appendix into the general
abdominal cavity

2. Fever
-due to the release of toxic materials (endogenous pyrogens) following the
necrosis of the appendiceal wall, and later by pus formation

3. Guarding
-occur when the abdominal wall becomes rigid during examination.

- occurs whenever there bis peritonitis , localized as in appendicitis, or even in

generalized peritonitis.

4. Loss of appetite and nause

-follows slowing and irritation of the bowel by the inflammatory process

Classic symptom- pain in the right lower quadrant (Mc Burneys Point)

4 signs

1. rovsings sign
deep palpation of the left iliac fossa may cause pain in the right iliac fossa
Description

Pressure over the descending colon causes pain in the right lower quadrant of the
abdomen

2. psoas sign
occasionally, an inflamed appendix lies on the poas muscle and the patient will lie with
the right hip flexed for the pain relief
Description
It is elicited by passively extending the thigh of the patient lying on their side with the
knees extended, or asking the patient to actively flex their thigh at the hip
Positive abdominal pain--- positive psoas sign

3. obturator sign
Description
If an inflamed appendix is in contact with the obturator internus, spasm of the muscle
can be demonstrated by flexing and internally rotating the hip----cause pain in the
hypogastrium

4. blumber sign
- rebound tenderness
Description
Deep palpation of the viscera over the suspected inflamed appendix followed by the
sudden release of the pressure causes the severe pain on the site indicating positive
blumber sign

Diagnostic tests

CBC (White blood cell count)

The white blood cell count in the blood usually becomes elevated with infection. In early
appendicitis, before infection sets in, it can be normal, but most often there is at least a
mild elevation even early in the process. Unfortunately, appendicitis is not the only
condition that causes elevated white blood cell counts. Almost any infection or
inflammation can cause this count to be abnormally high. Therefore, an elevated white
blood cell count alone cannot be used to confirm a diagnosis of appendicitis.

Urinalysis
Urinalysis is a microscopic examination of the urine that detects red blood cells, white
blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is
inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal
with appendicitis because the appendix lies near the ureter and bladder. If the
inflammation of appendicitis is great enough, it can spread to the ureter and bladder
leading to an abnormal urinalysis. Most patients with appendicitis, however, have a
normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a
urinary tract problem

Abdominal X-ray
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece

of stool that blocks the appendiceal opening) that may be the cause of appendicitis.
This is especially true in children.

Ultrasound
An ultrasound is a painless procedure that uses sound waves to provide images to
identify organs within the body. Ultrasound can identify an enlarged appendix or an
abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of
patients. Therefore, not seeing the appendix during an ultrasound does not exclude
appendicitis. Ultrasound also is helpful in women because it can exclude the presence
of conditions involving the ovaries, Fallopian tubes and uterus that can mimic
appendicitis.

Barium enema
A barium enema is an X-ray test in which liquid barium is inserted into the colon from
the anus to fill the colon. This test can, at times, show an impression on the colon in the
area of the appendix where the inflammation from the adjacent inflammation impinges
on the colon. Barium enema also can exclude other intestinal problems that mimic
appendicitis, for example Crohn's disease.

Computerized tomography (CT) scan

In patients who are not pregnant, a CT scan of the area of the appendix is useful in
diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other
diseases inside the abdomen and pelvis that can mimic appendicitis.

Medical /surgical managament

Appendectomy - can be performed as open surgery

using one abdominal incision about 2 to 4 inches (5 to
10 centimeters) long (laparotomy). Or the surgery can
be done through a few small abdominal incisions
(laparoscopic surgery). During a laparoscopic
appendectomy, the surgeon inserts special surgical
tools and a video camera into your abdomen to remove
your appendix.
In general, laparoscopic surgery allows you to recover
faster and heal with less pain and scarring. It may be
better for people who are elderly or obese. But
laparoscopic surgery isn't appropriate for everyone. If your appendix has ruptured and
infection has spread beyond the appendix or you have an abscess, you may need an
open appendectomy, which allows your surgeon to clean the abdominal cavity.

Nursing management

PRE-OP
1. Inform consent
2. NPO post midnight before surgery (except in case of STAT surgery)
3. Start IVF and IVTT meds antibiotic, pain relievers (morphine: only if diagnosis is
confirmed) and sedative

POST-OP
1. Monitor VS
2. Monitor signs of bleeding and infection
3. Clear liquids to solid foods once tolerated