Acute appendicitis ¢ Acute abdominal pain is defined as previously undiagnosed pain of... 70,000 appendicectomies are performed each year in the UK Appendicitis is more common in men App
Trang 1Acute appendicitis
¢ Acute abdominal pain is defined as previously undiagnosed pain of <72 hours duration
e« Accounts for about 2% of hospital admissions
¢ Inonly 50% of patients is the preoperative diagnosis correct
¢ Right iliac fossa pain accounts for about half of all cases of acute abdominal pain
Causes of right iliac fossa pain
¢« Appendicitis
se Urinary tract infection
se Pelvic inflammatory disease
¢ Renal colic
se Constipation
Causes of right iliac fossa mass
¢ Mucocele of the gallbladder
se Ovarian cyst
Appendicitis
¢ About 10% of the population will develop acute appendicitis
¢ The incidence is falling
Trang 2
70,000 appendicectomies are performed each year in the UK
Appendicitis is more common in men
Appendicectomy is performed more often in women
At 10-20% appendicectomies a normal appendix is removed
The risk of perforation is:
o Less than 10 years old = 50%
o 10-50 years old = 10%
o Over 50 years old = 30%
A women is more likely to have a ‘normal’ appendix removed
Clinical features of appendicitis
Central abdominal pain moving to right iliac fossa
Nausea, vomiting, anorexia
Low-grade pyrexia
Localised tenderness in right iliac fossa
Right iliac fossa peritonism
Percussion tenderness is a kinder sign of peritonism than rebound
Rovsing's sign = pain in right iliac fossa on palpation of the left iliac fossa Investigations
Appendicitis is essentially a clinical diagnosis
The following may be useful:
Urinalysis may exclude urinary tract infection
Pregnancy test to exclude ectopic pregnancy
Abdominal x-ray is of little value
A normal white cell count does not exclude appendicitis
Ultrasound may be helpful in the assessment of an appendix mass or abscess
Ultrasound adds little to the clinical diagnosis of acute appendicitis
Trang 3¢« Scoring systems and computer-aided diagnosis my be helpful
¢ Meta-analysis suggest the following to be useful predictors of
appendicitis in patients with abdominal pain
o Clinical signs of peritoneal irritation
Pat tent
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Jk a
Picture provided by Fahid Abu-Zant, Neblus Speciality Hospital, Neblus, Palestine
Management
¢ Incases of diagnostic doubt a period of ‘active observation' is useful
¢« Active observation reduces negative appendicectomy rate without
increased risk of perforation
e Intravenous fluids and analgesia should be given
¢ Opiate analgesia does not mask the signs of peritonism
e« Antibiotics should not be given until a decision to operate has been made
¢« Diagnostic laparoscopy should be considered particularly in young
women
se Whether a 'normal' appendix should be removed following laparoscopy is unclear
Appendicectomy
¢ Early appendicectomy for non-perforated appendicitis was first performed
in 1880s
¢ Open appendicectomy is usually performed via a Lanz incision and muscle splitting approach
e No evidence that burying the stump reduces the infection rate
¢ Consider a midline incision in elderly patients
Trang 4se Ifnormal appendix removed need to look for:
o Acute salpingitis
2A
oe
o reduced hospital stay
o rapid return to normal activity
se Overall benefits of laparoscopic approach not as great as for cholecystectomy
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Trang 5
Appendix mass
se Usually presents with a several day history
¢ Inflammation localised to the right iliac fossa by the omentum
e Patient is usually pyrexial with a palpable mass
¢ Initial treatment should be conservative
e Fluids, analgesia and antibiotics
¢ Observe the patient and mass
¢ Continue conservative whilst there is clinical improvement
Trang 6Post-ileal
Pre-ileal
iy”
Retrocaecal 2” ** o5.4,
Subcaecal
(2%) Pelvic
Œa (33%) Ẹ =
Appendix abscess
¢« Results from localised perforation
e« Abscess should be surgically or percutaneously drained
« Appendicectomy at initial operation can be difficult
se Need for appendicectomy after abscess drainage is unclear
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