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TitleAppendicitis
Tags Medical Specialties Diseases And Disorders Gastroenterology Peritoneum
File Size244.2 KB
Total Pages10
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flexion and pain on extension. A high retrocaecal appendix
may cause pain and tenderness below the right costal
margin. An inflamed appendix near the Fallopian tube

causes pelvic pain suggestive of an acute gynaecological
disorder such as salpingitis or torsion of an ovarian cyst.

The early phase of poorly localised visceral pain
typically lasts for a few hours until peritoneal inflam-
mation produces somatic localising signs. If untreated,
the inflamed appendix becomes gangrenous after 12–24
hours and perforates, causing spreading peritonitis unless
sealed off by omentum. The whole abdomen becomes
rigid and tender and there is marked systemic toxicity.
Perforation is particularly common in children. Some-
times, the pathological sequence is extremely rapid and
the patient presents with sudden peritonitis.

In older patients, a gangrenous or perforated appendix
tends to be contained by omentum or loops of small
bowel. This results in a palpable appendix mass. This
may contain free pus and is then known as an appendiceal
abscess. As with any significant abscess, there is a tachy-
cardia and swinging pyrexia. An appendix mass usually
resolves spontaneously over 2–6 weeks. In the elderly,
a delayed diagnosis may prouce an appendix abscess
walled off by loops of small bowel. There may be no
palpable mass and the symptoms and signs may not be
recognisable as appendicitis. These include non-specific
abdominal pain and features of small bowel obstruction
due to localised paralytic ileus. Occasionally, appendicitis
may present in a most unusual way. Examples include
discharge of an appendix abscess into the Fallopian tube
presenting as a purulent vaginal discharge, and inflam-
mation of an appendix lying in an inguinal hernia
presenting as an abscess in the groin.

MAKING THE DIAGNOSIS OF
APPENDICITIS

Acute appendicitis is a clinical diagnosis, relying almost
entirely on the history and physical examination. Investi-
gations are only useful in excluding other differential
diagnoses. If possible, the diagnosis should be made and
the appendix removed before it becomes gangrenous and
perforates. On the other hand, unnecessary appendicec-
tomies must be kept to a minimum.

Diagnosis of acute appendicitis poses little difficulty
if the patient exhibits the classic symptoms and signs
summarised in Box 19.1. The problem in appendicitis
occurs when the symptoms and signs are not typical.
The patient may present at a very early stage, or the
signs may have some other pathological cause. At least
two out of every three children admitted to hospital with
suspected appendicitis do not have the condition.

If the evidence for acute appendicitis is insufficient
and no other diagnosis can be made, the patient should be
kept under observation, admitted to hospital if necessary
and re-examined periodically. Eventually, the symptoms
settle or the diagnosis becomes clear.

Symptoms, diagnosis and management: coloproctology

Section

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266

(a)

(b)

(c)

Fig. 19.2 Acute appendicitis
(a) Macroscopic photograph showing acutely inflamed appendix.
The distended tip shows a purulent exudate on the serosal surface
(arrowed). (b) Microscopy showing mucosal ulceration Mu with acute
inflammatory cells within the lumen L. Inflammation extends through
the muscle wall M to the serosal surface S. (c) High-power view
showing acute inflammatory cells, mostly polymorphs P, destroying
glands G.

M
Mu

S

L

G

P

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SPECIAL POINTS IN THE HISTORY AND
EXAMINATION

Acute appendicitis typically runs a short course, between
a few hours and about 3 days. If symptoms have been
present for longer, appendicitis is unlikely unless an
‘appendix mass’ has developed. A recent or current sore
throat or viral-type illness, particularly in children, favours
the diagnosis of mesenteric adenitis (inflammation of the
mesenteric lymph nodes analogous to viral tonsillitis).
Urinary symptoms suggest urinary tract infection but
may also occur with pelvic appendicitis.

The patient with appendicitis is typically quiet,
apathetic and flushed; the lively child doing jigsaw
puzzles almost never has appendicitis! Oral foetor may
be present but is not a reliable sign of appendicitis.
Cervical lymphadenopathy tends to suggest a viral origin
for the abdominal pain. Mild tachycardia and pyrexia
are typical of appendicitis but a temperature much over
38°C makes the diagnosis of acute viral illness or urinary
tract infection more likely.

Signs of peritoneal inflammation in the right iliac
fossa are often absent in the early stages of the illness.
The patient should be asked to cough, blow the abdomi-
nal wall out and draw it in; all of these cause pain if the
parietal peritoneum is inflamed. In children, it may be
difficult to interpret apparent tenderness, especially if
the child cries and refuses to cooperate. This can usually
be overcome by distracting the child’s attention whilst
palpating the abdomen through the bedclothes or even
with the child’s own hand under the examiner’s hand.
Several signs (e.g. Rovsing’s sign—pressure in the left
iliac fossa causing pain in the right iliac fossa) have been
described which are said to point to the diagnosis of
appendicitis but these are all unreliable. One useful test
is to ask the child to stand, then to hop on the right leg. If
this can be achieved, there is unlikely to be any signifi-
cant peritoneal inflammation.

Rebound tenderness can best be demonstrated by
gentle percussion of the right iliac fossa. Pain on per-
cussion is a reliable sign of local peritonitis. Anterior

peritoneal tenderness on rectal examination (i.e. pelvic
peritonitis) supports the diagnosis of appendicitis,
provided other signs are consistent. In pelvic appendicitis,
it may be the only abdominal sign. Lack of rectal tender-
ness does not, however, exclude appendicitis.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of acute appendicitis theoretically
includes all the causes of an acute abdomen shown
earlier in Box 12.2. However, the main conditions of
practical importance are summarised in Box 19.2, along
with the main features distinguishing them from acute
appendicitis. These other conditions rarely need oper-
ation. Certain uncommon conditions such as Yersinia
ileitis and inflamed Meckel’s diverticulum are not
included in the list since they can only be distinguished
from appendicitis at laparotomy.

THE EQUIVOCAL DIAGNOSIS

If acute appendicitis can be diagnosed confidently on
clinical grounds, no further investigations other than
those dictated by age are required unless there are
secondary problems such as anaemia or dehydration.
These require full blood count and electrolyte esti-
mations. There are no diagnostic tests specific for
appendicitis but certain investigations are useful where
the diagnosis is in doubt.

The white blood count is usually unhelpful, as a
modest rise occurs in many conditions. If there is a great
rise (to over 16 000), the clinical diagnosis of appendicitis
is usually already clinically obvious, but it helps to ex-
clude non-suppurative gynaecological pathology. Urine
microscopy must be performed if there is any suggestion
of a urinary tract infection.

Abdominal X-rays are not needed unless there is
confusing evidence of abdominal pathology after a period
of observation. The presence of a single fluid level in the
right iliac fossa or even widespread small bowel dilatation
(see Fig. 19.5a) suggests local adynamic obstruction due
to appendicitis causing functional obstruction, but this is
an uncommon finding. Even less commonly, a perforated
appendix may allow sufficient free gas to escape to be
revealed on plain X-rays (see Fig. 19.5b). In adults with an
equivocal diagnosis of appendicitis, the plasma amylase
should be measured because the early features of
appendicitis and pancreatitis can be similar. There is no
place for barium enema in the diagnosis of appendicitis.
Abdominal ultrasound is largely unhelpful. CT scanning
is claimed by some to be accurate but submits the patient
to a high radiation dose and greatly increases the cost of
investigation.

Symptoms, diagnosis and management: coloproctology

Section

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268

Box 19.1 Cardinal features of acute appendicitis
● Abdominal pain for less than 72 hours
● Vomiting 1–3 times
● Facial flush
● Tenderness concentrated on the right iliac fossa
● Anterior tenderness on rectal examination
● Fever between 37.3 and 38.5°C
● No evidence of urinary tract infection on urine

microscopy

SUMMARY

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