Question 1 of 10

    Appendicitis (Appendicitis Unqualified)

    Appendicitis is an inflammation of the vermiform appendix. The typical symptoms include periumbilical pain, vomiting and nausea followed by fever and right lower quadrant abdominal pain.

    This disorder is promted by the following process: infectious.

    Presentation

    Classic presentation of acute appendicitis begins with pains, with vomiting setting in and fever coming in lastly. The appendix’s innervation enters the spinal cord at the same level as the umbilicus so the pain begins higher up the stomach area [7]. As the appendix becomes more swollen and irritates the adjoining abdominal wall, it will localise over a few hours into the right lower quadrant. The only exception is with children younger than 3 years of age. The pain is often severe and can be elicited through various signs.

    The signs include localised findings in the right iliac fossa and the abdominal wall becomes very sensitive to gentle pressures and palpation.

    Entire body system
    Fever
    • Mild fever Appendicitis usually causes a fever between 99 F (37.2 C) and 100.5 F (38 C).[healthline.com]
    • Also, the fever can increase and pain can spread.[wate.com]
    • Your child may also have these symptoms: Not wanting to eat Feeling sick to their stomach Vomiting Diarrhea Low-grade fever Swollen or bloated belly If the appendix bursts, your child may get a high fever because of the spreading infection.[seattlechildrens.org]
    • With either type of appendicitis, children might have symptoms of abdominal pain, fever, nausea, vomiting, or a poor appetite.[pedsurg.ucsf.edu]
    • The most frequently experienced symptoms of this infection in pregnant women include: Nausea and vomiting Appetite loss Pain in the abdomen at the lower right For pregnant women, fever and diarrhea are less common.[newhealthadvisor.com]
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  • neurologic
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  • gastrointestinal
    Abdominal Cramps
    • Patients often present with abdominal cramps localized within right lower quadrant and bloody stools.[jaocr.org]
    Abdominal Pain
    • (See also Acute Abdominal Pain .)[msdmanuals.com]
    • Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite.[en.wikipedia.org]
    • Case & Commentary: Part 4 Shortly after discharge, the abdominal pain returned.[psnet.ahrq.gov]
    • A 22-year-old woman presents with lower abdominal pain and vaginal discharge.[foamcast.org]
    Abdominal Rigidity
    • rigidity, and migration of pain from the periumbilical region to the right lower quadrant increases the likelihood of appendicitis.( 7 ) Although often atypical, the history and physical exam can be helpful in assessing a patient for appendicitis.[psnet.ahrq.gov]
    • Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity.[en.wikipedia.org]
    Abdominal Tenderness
    • Click here for Patient Education Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness.[msdmanuals.com]
    • When abdominal tenderness is present, a computed tomography (CT) scan can enhance the diagnostic accuracy of appendicitis.[psnet.ahrq.gov]
    • The doctor will ask about your symptoms and your medical history, do a physical exam to check for abdominal tenderness, and may order blood and urine tests.[umm.edu]
    • The most common signs and symptoms of appendicitis in adults and children are abdominal pain , loss of appetite , nausea and vomiting , fever , and abdominal tenderness.[medicinenet.com]
    • The physical examination findings are more obvious if peritonitis generalizes, with a more generalized right lower quadrant tenderness progressing to complete abdominal tenderness.[aafp.org]
    Acute Abdomen
    • INTRODUCTION Appendicitis, an inflammation of the vestigial vermiform appendix, is one of the most common causes of the acute abdomen and one of the most frequent indications for an emergent abdominal surgical procedure worldwide [ 1,2 ].[uptodate.com]
    • Second, Cope's "Early Diagnosis of the Acute Abdomen" clearly states that "appendicitis should never be lower than second on any" list of possible causes of abdominal pain.[appendicitis.pro]
    • Liu CD, McFadden DW: Acute abdomen and appendix.[journalofethics.ama-assn.org]
    • Acupuncture therapy in acute abdomen.[umm.edu]
    • Acute abdomen and appendix.[aafp.org]
    Colic
    • K-sign can be positive in other retroperitoneal pathologies like renal colic, ureteric colic and psoas abscess etc.[casesjournal.biomedcentral.com]
    • MDCT findings includes a distended cecum with circumferential wall thickening, peri-colonic infiltration, and peri-colic fluid (Fig. 5) .6,16,17 Pneumatosis can also be present. 6 Treatment includes bowel rest and antibiotics.[jaocr.org]
    • It also may allow the appendix to move behind the colon (called a retro- colic appendix).[medicinenet.com]
    • […] conditions include: Obesity Diabetes H.I.V. patients Cancer and/or chemotherapy patients Transplanted organ patients Pregnancy (risk is highest during the third trimester) Infants and young children The elderly There is also a condition called appendiceal colic[wikihow.com]
    Loss of Appetite
    • While everyone is different, the usual signs and symptoms of appendicitis include: Early Symptoms Constipation, diarrhea, or gas Dull, achy pain beginning around the belly button (navel), turning to sharp pain in the lower right portion of the abdomen Loss[sepsis.org]
    • Other symptoms of appendicitis include: loss of appetite nausea or vomiting constipation or diarrhea low-grade fever abdominal swelling/bloating Although loss of appetite and fever are common symptoms of appendicitis, not all patients will have these[livescience.com]
    • These are loss of appetite, fever, constipation, and nausea.[parentherald.com]
    • Also, symptoms can include: a low fever, nausea, vomiting, gas pain, diarrhea, swollen abdomen or a loss of appetite.[wate.com]
    • […] of appetite Low fever Nausea and vomiting Rebound tenderness: tenderness when pressure applied to the lower right abdomen is released More Advanced Symptoms Abdomen swelling and rigidity (hard) Pain on the right side of the abdomen when pressed on the[sepsis.org]
    Lower Abdominal Pain
    • A 22-year-old woman presents with lower abdominal pain and vaginal discharge.[foamcast.org]
    • Related: Lower abdominal pain in women: Causes and treatments Share this information People who read this article should try...[belmarrahealth.com]
    • Patients are usually in the reproductive age group and present with acute onset lower abdominal pain on the side of the ovary involved.[jaocr.org]
    • Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite.[en.wikipedia.org]
    Nausea
    • These include stomach cramping, nausea, and vomiting.[healthline.com]
    • Accompanying symptoms may include slight fever (above normal but less than 100 degrees), vomiting or nausea.[radiologyinfo.org]
    • Another frequent symptom of appendicitis is loss of appetite that may worsen over time and can result in nausea and vomiting.[medicinenet.com]
    • […] the usual signs and symptoms of appendicitis include: Early Symptoms Constipation, diarrhea, or gas Dull, achy pain beginning around the belly button (navel), turning to sharp pain in the lower right portion of the abdomen Loss of appetite Low fever Nausea[sepsis.org]
    • You may also have a loss of appetite, nausea, vomiting, and a low fever.[nlm.nih.gov]
    Obturator Sign
    • […] intestine does not localize well Psoas sign: Right lower quadrant pain with external rotation of the right thigh indicates appendicitis or psoas abscess and may indicate that the appendix is retrocecal in location as the iliopsoas muscle is retroperitoneal Obturator[sages.org]
    • The doctor may also move the patient's legs to test for pain on flexion of the hip (psoas sign), pain on internal rotation of the hip (obturator sign), or pain on the right side when pressing on the left (Rovsing's sign).[daviddarling.info]
    • , but in the latter half of pregnancy, right upper quadrant (RUQ) or right flank pain may occur The following accessory signs may be present in a minority of patients: Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal irritation Obturator[emedicine.medscape.com]
    • Obturator sign: The person being evaluated lies on her or his back with the hip and knee both flexed at ninety degrees.[en.wikipedia.org]
    Periumbilical Pain
    • The classical presentation consists of periumbilical pain (referred) which within a day or later localises to McBurney's point with associated fever, nausea and vomiting 2 .[radiopaedia.org]
    • The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.[emedicine.medscape.com]
    • View/Print Table TABLE 1 Common Symptoms of Appendicitis Common symptoms* Frequency (%) Abdominal pain 100 Anorexia 100 Nausea 90 Vomiting 75 Pain migration 50 Classic symptom sequence (vague periumbilical pain to anorexia/nausea/unsustained vomiting[aafp.org]
    Psoas Sign Positive
    Right Flank Pain
    • flank pain may occur The following accessory signs may be present in a minority of patients: Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal irritation Obturator sign (RLQ pain with internal and external rotation of the flexed[emedicine.medscape.com]
    Right Lower Quadrant Tenderness
    • His examination is significant for right lower quadrant tenderness to palpation.[foamcast.org]
    • The most important physical examination finding is right lower quadrant tenderness to palpation.[aafp.org]
    • For example, the diagnosis of appendicitis in the man with classic right lower quadrant tenderness and other typical signs and symptoms does not require confirmatory CT scan.[psnet.ahrq.gov]
    Rovsing's Sign
    • Classic physical exam signs include Rovsing's sign and tenderness at McBurney's point.[journalofethics.ama-assn.org]
    • He has a negative Rovsing sign[foamcast.org]
    • Rovsing Sign: Right lower quadrant pain with left lower quadrant palpation is a sign of referred pain from appendicitis as the innervation of the intestine does not localize well Psoas sign: Right lower quadrant pain with external rotation of the right[sages.org]
    • The doctor may also move the patient's legs to test for pain on flexion of the hip (psoas sign), pain on internal rotation of the hip (obturator sign), or pain on the right side when pressing on the left (Rovsing's sign).[daviddarling.info]
    • Rebound tenderness and Rovsing's sign was present on per abdominal examination.[casesjournal.biomedcentral.com]
    Severe Abdominal Pain
    • Liverpool are still waiting to discover the full extent of the complaint, although the symptoms do point to a bout of appendicitis – severe abdominal pain the greatest indication.[telegraph.co.uk]
    • When you should seek medical assistance You should take your child to the doctor if your child has severe abdominal pain or ongoing unexplained fever or irritability.[aboutkidshealth.ca]
    • Appendicitis is inflammation of the appendix and can lead to severe abdominal pain .[belmarrahealth.com]
    • The elderly often experience less fever and less severe abdominal pain than other patients do.[daviddarling.info]
    • It is one of the most common and significant causes of severe abdominal pain that comes on quickly.[en.wikipedia.org]
    Tenderness at McBurney's Point
    Vomiting
    • After an appendectomy, call your doctor if you have: Uncontrolled vomiting Increased pain in your abdomen Dizziness /feelings of faintness Blood in your vomit or urine Increased pain and redness in your incision Fever Pus in the wound Can Appendicitis[webmd.com]
    • Young patients often experience diarrhea and vomiting, while elderly patients typically experience less pain.[health.howstuffworks.com]
    • These include stomach cramping, nausea, and vomiting.[healthline.com]
    • I got sick early Monday morning and vomited for 2 days.[wikihow.com]
    • She was told to return for persistent vomiting, pain, or new fever.[psnet.ahrq.gov]
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  • cardiovascular
    Tachycardia
    • Fever is usually low-grade with mild tachycardia.[sages.org]
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  • urogenital
    Flank Pain
    • McBurney's sign ) pelvic pain, diarrhoea and tenesmus (pelvic appendix) flank pain (retrocaecal appendix) groin pain (appendix within an inguinal hernia - Amyand hernia ) or a femoral hernia ( De Garengeot hernia) leucocytosis nausea and vomiting atypical[radiopaedia.org]
    • […] that extends into the LLQ Male infants and children occasionally present with an inflamed hemiscrotum In pregnant women, RLQ pain and tenderness dominate in the first trimester, but in the latter half of pregnancy, right upper quadrant (RUQ) or right flank[emedicine.medscape.com]
    • Pain and tenderness can occur in a location other than the right lower quadrant. 6 A retrocecal appendix in a retroperitoneal location may cause flank pain.[aafp.org]
    Pelvic Pain
    • Appendicitis that occurs in these people can cause lower back pain or pelvic pain.[healthline.com]
    • McBurney's sign ) pelvic pain, diarrhoea and tenesmus (pelvic appendix) flank pain (retrocaecal appendix) groin pain (appendix within an inguinal hernia - Amyand hernia ) or a femoral hernia ( De Garengeot hernia) leucocytosis nausea and vomiting atypical[radiopaedia.org]
    • It is especially well suited in evaluating right lower quadrant or pelvic pain in pediatric and female patients.[aafp.org]
    • Hemorrhagic Ovarian Cyst Hemorrhage into an ovarian cyst can cause abrupt lower abdominal or pelvic pain.[jaocr.org]
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  • Workup

    Diagnosis is based almost entirely on the presentations and so it is often difficult as there are other conditions that can present same symptoms as appendicitis [8]. When the medical history and presentations isn’t enough to form a definitive diagnosis other approaches that can be considered include:

    • Gross and Microscopic Evaluation
    • Radionuclide Scanning
    • CBC Count
    • C-Reactive Protein
    • Liver and Pancreatic Function Tests
    • Urinary 5-HIAA
    • Urinalysis
    • Urinary Beta-HCG
    • CT Scanning
    • Abdominal Radiography
    • Ultrasonography
    • Barium Enema Study
    • MRI

    However, care must be taken to ensure that too much time is not spent on the diagnostic procedure.

    Laboratory

    Serum
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  • Urine
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  • Treatment

    When appendicitis is suspected, the patient is admitted to the hospital. Laparotomy is used to remove the inflamed appendix. The inflamed appendix is found and cut off the caecum while a stitch is used to prevent any contents in the gut from leaking out. Antibiotic medicines are often given just before the operation so as to reduce the risk of an infection developing at the site of operation [9].

    Prognosis

    The most common reason for emergency abdominal surgery is acute appendicitis. The appendectomy leads to a complication 4-15% of the time. This is not counting the discomfort of hospitalisation and surgery as well as associated costs [6].

    Delayed diagnosis and treatment is one of the major causes of morbidity and mortality and therefore the goal of the surgeon is to ensure early and accurate diagnosis.

    The overall mortality rate is 0.2-0.8% and this can be attributed to complications of the disease instead of the surgical intervention in itself. In children, the mortality rate ranges from 0.1% to 1% while in patients that are older than 70 years of age, the rates rise above 20% basically due to late diagnosis and delay in therapeutics.

    Complications

    Appendiceal Abscess
    • Perforation of the appendix can lead to a peri-appendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis).[medicinenet.com]
    • Complications Recognised complications include 5 : perforation: in up to 13-30% of cases abscess formation: appendiceal abscess generalized peritonitis pylephlebitis : infective thrombophlebitis of the portal circulation complicating hepatic abscess Clinically[radiopaedia.org]
    Appendicitis
    • Appendicitis is inflammation of the appendix.[en.wikipedia.org]
    • British Dictionary definitions for appendicitis noun 1. inflammation of the vermiform appendix Word Origin and History for appendicitis appendicitis in Medicine appendicitis ap·pen·di·ci·tis (ə-pěn'dĭ-sī'tĭs) n.[dictionary.reference.com]
    • ) , appendicitis , Unqualified appendicitis , Appendicitis NOS , Appendicitis , Appendicitis [Disease/Finding] , Appendicitis, unqualified (disorder) , Appendicitis NOS (disorder) , Appendicitis (disorder) , inflammation; appendix , appendix; inflammation[fpnotebook.com]
    • Appendicitis Symptoms and Pain The main symptom of appendicitis is pain.[medicinenet.com]
    • Imaging for Appendicitis Factors Affecting Imaging in Appendicitis 1.[emergencymedicinecases.com]
    Constipation
    • You may also become constipated or develop severe diarrhea.[healthline.com]
    • [HHH p.36] Constipation: This condition generally could not happen if we were not constipated.[herballegacy.com]
    • Moving around after surgery rather than lying in bed can help prevent constipation.[urmc.rochester.edu]
    • Increase fiber intake to avoid constipation, which can contribute to appendicitis and lead to further pain.[belmarrahealth.com]
    Crohn's Disease
    • The appendix may also be affected by Crohn disease or ulcerative colitis with pancolitis ( inflammatory bowel disease ).[msdmanuals.com]
    • Cross-sectional imaging in Crohn disease.[jaocr.org]
    • Obstruction may be caused by 1 : lymphoid hyperplasia ( 60%) appendicolith ( 33%) foreign bodies ( 4%) Crohn disease or other rare causes, e.g. stricture, tumour, parasite One of the biggest challenges of imaging the appendix is finding it.[radiopaedia.org]
    • Lymphoid hyperplasia can be the result of Crohn's disease, irritable bowel syndrome , mononucleosis , measles or gastrointestinal infections.[health.howstuffworks.com]
    • Lymphoid hyperplasia is associated with inflammatory and infectious disorders such as Crohn disease, measles, amebiasis, gastroenteritis, respiratory infections, and mononucleosis.[healthcommunities.com]
    Ectopic Pregnancy
    • Ectopic pregnancy — A pregnancy that develops outside of the mother's uterus, such as in the fallopian tube.[encyclopedia.com]
    • Diagnostic clues to ectopic pregnancy.[jaocr.org]
    • More specific causes of appendicitis include: Gallstones Ectopic pregnancy Ovarian cysts Irritable bowel syndrome Urinary tract infection Crohn’s disease Indigestion Gas Peptic ulcers Kidney infection Lactose intolerance Food allergies Constipation Hernia[belmarrahealth.com]
    • Diagnosis of appendicitis Appendicitis can mimic the symptoms of other disorders such as gastroenteritis, ectopic pregnancy and various infections (including those of the kidney and chest).[betterhealth.vic.gov.au]
    • Differential Diagnosis: The differential diagnosis of appendicitis in children includes intussusception, Meckel’s diverticulum, gastroenteritis, constipation, mesenteric adenitis, pyelonephritis, nephrolithiasis, pelvic inflammatory disease, ectopic pregnancy[sages.org]
    Ileus
    Intestinal Obstruction
    • The Mayo Clinic’s health information pages list several possibilities, including acid reflux, diverticulitis, endometriosis, kidney stones, intestinal obstruction, stomach flu and hernias.[empowher.com]
    • Elderly: diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.[en.wikipedia.org]
    • Nausea and vomiting also may occur later due to intestinal obstruction from the expanding inflammatory mass or abscess rather than from local inflammation.[medicinenet.com]
    • Features include the following: Abdominal pain: Most common symptom Nausea: 61-92% of patients Anorexia: 74-78% of patients Vomiting: Nearly always follows the onset of pain; vomiting that precedes pain suggests intestinal obstruction Diarrhea or constipation[emedicine.medscape.com]
    • […] unclear and, thus, can be reserved for use in such cases. 5 View/Print Table TABLE 4 Differential Diagnosis of Acute Appendicitis Gastrointestinal Abdominal pain, cause unknown Cholecystitis Crohn's disease Diverticulitis Duodenal ulcer Gastroenteritis Intestinal[aafp.org]
    Intussusception
    • Differential Diagnosis: The differential diagnosis of appendicitis in children includes intussusception, Meckel’s diverticulum, gastroenteritis, constipation, mesenteric adenitis, pyelonephritis, nephrolithiasis, pelvic inflammatory disease, ectopic pregnancy[sages.org]
    • 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[en.wikipedia.org]
    • […] reserved for use in such cases. 5 View/Print Table TABLE 4 Differential Diagnosis of Acute Appendicitis Gastrointestinal Abdominal pain, cause unknown Cholecystitis Crohn's disease Diverticulitis Duodenal ulcer Gastroenteritis Intestinal obstruction Intussusception[aafp.org]
    • […] valve, typically in the right lower quadrant or lower central abdomen. 19 Inflammation occurs due to mucosal ulceration from ectopic gastric mucosa or due to luminal obstruction by an enterolith. 12 Meckel's diverticulum may also act as a lead point for intussusception[jaocr.org]
    Leukocytosis
    • In pregnant women, the physiologic leukocytosis renders the CBC count useless for the diagnosis of appendicitis.[emedicine.medscape.com]
    • Radiography/Labs: A CBC may initially show a normal leukocyte count but will eventually progress to leukocytosis with a left shift.[sages.org]
    • The combination of pain, anorexia, leukocytosis, and fever is classic.[en.wikipedia.org]
    • Common symptoms of pregnancy may mimic appendicitis, and the leukocytosis of pregnancy renders the WBC count less useful.[aafp.org]
    • Patients present with abdominal pain, fever, and leukocytosis.[jaocr.org]
    Liver Abscess
    • Such fluids may come from a perforated duodenal ulcer, gallbladder disease, or inflammatory diseases of the liver , for example, a liver abscess.[medicinenet.com]
    Meckel Diverticulum
    • Meckel diverticulum: radiologic features with pathologic Correlation.[jaocr.org]
    • Differential Diagnosis: The differential diagnosis of appendicitis in children includes intussusception, Meckel’s diverticulum, gastroenteritis, constipation, mesenteric adenitis, pyelonephritis, nephrolithiasis, pelvic inflammatory disease, ectopic pregnancy[sages.org]
    • A Meckel's diverticulum is a small outpouching of the small intestine which usually is located in the right lower abdomen near the appendix.[medicinenet.com]
    • Other right lower quadrant conditions such as inflammatory bowel disease, cecal diverticulitis, Meckel's diverticulum, endometriosis and pelvic inflammatory disease can cause false-positive ultrasonography results. 12 View/Print Figure FIGURE 3.[aafp.org]
    Mesenteric Lymphadenitis
    • lymphadenitis Necrotizing enterocolitis Neoplasm (carcinoid, carcinoma, lymphoma) Omental torsion Pancreatitis Perforated viscus Volvulus Gynecologic Ectopic pregnancy Endometriosis Ovarian torsion Pelvic inflammatory disease Ruptured ovarian cyst (follicular[aafp.org]
    Neoplasm
    • It can be difficult to exclude an underlying neoplasm in the setting of acute diverticulitis.[jaocr.org]
    • […] secondary to inflammatory bowel disease (IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms[emedicine.medscape.com]
    • Appendicitis Gastrointestinal Abdominal pain, cause unknown Cholecystitis Crohn's disease Diverticulitis Duodenal ulcer Gastroenteritis Intestinal obstruction Intussusception Meckel's diverticulitis Mesenteric lymphadenitis Necrotizing enterocolitis Neoplasm[aafp.org]
    Pelvic Abscess
    • Eventually, the appendix would perforate resulting in pelvic abscesses.[jama.jamanetwork.com]
    • “The reason we take the appendix out and do it as an emergency is the belief, dating back to 1886, that the appendix will eventually become gangrenous and cause a pelvic abscess ,” Dr.[nytimes.com]
    • In 30% of cases where the appendix has become gangrenous, recovery is complicated by abdominal/pelvic abscess formation.[radiopaedia.org]
    • A pelvic abscess is usually drained by radiologists guided by ultrasound.[dailymail.co.uk]
    • CT findings include enlarged ovaries with abnormal enhancement, dilated and fluid filled fallopian tubes with enhancing wall from pyosalpinx, stranding of the pelvic fat, enhancement of the adjacent peritoneum, and pelvic abscesses in advanced cases ([jaocr.org]
    Pelvic Inflammatory Disease
    • Right lower quadrant pain (C) has a sensitivity of 81% and fever (A) has a sensitivity of 67%. 2.This patient presents with signs and symptoms consistent with pelvic inflammatory disease (PID) and should be treated with ceftriaxone 250 mg IM and 2 weeks[foamcast.org]
    • Pelvic Inflammatory Disease Acute pelvic inflammatory disease can present with fever and lower abdominal pain, similar to that of acute appendicitis.[jaocr.org]
    • Pelvic inflammatory disease (PID).[medicinenet.com]
    • Differential Diagnosis: The differential diagnosis of appendicitis in children includes intussusception, Meckel’s diverticulum, gastroenteritis, constipation, mesenteric adenitis, pyelonephritis, nephrolithiasis, pelvic inflammatory disease, ectopic pregnancy[sages.org]
    • The imaging differential includes: inflammatory bowel disease , especially Crohn disease , which may affect the appendix other causes of terminal ileitis pelvic inflammatory disease (PID) right sided diverticulitis Meckel's diverticulitis acute epiploic[radiopaedia.org]
    Perforated Viscus
    • viscus Volvulus Gynecologic Ectopic pregnancy Endometriosis Ovarian torsion Pelvic inflammatory disease Ruptured ovarian cyst (follicular, corpus luteum) Tubo-ovarian abscess Systemic Diabetic ketoacidosis Porphyria Sickle cell disease Henoch-Schönlein[aafp.org]
    Peritonitis
    Testicular Torsion
    • Testicular torsion — A condition involving the twisting of the spermatic cord inside the testicle that shuts off its blood supply and can seriously damage the testicle.[encyclopedia.com]
    • Men: testicular torsion Adults: new-onset Crohn's disease, ulcerative colitis, regional enteritis, cholecystitis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma and epiploic appendagitis.[en.wikipedia.org]
    • (follicular, corpus luteum) Tubo-ovarian abscess Systemic Diabetic ketoacidosis Porphyria Sickle cell disease Henoch-Schönlein purpura Pulmonary Pleuritis Pneumonia (basilar) Pulmonary infarction Genitourinary Kidney stone Prostatitis Pyelonephritis Testicular[aafp.org]
    Typhlitis
    • In 1886, Fitz 1 assembled a large amount of autopsy data and reviewed the literature trying to understand what caused typhlitis and pelvic infections, disorders that were highly lethal at the time.[jama.jamanetwork.com]
    • Abscess in women Symptoms: vaginal discharge, adnexal or uterine tenderness, lower abdominal pain, cervical motion tenderness, fever Cause: chlamydia and neisseria gonorrhoea most commonly Treatment: ceftriaxone 250 mg IM doxycycline 100 mg BID x 14 days Typhlitis[foamcast.org]
    • Differential Diagnosis: The differential diagnosis of appendicitis in children includes intussusception, Meckel’s diverticulum, gastroenteritis, constipation, mesenteric adenitis, pyelonephritis, nephrolithiasis, pelvic inflammatory disease, ectopic pregnancy, typhlitis[sages.org]
    • […] 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[en.wikipedia.org]
    • Neutropenic Colitis (Typhlitis) Neutropenic colitis has a similar presentation of acute appendicitis, but occurs particularly in immunosuppressed patients with leukemia, post-transplantation status, or acquired immunodeficiency.[jaocr.org]
    Ureterolithiasis
    • In addition, acute genitourinary diseases, such as pyelonephritis and ureterolithiasis, can present with similar symptoms.[jaocr.org]
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  • Etiology

    Acute appendicitis is the end result when the appendix lumen is obstructed. When this happens, the appendix becomes filled with mucus and swells [2]. This increases pressures inside the appendix walls and lumen leading to occlusion of the small vessels, stasis of lymphatic flow and thrombosis. At this stage, it is very difficult for spontaneous recovery to occur. With the thrombosis continues to spread, the appendix first becomes ischemic and after a while it becomes necrotic. The dying walls begin to leak bacteria and thus suppuration occurs (pus around and within the appendix). An appendiceal rupture or a burst appendix is the end result of the cascade. When this happens, peritonitis sets in leading to septicaemia and death in many cases.

    The main causative agent for peritonitis is faecal deposits referred to as fecaliths or appendicoliths but the following have also been known to cause appendicitis: lymphadenitis, intestinal worms, trauma, foreign bodies and bezoars.

    Epidemiology

    Appendicitis is one of the most common surgical emergencies. It is also one of the most common causes of abdominal pain. In the United States for example, there are 250,000 cases of appendicitis reported every year. Since the 1940s however, the incidence of appendicitis has continued to decline and presently, the annual incidence is 10 cases for every 100,000 people. 7% of the US population get appendicitis meaning 1.1 cases for every 1000 people each year. There have been talks of familial predisposition as well [3].

    In Africa and Asia, the incidence of acute appendicitis is lower and this may be due to dietary habit of the individuals in those geographic areas. Records show that appendicitis is lower in cultures where there is a higher intake of dietary fibre. Dietary fibre is believed to decrease the viscosity of faeces and this decreases time for bowel transit thereby discouraging the formation of fecaliths which will predispose individuals to obstructions of the appendiceal lumen.

    Over the last few years, there has been a marked decrease in the frequency of appendicitis in Western Countries. This may be related to changes in the intake of dietary fibre. This has given credence to the theory that a higher incidence of appendicitis in those areas is as a result of poor intake of fibre in such countries.

    In teenagers and young adults, there is a slight male preponderance of 3:2. In adults, the incidence in men is 1.4 times greater than in women. There is equality in primary appendectomy in both males and females [4].

    Sex distribution
    Age distribution

    Pathophysiology

    The obstruction of the appendiceal lumen is what causes appendicitis as seen above in the etiology. The obstruction brings about an increase in pressure within the lumen and this increase in pressure is related to the continual secretion of fluids and mucus from the mucosa as well as stagnation of the secreted material [5].

    At the same time intestinal bacteria within the appendix multiplies leading to the recruitment of the white blood cells. This leads to the formation of pus while intraluminal pressure continues to increase.

    When appendiceal obstruction persists, the intraluminar pressure will go beyond the pressure of the appendiceal veins leading to the outflow of the obstruction. Consequently, appendiceal wall ischemia will begin leading to a loss of epithelial integrity which will allow appendiceal wall to be invaded by bacteria.

    In a few hours, the localised condition will worsen due to thrombosis of the appendicular artery and veins. This will lead to perforation and gangrene of the appendix. As the process continues, peritonitis or a periappendicular abscess may occur.

    Prevention

    There is no way to predict when appendicitis will occur and thus prevent it from happening but epidemiological evidence suggest the need to avoid diets that are low in fibre and high in sugar.

    Also, infections and a family history increase chances of developing appendicitis [10].

    Summary

    Also referred to as epityphlitis, appendicitis is the inflammation of the appendix. It is a surgical emergency in many cases [1]. Due to the high level of mortality associated with a ruptured appendix and the fact that it can bring about sepsis and peritonitis, most cases of appendicitis require a removal of the inflamed appendix by laparoscopy and laparotomy.

    It was first described in 1886 by Reginald Fitz and today, it is recognised as one of the most significant causes of severe and acute abdominal pain in the world today.

    Patient Information

    Appendicitis is a disease where your appendix gets filled with pus and inflamed. The appendix is a projection from the colon  and it is found in the lower right part of the abdomen. Although the appendix doesn't have any known benefits to the body, it can still cause a great deal of problems. 

    When appendicitis sets in, the symptoms often beging around the belly button before shifting to the lower right abdomen. The pain of appendicitis increases within 18 hours of first signs, becoming severe. 

    This condition can affect anyone but it is mostly seen in people aged 10-30. 

    The main treatment is the surgical removal of the appendix. 

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    References

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    7. Fitz, RH. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Am J Med Sci 1886; 92:321.
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    9. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215:337.
    10. Burkitt DP. The aetiology of appendicitis. Br J Surg 1971; 58:695.

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