Appendicitis

Arises from the posteromedial aspect of the cecum, 2 cm inferior to the ileocecal valve

Where is the appendix?

fecalith impaction (adults), lymphoid hyperplasia (children), carcinoid tumor

Appendix luminal obstructions occur secondary to

Periumbilical pain, N/V, mild tenderness, SIRS

Presentation of distention of the appendix’s lumen

Pain radiates to the RLW, low grade fever, mild leukocytosis, Sepsis, anorexia

Presentation of infection → ischemia (of the appendix)

Peritonitis (succus spills out), increased pain/TTP, higher fever, leukocytosis, Septic shock

Presentation of Perforation of the appendix

rectal tenderness, obturator sign + (passively rotating the hip joint internally with the knee flexed, causing pain in the right lower quadrant (RLQ))

If the appendix is in the pelvis, what will you see?

Psoas + (pain on passive extension of the right thigh)

If the appendix is in the retroperitoneal or retrocecal pain, what will you see?

Pain at McBurney’s point

If the appendix is in the iliac fossa, what will you see?

Pregnancy, pelvic mass

Which patients may have RUQ pain with appendicitis

Alvarado Score

Clinical scoring system for appendicitis that uses both physical and lab findings - sensitivity of 99%

Leukocytosis (75% neutrophils), CRP +, CMP (electrolytes, BUN, Creatinine), Blood glucose, LFTs, UA (hydration status, blood may indicate calculi), Hcg (preg r/o)

Lab findings of Appendicitis

KUB (may show ileus or fecalith), U/S (may show incompressible inflamed appendix - peds, pregs), CT 🏆 (enlarged appendix - wall thickening, enhancement, periappendiceal fat stranding), MRI (peds, pregs)

Imaging studies for Appendicitis

Gastroenteritis, UTI, Calculi, Ovarian Cyst, Ectopic pregnancy, PID, Meckel Diverticulum, Rectus Sheath Hematoma (follows mild trauma, + fothergill sign), diverticulitis, Crohn’s, Colon cancer

DDX for Appendicitis

Gastric or pancreatic tissue - 2 ft from the iliocecal junction and 2% of the pediatric population

Rule of 2s for Meckel Diverticulum - removed appendix as well

Children, developmentally delayed, elderly

Which patient populations have a higher rate of perforation due to delay in diagnosis?

Appendectomy → preterm labor

How do you treat appendicitis in pregnancy patients?

Fothergill Sign

hematoma that is typically unilateral, gets bigger when the patient sits up and does not cross midline

DO NOT WITHHOLD parenteral analgesics, resuscitations based intravascular fluid defects, Abx, NG tube (if vomiting, SBO, or ileus), urinary catheter (monitor fluid output)

Pre-op management of Appendicitis

E.coli, enterococci, viridans streptococci, B.Fragils, Lactobacillus species, Prevotella melaninogenica, bilophila wadsworthia

Most common organisms for Abx management

Zosyn, Cipro + metro (perf), CPH (non-perf)

Abx for Appendicitis

Laparoscopic (if pre-op is uncertain, less post-op pain - better for females and obese patients)

For Appendicitis, most cases are

McBurney’s incision

Open appendectomy requires a

3 port approach (midline is the largest), Patient in trendelenburg (Veress needle or Hasson trocar to gain access, insufflated with CO2), Tilt patient to the left, firmly grasp the appendix and divide with a laparoscopic GIA stapler

Surgical Technique for Lap Appendectomy

Send Appendix to path (determine if carcinoid (most common - if less than 2 cm appendectomy is the treatment of choice), lymphoma, adenocarcinoma)

Post-op game plan

Surgical site infection (more common with perforated appendix)

Complications for appendectomy

remove sutures, irrigate, PO Abx, follow up until healed

Treatment plan for a wound infection of the superficial skin

Exploratory laparotomy/laparoscopy with wash outs, IV abx, admit, maybe percutaneous drain (IR)

Treatment plan for a wound infection of the muscle to fascia (deeper) - fever, anorexia, ill-appearing