Appendix and Appendicitis

Most common cause of appendicitis = E. coli

• Campylobacter, which is another type of bacteria, can also lead to inflammation of the appendix and subsequent appendicitis.

Misdiagnosed in women a lot more because of ectopic pregnancy, ruptured follicular cyst, ovarian torsion and other gynecological issues that can present with similar abdominal pain, leading to delays in appropriate treatment.

Abx for up to 24 hours post-appendectomy if not perforated

• If perforated, need it for 7-10 days

Elderly do not get pain or typical symptoms as younger patients, making diagnosis more challenging and often leading to a higher incidence of complications.

Appendicitis is associated with fetal loss and preterm labor, even if the risk is low

Remember that taenia coli can be useful to help locate the appendix

McBurney point = the area on the right side of the abdomen, approximately one-third of the distance from the anterior superior iliac spine to the umbilicus, which is a key landmark for diagnosing appendicitis.

Viral infection can precede appendicitis and may exacerbate the inflammatory response in the appendix, leading to increased risk of complications if not addressed promptly.

• Can create pressure in the abdomen, eventually leading to ischemia and necrosis of the appendix, which may necessitate surgical intervention to prevent further complications.

Appendicolis is due to the obstruction of the appendiceal lumen, often caused by fecaliths, lymphoid hyperplasia, or foreign bodies, resulting in inflammation and infection of the appendix.

• Suction the fecal matter first, and then irrigate the area with saline solution to reduce the risk of infection and promote healing.

If base of appendix is inflamed, part of healthy colon is removed to ensure total coverage of the affected area and to prevent recurrence of appendicitis.

In recurrent appendicitis, think malignancy as a possible underlying issue, particularly in older patients, and consider further diagnostic evaluation to rule out any serious conditions.

• Colonoscopy if 45+ years of age, but don’t do it after 3 months following appendectomy to ensure healing

Fecalith is the most common cause of obstruction that leads to appendicitis, as it can block the lumen of the appendix, leading to increased pressure and subsequent inflammation.

ABX treatment = cephalosporin with metronidazole, fluoroquinolones unless QT prolongation

Classic symptoms:

• Right lower quadrant pain: Often starts as periumbilical pain that migrates to the RLQ

• Nausea and vomiting: Accompanied by loss of appetite leading to anorexia

• Fever: Usually low-grade and may develop as the inflammation progresses.

• Course: anorexia —> abdominal pain —> vomiting

CT scan with contrast is what is done for imaging

If vital signs were to change by a large amount, that’s further likelihood of a serious complication such as perforation or abscess formation, necessitating immediate surgical intervention.

Rovsing sign: a clinical test where palpation of the left lower quadrant causes pain in the right lower quadrant due to the movement of the intestines, indicating possible appendicitis.

Psoas sign: a clinical sign where pain is elicited upon extension of the hip, suggesting irritation of the psoas muscle due to inflammation of the appendix.

• Patient lays on their left side and raises their right leg while attempting to extend it, which may reproduce pain in the right lower quadrant, further supporting the diagnosis of appendicitis.

Obturator sign: a clinical test where flexion and internal rotation of the hip causes pain in the right lower quadrant, indicating possible appendicitis due to irritation of the obturator internus muscle.

Guarding: involuntary tensing of the abdominal muscles that occurs in response to palpation, indicating irritation of the peritoneum, which can be a sign of appendicitis.

Tenderness will be present in all depths of palpation

Oral contrast is always used for GI imaging to enhance the visualization of the gastrointestinal tract, helping to distinguish between normal and pathological conditions such as appendicitis.

If bowel surgery is already done, it is worth it to do appendectomy to decrease the difficulty of later appendectomy and to minimize the risk of complications that may arise from an inflamed appendix during subsequent procedures.

If the appendix is perforated, remove the appendix and also consider percutaneous drainage

• In perforated appendix for kids, go for percutaneous drainage especially if recent perforation; in 4-6 weeks, come back to remove the appendix

Interval appendectomy is a good option, as it allows for the removal of the appendix after the inflammation has resolved, thereby reducing the risk of complications and ensuring a safer surgical procedure.

If appendicitis, just remove the appendix