Good morning, I am Dra Carmela Andal-Macalipay. I’m your lecturer for today.

Let’s start with the case of patient AA, Patient AA, a 19 year old male presents with 2 day
history of intermittent right lower quadrant abdominal pain.
He reports that the pain has progressively worsened and has slowly moved from just below
his belly button and it now more intense in the right lower quadrant. Also reports that the
pain is made worse by walking
He complains of one episode of vomiting and intermittent nausea. No other significant
medical history.
Please note of his chief complaint, history of present illness and his signs and symptoms

On physical examination:
VS are Temp 38.7 C, HR 95, RR 18, BP 110/73 SpO2 99% on RA.
Patient appears uncomfortable and is sitting quietly on the stretcher.
There is tenderness over the right lower quadrant of the abdomen with rebound
tenderness. No other abnormal findings on exam.

Based on the case previously mentioned, do you have questions or can you think of missing
information that you think is important in diagnosing the patient?
(wait for response)
If so, given the said information, what is your diagnosis?
(wait for response)
How will you manage this patient?

Abdominal pain is one of the most common causes of ER consults. It can result form many
different conditions. Moderate or severe pain can be a sign of serious illness or
complications and should be addressed immediately.
So today, we will discuss a very common diagnosis at the ER department which is
appendicitis.

APPENDICITIS
Acute appendicitis is one of the most common atraumatic surgical emergencies. It can
affect patients at any age, however the incidence peaks around the second and third
decades of life. Reports of male to female predominance are conflicting, with some sources
citing either sex with a slight majority. In pregnancy, appendicitis is the most common non-
obstetric surgical emergency. Although the incidence peaks earlier in life, appendicitis can
present at any point in life. Thus, the diagnosis should be considered in patients of all ages
with atraumatic abdominal pain.

Our learning objectives are as follows:

1.Be able to diagnose and describe the typical presentation of appendicitis
2.Be able to describe the etiology and progression of the pathology
3.Be able to discuss complications of acute appendicitis if not treated and the
consequent need to have a high index of suspicion in atypical cases
4.To enumerate the management of appendicitis

For the flow of discussion, here is our outline:

Etiology and Pathogenesis
Clinical Diagnosis
Laboratory Findings
Imaging/s
Differential Diagnosis
Management
Outcomes and Postoperative Course

The etiology of appendicitis is perhaps due to luminal

obstruction that occurs as a result of lymphoid hyperplasia in
pediatric populations; in adults, it may be due to fecaliths, fibrosis,
foreign bodies (food, parasites, calculi), or neoplasia

SEQUENCE
SEQUENCE
SEQUENCE
SEQUENCE
SEQUENCE SUMMARY
CLASSIC PRESENTATION
It is important to elicit an accurate history from the patient and/
or family, in the case of pediatric patients
Inflammation of the visceral peritoneum usually progresses to the parietal peritoneum
presenting with migratory pain which is a classic sign of appendicitis
Ø Anorexia, nausea and vomiting and fever
Most patients lay quite still due to parietal peritonitis. Patients
are generally warm to the touch (with a low-grade fever,
∼38.0°C [100.4°F]) and demonstrate focal tenderness with
guarding.
McBurney’s point, which is found one-third of the
distance between the anterior superior iliac spine and the umbilicus,
is often the point of maximal tenderness in a patient with an
anatomically normal appendix.
Certain physical signs with their
respective eponyms can be helpful in discerning the location
of the appendix: Rovsing’s sign, pain in the right lower quadrant
after release of gentle pressure on left lower quadrant (normal
position); Dunphy’s sign, pain with coughing (retrocecal appendix); obturator sign, pain
with internal rotation of the hip (pelvic appendix); iliopsoas sign, pain with flexion of the
hip
(retrocecal appendix).

SIGNS TO ELICIT
Patients with appendicitis usually have leukocytosis.
C-reactive protein, bilirubin, Il-6, and procalcitonin have all been suggested
to help in the diagnosis of appendicitis, specifically
in predicting perforated appendicitis
a pregnancy test is also essential in women of
childbearing age. Lastly, a urinalysis can be valuable in ruling
out nephrolithiasis or pyelonephritis.s

About
The Alvarado score was developed to assist in diagnosing appendicitis.
Studies that look at the score's ability to rule out appendicitis (using Alvarado < 3-4) have a
sensitivity of 96%. Studies that use the score to rule in appendicitis (using Alvarado > 6-7)
have a sensitivity of 58-88%, depending on the study and score cutoffs used.
McKay et al. recommend a CT scan for a score of 4-6 and surgical consultation for a score ≥
7. For a score of ≤ 3, the authors suggest that a CT scan is unnecessary for diagnosing
appendicitis given the low likelihood of appendicitis.
A score is assigned by the following variables.
• +2 points - Right lower quadrant tenderness
• +1 point - Elevated temperature (>37.3°C or 99.1°F)
• +1 point - Rebound tenderness
• +1 point - Migration of pain to the right lower quadrant
• +1 point - Anorexia
• +1 point - Nausea or vomiting
• +2 point - Leukocytosis > 10,000
• +1 point - Leukocyte left shift

Imaging is often utilized to confirm a diagnosis of appendicitis

because a negative operation rate is acceptable in <10% of
male patients and <20% of female patients.
And Routine use of crosssectional
imaging somewhat reduces the rate of negative laparotomies.
Imaging studies are most appropriate for patients in whom
a diagnosis of appendicitis is unclear or who are at high risk from
operative intervention and general anesthesia, such as pregnant
patients or patients with multiple comorbidities.
Features on a CT scan that suggest appendicitis include
enlarged lumen and double wall thickness (greater than 6 mm), wall thickening (greater
than 2 mm), periappendiceal fat
stranding, appendiceal wall thickening, and/or an appendicolith

An easily compressible
appendix <5 mm in diameter generally rules out appendicitis.
Features on an ultrasound that suggest appendicitis include
a diameter of greater than 6 mm, pain with compression,
presence of an appendicolith, increased echogenicity of the fat,
and periappendiceal fluid.
Ultrasound is cheaper and more
readily available than CT scan

MRI of the abdomen has a sensitivity of 0.95 (95% CI

0.88–0.98) and specificity of 0.92 (95% CI 0.87–0.95) for identification
of acute appendicitis, however is expensive.
It is usually recommended for pregnant or pediatric patients
Causes of acute abdominal pain that are often confused with
acute appendicitis include acute mesenteric adenitis, cecal
diverticulitis, Meckel’s diverticulitis, acute ileitis, Crohn’s disease,
acute pelvic inflammatory disease, torsion of ovarian cyst
or graafian follicle, and acute gastroenteritis

The preferred approach to manage patients with uncomplicated

appendicitis is an appendectomy.
Emergent surgery is often performed in
patients with appendicitis,
Currently, delaying surgery less than 12 hours
is acceptable in patients with short duration of symptoms (less
than 48 hours) and in nonperforated, nongangrenous appendicitis
Numerous meta-analyses comparing
laparoscopic to open appendectomy have demonstrated relative
equivalence of the techniques, with laparoscopic appendectomy
resulting in a shorter length of stay (LOS), faster return to
work, and lower superficial wound infection rates, especially
in obese patients.34,35 Open appendectomy results in shorter
operative times and lower intra-abdominal infection rates

Perforated and gangrenous appendicitis and appendicitis with

abscess or phlegmon formation are considered complicated
conditions.
Such patients are often acutely ill and dehydrated
and require resuscitation.
Perforated appendicitis can be managed either operatively
or nonoperatively. Immediate surgery is necessary in
patients that appear septic, but this is usually associated
with higher complications, including abscesses and enterocutaneous
Fistulae
The majority of patients with perforated
appendicitis (80%) have resolution of their symptoms with
drainage and antibiotics. There remains debate about the value
of performing an interval appendectomy 6 to 8 weeks after the
original inflammatory episode.44

OEPRATIVE INTERVENTION
Older adult patients can have diminished inflammation and thus
present with perforation or abscess more frequently.
Appendicitis occurs in 1 in 800 to 1 in 1000 pregnancies,
mostly in the first and second trimesters
Patients with recurrent right lower quadrant abdominal pain not
associated with a febrile illness with imaging findings suggestive
of an appendicolith or dilated appendix are classified as having chronic appendicitis.88
Patients often report resolution
of symptoms with an appendectomy.

Appendectomy is a relatively safe procedure with an extremely

low mortality rate (less than 1%). The commonest adverse
events include soft tissue infections

IN SUMMARY
• Inflammation of the appendix is a significant public health problem
• Appendicitis is a clinical diagnosis.
• Acute Appendicitis is the most common surgical emergency of the abdomen while
appendectomy is one of the most frequently performed surgical procedures.
• Patients with uncomplicated appendicitis do not require further antibiotics after
an appendectomy, while patients with perforated appendicitis are treated with 3
to 7 days of antibiotics.

QUESTIONS
EVALUATIONS
REFERENCES
THANK YOU