ACUTE

APPENDICITIS
INTRODUCTION

• The appendix is a small, pouch-like sac of tissue that is located

in the first part of the colon (cecum) in the lower- right abdomen.

• Vermiform appendix, is a vestigial hollow tube that is closed at

one end and is attached at the other end to the cecum, a pouch
like beginning of the large intestine into which the small
intestine empties its contents.

• The function of the appendix is unknown.

Cont..

• The appendix is a small, finger-like appendage about 10 cm (4 in)

long that is attached to the cecum just below the ileocecal valve.

• The appendix receives its blood supply via the appendicular artery
(derived from the ileocolic artery), and drains through the
appendicular vein.
DEFINITION

• Appendicitis is an inflammation of appendix that develops most

common in adolescents and young adults.

• Appendicitis is acute inflammation of the appendix, and is the most

common cause for acute, severe abdominal pain. The abdomen is
most tender at McBurney’s point – one third of the distance from
the right anterior superior iliac spine to the umbilicus. This
corresponds to the location of the base of the appendix
EPIDEMIOLOGY
• Approximately 9% of men and 7% of women will experience an
episode during their lifetime.

• Appendicitis is more common in males, in those aged 21-30

years and in females, in those aged 11-20 years.

• Approximately 20% of all patients have evidence of perforation

at presentation, but the percentage risk is much higher in
patients under 5 or over 65 years of age.
RISK FACTORS
• Infection, possibly stomach infection that has traveled to the site of
appendix.

• Obstruction such as a hard piece of stool getting trapped in the appendix

leading to infection of the appendix.

• Extreme of age

• Previous abdominal surgery

• Position of Appendix (Retrocecal 56.5%), HTN (15.5%), CAD (9.0%), DM

(11.0%)

(Naderan, M. et al 2016)
CAUSES
• Acute appendicitis seems to be the end result of a primary
obstruction of the appendix.

• Once this obstruction occurs, the appendix becomes filled with

mucus and swells. This continued production of mucus leads to
increased pressures within the lumen and the walls of the appendix.

• The increased pressure results in thrombosis and occlusion of the

small vessels, and stasis of lymphatic flow.
Common Causes

1. Fecal impaction and/or a fecality

• A layered buildup of calcium salts and fecal debris around a piece of fecal material
within the appendix

2. Lymphoid Hyperplasia

• The appendix contains lymphoid (immune system) tissue that can become inflamed
as a result of infection or inflammatory bowel disease (IBD)

3. Parasites

• Examples: Schistosomes species, pinworms, Strongyloides, stercoralis

Uncommon Causes:

1. Tumors

2. Foreign Material

• A wide variety of foreign objects can become lodged in the

appendix. Some of these include: shotgun pellets, intrauterine
devices, tongue studs, and activated charcoal

• Trauma, intestinal worms, lymphadenitis

TYPES

Acute Appendicitis:

• Acute appendicitis, as its name implies, develops very fast, usually in a span
of several days or hours. It is easier to detect and requires prompt medical
treatment, usually surgery.

• Acute appendicitis occurs when the vermiform appendix is completely

obstructed, either because of a bacterial infection, feces or other types of
blockage. Infection may also cause swelling of the lymph nodes, which then
adds pressure on the appendix, cutting off its blood supply.
Cont..

Appendicitis Can Be Chronic (But It's a Rare Condition)

• Chronic appendicitis is an inflammation that can last for a long time. This is
rare according to a report published in Therapeutic Advances in
Gastroenterology, it only occurs in only 1.5 percent of recorded acute
appendicitis cases.

• Basically, chronic appendicitis means that the appendiceal lumen is only

partially obstructed, causing inflammation. The inflammation worsens over
time, causing internal pressure to buildup.
Cont..

Stump Appendicitis: A Rare Appendectomy Side Effect

• In most instances of appendicitis, an appendectomy is the usual

procedure recommended, and it works by completely taking out the
appendix to prevent it from rupturing.

• If the appendix has already ruptured, additional treatment measures

are performed during an appendectomy, as the infection needs to be
prevented from spreading.
CLINICAL MANIFESTATIONS
• Local tenderness is elicited at McBurney’s point when pressure
is applied. Rebound tenderness (ie, production or intensification
of pain when pressure is released) may be present.

Symptoms
• Abdominal pain >95%
• Anorexia >70%
• Constipation 4-16%
Cont...

• Fever 10-20%

• Migration of pain to right lower quadrant 50-60%

• Nausea Vomiting >65%

Signs

• Abdominal tenderness >95%

• Right lower quadrant tenderness >90%

• Rebound tenderness 30-70%

• Rectal tenderness 30-40%

• Cervical motion tenderness 30%

• Rigidity 10%
Cont…

• Psoas sign 3-5%

• Obturator sign 5-10%

• Rovsing's sign 5%

• Palpable mass <5%

ASSESSMENT AND DIAGNOSTIC FINDINGS
Cont..

• Rovsing’s sign: Palpating in the

left lower quadrant causes pain in
the right lower quadrant

• Obturator’s sign: Internal rotation

of the hip causes pain, suggesting
the possibility of an inflamed
appendix located in the pelvis
• Dunphy's sign: Increased pain in the right lower quadrant with
coughing.

• Iliopsoas sign: Extending the right hip causes pain along

posterolateral back and hip, suggesting Retrocecal appendicitis.
• Sitkovskiy (Rosenstein)'s sign: Increased pain in the right
iliac region as the person is being examined lies on his/her left
side.
Diagnosis

• Diagnosis is based on results of a complete physical

examination and on laboratory and x-ray findings.

• The complete blood cell count demonstrates an elevated white

blood cell count.

• The leukocyte count may exceed 10,000 cells/mm3, and the

neutrophil count may exceed 75%.
ALVARADO SCORE
• The Alvarado score is the most widely used scoring system. A
score below 5 suggests against a diagnosis of appendicitis,
whereas a score of 7 or more is predictive of acute appendicitis
Abdominal x-ray films
Ultrasound studies
• Aperistaltic, non-
compressible, dilated
appendix (>6 mm outer
diameter)

• Distinct appendiceal wall

layers

• Periappendiceal fluid
collection/enlargement
CT scans

• Dilated appendix with

distended lumen ( >6
mm diameter)

• Thickened and
enhancing wall

• Thickening of the caecal

apex (up to 80%)
MANAGEMENT
• Surgery is indicated if appendicitis is diagnosed.

• To correct or prevent fluid and electrolyte imbalance and dehydration,

antibiotics and intravenous fluids are administered until surgery is performed.

• Analgesics can be administered after the diagnosis is made. (Morphine

sulphate 10 mg/ml)

Antibiotics

• Cefotaxime 250mg, 500mg

• Levofloxacin 500 mg

• Metronidazole 500mg/100ml, 400 mg tablet

• Appendectomy (ie, surgical removal of the appendix) is
performed as soon as possible to decrease the risk of
perforation. It may be performed under a general or spinal
anesthetic with a low abdominal incision or by laparoscopy.
Open Appendectomy
• https://www.youtube.com/watch?v=E1ljClS0DhM

• https://www.youtube.com/watch?v=18eYVp244mQ
NURSING MANAGEMENT

• Goals include relieving pain, preventing fluid volume deficit,

reducing anxiety, eliminating infection from the potential or actual
disruption of the GI tract, maintaining skin integrity, and attaining
optimal nutrition.

• The nurse prepares the patient for surgery, which includes an

intravenous infusion to replace fluid loss and promote adequate
renal function and antibiotic therapy to prevent infection.
Pre-Operative care:
• Assessment History taking physical examinations, Regarding
pain, nausea vomiting, abdominal rebound tenderness, Anorexia
• Monitor vital signs B.P., Temperature for baseline data

• NPO and I.V. Fluids be started

• Naso-gastric aspiration

• Monitor for signs of ruptured appendix and peritonitis

• Position right-side lying or low to semi fowler position to promote

comfort.
Cont..
• Auscultate Bowel Sounds

• Administer antibiotics as prescribed

• Preparation for surgery i.e. physically & psychologically

• Alley anxiety & fears

• Written consent for surgery

• Prepare and send the patient for surgery without delay

• OT clothes and pre medications to be given 45 minutes before operation

Post-Operative Nursing care:
• Clear airway

• Proper breathing and adequate tissue perfusion by IVF

• Naso-gastric suction to be done regularly to relieve tension on sutures

• Provide safety & effective care environment to the patient

• Care of all drainage tubes

• Care of surgical wounds. Watch for soapage/bleeding

• Daily A.S. dressing and watch for signs of infections

• Nutritional status maintained by I.V. fluids

• Observe for return of bowel sounds,

• Intake and output maintained

• Monitor vital signs & fluid, electrolytes balance

• Encourage early ambulation to prevent post operation complications.

• Maintain NPO till bowel sounds return then start clear fluids orally

• Medication as per prescription to be given by using 6 rt of Nursing standards of

medication

• Drugs – Antibiotics, analgesic & Anticholenergies i.e. Injection Aciloc as per prescription

• After surgery, the nurse places the patient in a semi-Fowler position. This position
NURSING DIAGNOSIS
• Acute Pain May be related to, Distension of intestinal tissues by inflammation,
Presence of surgical incision

• Risk for Fluid Volume Deficit, Risk factors may include, Preoperative vomiting,
postoperative restrictions (e.g., NPO), Hypermetabolic state (e.g., fever, healing
process) Inflammation of peritoneum with sequestration of fluid

• Risk for Infection, Risk factors may include, Inadequate primary defenses;
perforation/rupture of the appendix; peritonitis; abscess formation, Invasive
procedures, surgical incision

• Deficient Knowledge May be related to Lack of exposure/recall; information

misinterpretation, Unfamiliarity with information resources
Discharge and Home Healthcare Guidelines

• MEDICATIONS. Be sure the patient understands any pain medication

prescribed, including doses, route, action, and side effects.

• INCISION. Sutures are generally removed in the physician’s office in 5 to 7

days.

• COMPLICATIONS. Instruct the patient that a possible complication of

appendicitis is peritonitis.

• NUTRITION. Instruct the patient that diet can be advanced to her or his normal
food pattern as long as no gastrointestinal distress is experienced.
CONCLUSION

• Appendicitis is a condition that is prevalent in the developed

world and should have minimal complications. Surgical action
should be taken without delay. If left untreated there is a risk of
peritonitis, which is the main complication of this condition.

• Medical awareness of appendicitis has improved and

complications are less common.
REFERENCES
• Smeltzer, S.C, Bare, B.G, Hinkle, J.L, Cheever,K.H, (2010), Brunner and
Suddarth’s Textbook of Medical Surgical Nursing (12th ed.),LippincottWilliams and
Wilkins, 976-1067

• Longo,D.L ,Kasper,D.L ,Fauci,A.S, Hauser,S.L, et al.(2012), Harrison’s Principles

of Internal Medicine (18th ed), McGraw Hill Companies, Inc.Vol.(1), 299-322

• Jayce, M, Black, et al. (2004), Medical Surgical Nursing, Published by Saunder’s

Company, 7th Edition-, PP 809-14

• Teach me anatomy (2017), The cecum and appendix, Retrieved from:

http://teachmeanatomy.info/abdomen/gi-tract/cecum appendix/
Thank You!