A 23-year-old with right lower quadrant abdominal pain

• Appendicitis: Anorexia, periumbilical pain → right lower quadrant pain, vomiting, Psoas sign, Rovsing sign
• Perforated peptic ulcer: sudden onset abdominal pain that started in the epigastrium passing down the paracolic gutter, referred to the shoulder, H/O chronic dyspepsia
• Ureteric colic due to urolithiasis: severe intermittent colicky flank pain radiating to the groin without fever
• Diverticulitis: elderly patient with H/O westernised diet, irregular bowel habits, constipation
• Typhoid: fever, diarrhoea, and diffuse abdominal pain
• Amoebiasis: H/O blood-stained mucoid diarrhoea
• Regional enteritis: H/O abdominal cramping, weight loss and diarrhoea
• Right sided pyelonephritis: Increased frequency of micturition, loin tenderness, pyuria and fever (39 degrees celsius)
• Testicular torsion: Testicular pain, swollen and tender testis, lost cremasteric reflex
• Acute pancreatitis: Severe epigastric pain with nausea, vomiting and anorexia. Best ruled out by checking the serum amylase levels.
• Rectus sheath hematoma: Localised pain with no gastrointestinal symptoms with a H/O of strenuous physical activity or mild trauma.
• Carcinoma of the caecum: Especially in the older population. Altered bowel habits, unexplained anaemia and a palpable mass are characteristic
• Hernia incarceration: H/O abdominal pain, constipation, vomiting
• Inflammatory bowel disease: H/O abnormal bowel habits

• Right-sided ectopic pregnancy: Amenorrhoea (about 6-8 weeks LNMP), right-sided abdominal pain, vaginal bleeding, cervical motion tenderness, adnexal mass, breast tenderness, anaemia, positive pregnancy test (rarely hemorrhagic shock)
• Ovarian torsion: Acute onset severe pelvic/ lower abdominal pain, adnexal mass, H/O ovarian cyst
• Pelvic inflammatory disease: pelvic/lower abdominal pain, purulent vaginal discharge, cervical motion tenderness, adnexal tenderness, dysuria, dysmenorrhea, Neisseria gonorrhea and Chlamydia are the usual suspects.
• Tubo-ovarian abscess: tender fixed fluctuant mass on the right side. H/O of pelvic peritonitis suggests that the abscess may have ruptured
• Mittelschmerz: mild unilateral lower abdominal pain that occurs midcycle, duration from few hours to few days, normal pelvic exam, no fever, negative pregnancy test

• • Mesenteric lymphadenitis: current or recent URTI (nasal discharge, cough, throat pain, etc.), high fever, generalized abdominal pain, tender lymphadenopathy in small bowel mesentery, cervical lymph nodes are enlarged.
  • Yersinia enterocolita (pseudoappendicitis): RLQ pain, vomiting, bloody diarrhoea, H/O sick contacts e.g. infected children at daycare
  • Pneumococcal pneumonia: Pneumonia associated with nausea and vomiting, and diffuse abdominal pain. Findings on chest auscultation and chest x ray will confirm diagnosis.
  • Gastroenteritis: Nausea, vomiting, watery diarrhoea (viral) or bloody diarrhoea (bacterial), myalgia, fever, H/O of contact with contaminated food and people with similar symptoms.
  • Intussusception: Nausea, vomiting, crampy abdominal pain, “red currant jelly” stool, “sausage-shaped mass” in the abdomen
  • Meckel’s diverticulum: Painless rectal bleeding (current jelly stool). Abdominal pain may be left or centrally placed
  • Henoch Schonlein purpura: Preceded by a URTI. Characterised by rashes on the extensor surfaces of the limbs and buttocks, joint pain as well as renal manifestations such as microscopic hematuria.
  Children with acute appendicitis may have typical symptoms of viral URTI followed by onset of true acute appendicitis

• Anorexia

95% of the time

• Anorexia → periumbilical abdominal pain → nausea and vomiting → shift to right lower quadrant pain + Fever

Murphy’s triad: Migrating Pain → Nausea and Vomiting → Fever (usually in this order)

Vomiting is due to pylorospasm and involves stomach contents

• The visceral peritoneum is supplied by the autonomic visceral (splanchnic) nerves There is no laterality to the unmyelinated C-fibers of visceral nerves which enter the spinal cord bilaterally at multiple levels. The CNS attributes the pain signals to the physical location whose dermatome corresponds to the same entry level in the spinal cord
• On the other hand, the parietal peritoneum is supplied by the somatic nerves
• The appendix is part of the midgut. Visceral pain from the midgut is referred to the peri-umbilical region (T8-T10 dermatome)
• The visceral peritoneum is often inflamed in the early hours of acute appendicitis causing the patient to experience vague periumbilical pain (referred to the T8-T10 dermatome)
• Inflammation progresses to the parietal peritoneum and the pain becomes sharp, severe, and localized in the RLQ

• The patient describes the migratory pain characteristic of acute appendicitis

Points at the umbilicus then RLQ

• A patient with true acute appendicitis will decline their favourite food e.g. a hamburger, when offered

Useful in children with vague abdominal pain

Most patients with appendicitis have anorexia

• This is a point located one-third of the way from the right anterior superior iliac spine to the umbilicus.

Superficial landmark for the base of the appendix

• A point located on a line between the anterior superior iliac spines, one third of the distance from the right anterior iliac spine.

Superficial landmark for the position of the appendix

• Peritonitis is inflammation of the peritoneum which leads to an intense inflammatory response and profound loss of intravascular fluid into the peritoneal space (SIRS)

It can be due to infection and/or sterile chemical irritations e.g. bleeding

Peritonitis can be complicated by bleeding and sepsis resulting from the inciting event

• Excruciating abdominal pain and tenderness
• Rebound tenderness and Jar tenderness
• Board-like involuntary rigidity
• Shallow respiratory movements (due to pain produced by diaphragmatic breathing)
• Retching (vomiting)
• Facies Hippocratica (produced by dehydration, pain, and anxiety)

Abdominal distension due to ileus may be present

Peritonitis progresses in stages: Stage of prostration (primary shock) → Stage of reaction (masked peritonitis) → Stage of frank peritonitis (with facies hippocratica)

• Rebound tenderness is abdominal pain worsened after withdrawal of the palpating hand

It is a sign of peritonitis. The inflamed peritoneum is painful when disturbed, especially when the two inflamed peritoneal surfaces slide over one another. The site of pain is well localized since the parietal peritoneum has somatic sensory afferents.

Rebound tenderness can also be elicited by gentle percussion, or pinching and releasing

The pain can occur at the site of pressure or remote from it

• Jar tenderness is tenderness produced by the heel-drop test

The patient stands on the floor with straightened knees, rises on their toes, then drops to the heels

It is superior to rebound tenderness for localizing peritoneal irritation in the pelvis and in patients with a rigid abdomen

Abdominal pain on walking or running is equivalent to a Markle sign

• McBurney’s point tenderness
• Blumberg’s sign: rebound tenderness in the RLQ
• Rovsing’s sign: RLQ pain elicited on deep palpation of the LLQ
• Iliopsoas sign: RLQ pain elicited on flexion of the right hip
• Obturator sign: RLQ pain elicited on internal rotation of the right hip

• Tenderness on palpation of the petit triangle (inferior lumbar triangle)
• Iliopsoas sign positive

Tenderness may not be elicited on palpating the RLQ because the caecum prevents the applied pressure from reaching the appendix.

Retrocecal appendix may also cause flank pain

• Anteriorly – External abdominal oblique
• Posteriorly – Latissimus dorsi
• Inferiorly – Iliac crest (base of triangle)
• Floor – Internal abdominal oblique

• Obturator sign positive
• Tenderness in the pouch of Douglas
• Diarrhoea – inflamed appendix is in contact with rectum
• Suprapubic tenderness and tenesmus

A pelvic appendix is more common in children

Inflammation of the bladder may cause increased frequency of urination

Tenderness may not be elicited on palpating the RLQ

Paralytic ileus secondary to inflamed bowel

• Complete Blood Count: Leukocytosis with a left shift (increase in band cells)
• CRP: Elevated
• b-hCG: for women of childbearing age to rule out ectopic pregnancy

b-hCG may be unremarkable but remember that pregnant women can get appendicitis too!

Urinalysis can be performed to rule out cystitis

• Pyuria

Due to ureteral or bladder irritation by the inflamed appendix

Bacteriuria (bacteria in urine) should not be present in a catheterized urine specimen

• Alvarado’s score is a 10-point scoring system using clinical and laboratory criteria to estimate the likelihood of appendicitis

Appendicitis is majorly a clinical diagnosis

Alvarado’s score used 3 symptoms, 3 physical exam findings, and 2 laboratory parameters

Interpretation:

• Score of 1 -4 = Unlikely diagnosis of appendicitis
• Score of 5-6 = Possible diagnosis of appendicitis (Abdominal ultrasound and contrast enhanced CT are indicated to rule in appendicitis)
• Score of 7-8 = Probable acute appendicitis
• Score of 9-10 = Very probable acute appendicitis

• Acute appendicitis
  • Migration of pain to the RLQ + 1
  • Anorexia + 1
  • Nausea and vomiting + 1
  • Tenderness in the RLQ + 2
  • Rebound tenderness + 1
  • Elevated temperature > 37.3 C + 1
  • Lekucotosis > 10,000 mm3 + 2
  • Shift to the left + 1

High likelihood of acute appendicitis using Alvarado’s score

• Periappendicitis is any pathology that causes peritonitis leading to inflammation of the tissue surrounding the appendix e.g. perforated peptic ulcer and pelvic inflammatory disease, causing inflammation of the tissue surrounding the appendix

Leads to signs and symptoms suggestive of appendicitis

Consider if there is pus in the pelvis yet the appendix appears non-perforated and non-inflamed

In this case, the abdomen is explored for the source of peritonitis

• Pseudoappendicitis is a disease that presents exactly like appendicitis but is due to another cause

Yersinia enterocolitis is the classical cause – RLQ pain, fever, vomiting, bloody diarrhoea, and sick contacts

It is self-limiting, but can lead to fatal sepsis in immunosuppressed individuals

Treat with doxycycline

• RLQ ultrasound
• Abdominal CT with contrast

RLQ ultrasound is the best initial imaging test

A CT scan can be performed if the diagnosis is questionable based on history, physical exam, and labs

No further imaging is required

• When the diagnosis is uncertain

This is the best initial imaging test for women and children

• Distended appendix > 6mm
• Non-compressible, aperistaltic, distended tubular structure
• Target sign (the appendiceal lumen and edematous muscularis are hypoechoic while the inflamed mucosa is hyperechoic)
• Fecalith (focal hyperechogenicity with posterior acoustic shadowing)

A perforated appendix is compressible

• When the diagnosis is still unclear

It is ordered for adult men and non-pregnant women

CT may not easily visualize the appendix in children since they have less peri-appendiceal fat

It is very accurate

Can be ordered with contrast

• Distended appendix > 6mm
• Edematous appendix with peri-appendiceal fat stranding
• Fecalith (focal hyperdensity within the lumen)
• Halo or target sign

Fat stranding is seen in inflammation. It is increased attenuation of fat in an ill-defined linear, reticular, or reticulonodular pattern

• It is not helpful

A fecalith can be spotted in the RLQ occasionally

• Transvaginal ultrasound or CT scan

Ovarian torsion is a surgical emergency

Delays result in necrosis of the ovary (which can only be salvaged 10% of the time due to delays in diagnosis)

• Abdominal pain in PID may be bilateral from onset and is associated with purulent vaginal discharge (smear will show bacteria)
• PID has cervical motion tenderness and right adnexal tenderness
• Nausea and vomiting are less common in PID

The patient may have risk factors for PID too: unprotected intercourse, H/O of STD or PID, multiple sexual partners

CT scan or Transvaginal ultrasound can be used to differentiate if unequivocal

• It is difficult to diagnose appendicitis in children since they cannot give a history and have frequent gastrointestinal upset

Their appendix is prone to perforate (45%) since their omentum is underdeveloped and less capable of containing the rupture

Diffuse peritonitis can develop rapidly

Remember that children with appendicitis have complete aversion to food and vomit a lot

• Abdominal pain presents later in the course
• It usually has an atypical presentation

Their appendix is more prone to perforate (50%) or become gangrenous

They also have a higher rate of morbidity and mortality with a perforated appendix

• Bowel perforation caused by colon cancer or even carcinoma of the cecum

This can mimic appendicitis in the elderly

Microcytic anemia should prompt for workup of colon cancer

• Diagnosis is delayed as early non-specific symptoms e.g. nausea and vomiting are attributed to the pregnancy

Appendicitis is the most common cause of extrauterine abdominal pain in pregnancy

Fetal loss occurs in 3-5% of cases, increasing to 20% if there is perforation

Pain can occur in the RUQ as the uterus displaces the cecum and appendix superiorly

• The appendix is most likely perforated

Can progress into diffuse peritonitis, or the omentum can wall of the perforation to create a localized abscess

Confirm with a CT scan and treat conservatively with Intravenous antibiotics

Large abscesses (> 4cm) can be drained percutaneously or surgically

• Appendectomy (surgery)
  • Laparoscopic approach
  • Open approach

Incisions for open appendectomy include Gridiron, Lanz, and Rutherford-Morrison incision (extended gridiron).

Can be done under spinal or general anaesthesia.

• Appendicitis is treated urgently but is not necessarily a true surgical emergency

Surgery is done urgently (within 24 hours) to prevent perforation and diffuse peritonitis

Emergent appendectomy is done within 8 hours

The risk of perforation is low in the first 36 hours with a 5% risk of perforation in each subsequent 12-hour period

• Clean-contaminated

<10% infective rate. Antibiotic prophylaxis may be required.

• Peri-operative antibiotics reduce the risk of post-operative wound infection

It is given to patients with both acute perforated and non-perforated appendicitis

For acute non-perforated appendicitis, IV broad spectrum antibiotics are started 1 hour pre-op and should not exceed 24 hours post-op

For perforated and gangrenous appendicitis IV antibiotics can be given until fever and leukocytosis resolves (3-5 days)

• The caecum is mobilised and the taenia coli are traced to their confulence

The base of the appendix is located where the taenia coli meet

• A normal appendix is found during appendectomy

10% of the elderly, infants, and young women

The appendix is removed anyway and other causes that mimic appendicitis are searched for

If the cause if Crohn’s disease (regional enteritis) the appendix is not removed since there is a high risk of forming a enterocutaneous cecal fistula

• The Oschner-Sherren regimen is a non-operative treatment regimen used for the management of an appendix mass (abscess/phlegmon)
  • Nil per oral
  • Nasogastric tube decompression
  • Antipyretics and analgesics
  • IV fluids
  • IV antibiotics
  • Monitor vitals and the size of the mass

“PAIN” – Pain meds, Antibiotics, IV fluids, NPO + NG tube

It is performed for acute appendicitis with abscess/phlegmon. Abscess may resolve on its own with antibiotics

Percutaneous or surgical drainage can be performed for large abscesses

Interval appendectomy may be performed 6-12 weeks after resolution

Non-operative management and percutaneous drainage has lower morbidity and mortality compared to immediate appendectomy, but longer hospital stay. It also has low failure rates, and even if it fails surgery can be done.

The regimen is discontinued if the pulse rate increases, abdominal pain becomes diffuse, or the mass increases in size

• Interval appendectomy is an appendectomy that is done 6-12 weeks after the resolution of acute appendicitis with a mass (abscess or phlegmon)

It’s main aim is to prevent recurrent appendicitis

At interval appendectomy often the residual appendix is scarred and involuted.

Its role is controversial. Some sources say interval appendectomy is not necessary

• Possibly…

Surgery (appendectomy) remains the gold standard

Antibiotics alone will not prevent the progression to gangrene and perforation, especially when there is a fecalith (obstructive)

However, studies show that 90% of patients with CT-confirmed appendicitis who are managed non-operatively have successful outcomes. Approximately 25% of these patients will require surgery within 1 year for recurrent appendicitis

Non-operative treatment can be considered in patients with high operative risk or in relatively well-patients with limited signs

• A closed loop obstruction is mechanical obstruction of the bowel at two points along its length such that there is no outlet for bowel contents and pressure

Pressure builds up and the loop of the bowel continues to distend until venous pressure exceeds arterial inflow. Blood supply is compromised and ischemia and infarction follow

• The appendix is a blind loop (its distal end is closed)
• Obstruction of the proximal lumen creates a closed-loop obstruction
• Mucus is secreted and accumulates within the closed-loop causing pressure to build up in the appendix
• The appendix distends and intraluminal pressure exceeds venous pressure leading to venous congestion. Pressure continues to increase until arterial inflow is compromised
• The areas with the poorest blood supply become ischemic and gangrenous. This allows bacteria to translocate into the mucosa and submucosa
• The wall becomes weakened and perforate (usually at the antimesenteric border just beyond the point of obstruction where tension is high)

Increased intraluminal pressure alone is not directly responsible for perforation

• Fecalith
• Lymphoid hyperplasia (children)
• Inspissated barium (impacted barolith) after radiological studies
• A tumor e.g. adenocarcinoma or carcinoid of the appendix
• Ingested seed
• Parasites e.g. Enterobius vermicularis, Ascaris lumbricoides

Fecalith is the most common cause

Lymphoid hyperplasia is common in children

• Obstructing colon cancer with functioning ileocecal valve
• Diverticulitis
• Incarcerated hernia
• Volvulus
• Acute cholecystitis
• Ritcher’s hernia

In Ritcher’s hernia only part of the circumference of the bowel wall is trapped in the sac

• Perforated appendix
• Gangrenous appendicitis
• Appendiceal abscess
• Appendiceal phlegmon
• Pyelephlebitis

• Bleeding (from appendicular artery stump)
• Surgical site infection (most common, 5-10%)
• Adynamic Ileus
• Fecal fistula
• Incisional hernia
• Adhesions and intestinal obstruction (late complication)

Among other general surgical complications – Pneumonia, Venous thromboembolism

Bleeding can occur from the appendicular artery stump

Surgical site infection can occur from a break in sterile technique or spillage. It can be organ space, deep or superficial.

Fecal fistula can be caused by leakage from the appendicular stump, inflammation of the cecum, or appendectomy in Crohn’s disease