The most common acute condition leading to abdominal surgery, appendicitis can be difficult to pinpoint because signs and symptoms can vary widely and may occur with other disorders. In up to 20% of patients who undergo emergency appendectomy, pathologic examination of the tissue shows a normal appendix. Yet misdiagnosed or untreated, appendicitis can be life-threatening.
Appendicitis is an acute inflammation of the appendix, a fingerlike organ attached to the cecum with no known function. Obstruction of the appendix lumen, most commonly by a hard fecal mass (fecalith), typically triggers the inflammation. Ulceration of the appendix mucosa has been recendy reported as a major cause of the disease.
Ineffective fluid drainage from the appendix lumen lets bacteria invade the appendix wall, triggering infection. If the infected appendix isn’t removed, it can perforate and cause peritonitis. Perforation is most likely within 48 hours after appendicitis develops, with the incidence as high as 80%.
Symptoms: Abdominal pain plus…
Abdominal pain is the classic appendicitis symptom, commonly accompanied by additional signs and symptoms.
- Pain usually begins in the periumbilical region. As inflammation increases, the pain becomes more severe and localized to the right lower quadrant midway between the anterior iliac crest and the umbilicus, an area known as McBurney’s point.
- Rebound tenderness is a sign of acute appendicitis and peritoneal inflammation. If the practitioner applies firm, slow pressure to the abdomen at a point away from the reported pain and quickly releasing it triggers severe pain, rebound tenderness is present.
- Anorexia is common, and up to 60% of patients have nausea and vomiting.
- Temperature elevation of 99° F (37° C) to 100.5° F (38° C) may occur, or temperature may be normal.
- Elevated white blood cell (WBC) count of greater than 10,000/mm 3 is common, (Normal, 4,500/mm 3 to 10,000/mm 3
Signs and symptoms of perforation include a WBC count of 20,000/mm 3 or greater; a tense, rigid abdomen; and a temperature of 102° F (39° C) or higher. Older adults with altered pain perception delay seeking treatment and are more likely to develop perforation.
Reaching a tentative diagnosis
Various disorders can cause signs and symptoms similar to those of appendicitis, especially in women. Acute gastroenteritis, pyelonephritis, ectopic pregnancy, and pelvic inflammatory disease are a few examples. No one diagnostic test can confirm appendicitis, but lab results, imaging studies, the patient history, and physical examination findings can help the practitioner rule out other conditions.
The abdominal computed tomography scan has become the most important imaging study for detecting appendicitis. Other imaging studies, such as ultrasound and an X-ray of the kidneys, ureters, and bladder, may reveal an inflamed appendix or another abnormality. Even if diagnostic studies don’t clearly point to appendicitis, anyone with highly suspicious signs and appendicitis symptoms should be evaluated by a surgeon because missing this diagnosis can be deadly.
A patient with suspected appendicitis needs to be hospitalized and closely monitored. In anticipation of surgery, he should be kept N.P.O. and have an intravenous (I.V.) line inserted for fluid administration. He may receive opioids for pain and I.V. antibiotics to reduce the risk of postoperative wound infection or to treat septicemia, if indicated. If the surgeon believes the appendix is inflamed, he’ll remove it laparoscopically or via laparotomy to prevent perforation, (See Two appendectomy techniques.)