Acute appendicitis, symptoms of appendicitis. McBurney's point.

Appendix is a blind tube (have one opening) located at the end of the cecum under the iliocecal junction, and has all of the gastrointestinal tract tissue layers, it also has lymphoid tissue.
The function of the appendix is still unknown, but some doctors think that it has a role in the body immunity especially in children.

Appendix positions:

Most commonly: retro cecal (60-70%)
Second most common: pelvic (20%)
Others: Para-cecal, prei-ilial and post-ilial (2-5%)

appendix

Acute appendicitis:

Is the most common surgical emergency, and if the surgeon can’t diagnose appendicitis it is a huge disaster!

Most of the time misdiagnosis of acute appendicitis happens due to the habit that the doctors develop, which is treating the appendicitis symptoms only, and not taking a full adequate history or a good physical examination to diagnose the illness correctly.

For example: A patient comes complaining of abdominal pain, so the doctor prescribes some analgesia without asking any further questions or doing any examination.
After 2 or 3 days the same patient comes with perforated appendix!!!

Complications:

Mortality rate and complications in acute appendicitis are very minimal if the doctor treats the condition early. The optimum time to treat acute appendicitis is within (24-48 hrs) from the time that the patient developed signs and symptoms in. Complications of acute appendicitis could be very serious: Perforation of the appendix can lead to:

  1. Multiple abscesses inside the peritoneal cavity (This could lead to septicemia and death).
  2. Multiple adhesions inside the abdomen. (The patient will constantly come complaining of intestinal obstruction then).

Clinical picture:

Presentation is not always typical.

The percentage of patients who show typical acute appendicitis presentation is only (50-60%) of the cases.

Typical presentation:

Pain starts in the peri-umbilical region, then after (6-24 hrs) it shifts to the right iliac fossa. Exactly at McBurney’s point (point of maximal tenderness).

McBurney point
McBurney’s point: is the name given to the point over the right side of the abdomen that is one-third of the distance from the ASIS (anterior superior iliac spine) to the umbilicus (the belly button). This point roughly corresponds to the most common location of the base of

Why does the pain start at the peri umbilical region?

Because at first the pain is visceral then it becomes somatic:

At first the inflammation starts at the mucosa then it will extend to the wall finally it will reach the serosa.

So at the first stage of the inflammation the patient will feel the pain through the autonomic nervous system. And since the umbilicus area and the appendix are
innervated by the same segment (T10), the brain wouldn’t be able to tell where exactly the pain is coming from.

After the inflammation has reached the serosa and the parietal peritoneum (innervated by the somatic nerves) gets irritated, then the pain will shift to the right iliac fossa where the inflammation really is.

In the case of retro-cecal appendicitis:

The presentation might not be fast and straight forward, because the appendix is hiding behind the cecum, so there won’t be any clear features on examination for the first time. But after 2-3 days the presentation will become very prominent. So don’t ignore the patient even if the presentation is not typical or clear because at the time that the presentation gets clear, it might be too late and the patient will suffer more than he has to.

In the case of pelvic appendicitis:

The pelvic cavity is a boney cavity, that’s why when you examine the abdomen of a patient whose inflamed appendix is positioned in the pelvis, you will find out that his/her abdomen is soft and lax with no rigidity and you might miss the diagnosis.

Other associated factors:

  1. The pain is also accompanied with Anorexia, so if the patient’s appetite is not affected by the pain then you have to question your diagnosis.
  2. Nausea & Vomiting can also be one of the accompanied symptoms, but it’s not pronounced. It means that the patient will not vomit a lot, only once or twice.
  3. Other symptom is LOW grade fever.

If a patient comes with recent Rt. Iliac fossa pain and high grade fever, it’s unlikely to be appendicitis.

Appendicitis cause HIGH grade fever after 4 days; when the appendix perforates and cause intra abdominal abscess or peritonitis. The acute appendicitis patient does not develop high grade fever on the same day that he/she first showed symptoms in.

If the patient comes with Atypical symptoms like: if the pain started at the Rt. Iliac fossa immediately with no shifting, we should not just prescribe analgesia and send him/her home (symptomatic treatment).

This patient should be admitted and put under observation and re-evaluate him/her each 6 hours.

Symptomatic treatment should only be given to previously diagnosed patient with known disease.

Age group:

age group appendicitis
Most common age group affected is adolescents and young adults 3rd and 4th decade (20-30yrs).

Children and elderly are less likely to develop acute appendicitis, but if they did, they will have more serious presentation and complications.

Investigations:

The diagnosis is clinical; for there is no specific test to confirm the diagnosis of acute appendicitis.

The doctor can order WBC count and urine analysis to support the diagnosis.

If you found leukocytosis (13000-14000), then this can support your diagnosis. But if the WBS count was normal, it will not exclude appendicitis from the differential diagnosis.

Physical Examination:

The patient will have these findings:

Tenderness and rebound tenderness:

Tenderness is a sign. When you palpate the patient’s abdomen, the patient will be in pain

Rebound tenderness: when you press on the abdomen then suddenly remove your hand; the patient will feel pain on removal of your hand.

Rebound tenderness is an important sign for any intra abdominal inflammatory process.

When doing the rebound tenderness test, you must be very gentle. Also you should not repeat the examination many times; for that would irritate the patient and sometimes even perforate the appendix.

When do we repeat the rebound tenderness test?

If the patient didn’t have rebound tenderness at the first time, we can repeat the test again after 6-12 hours.

The patient will also have rigidity and guarding.

Differential Diagnosis:

ANY RT. ILIAC FOSSA PAIN IS DIAGNOSED AS ACUTE APPENDICITIS UNTIL PROVEN OTHERWISE

(The doctor wanted to mention the DDx but he ran out of time so I wrote them down since they should’ve been talked about).

In children:
Gastroenteritis, mesenteric adenitis, Meckel’s diverticulitis, intussusception, Henoch-Schonlein purpura, lobar pneumonia

In adults:
regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma:
in men: testicular torsion
in women: pelvic inflammatory disease, ectopic pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle)

In elderly:
diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.

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