Appendicitis.docx

Appendicitis.docx

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Appendicitis

Appendicitis

FromWikipedia,thefreeencyclopedia

Appendicitis

Anacutelyinflamedandenlargedappendix,slicedlengthwise.

Classificationandexternalresources

ICD-10

K35 - K37

ICD-9

540-543

DiseasesDB

885

MedlinePlus

000256

eMedicine

med/3430 emerg/41ped/127 ped/2925

PatientUK

Appendicitis

MeSH

C06.405.205.099

Appendicitis （alsocalled epityphlitis[1]）is inflammation ofthe appendix.Appendicitiscommonlypresentswithright iliacfossa abdominalpain, nausea, vomiting,and decreasedappetite.[2] However,onethirdtoahalfofpersonsdonothavethesetypicalsignsandsymptoms.[3] Severecomplicationsofarupturedappendixincludewidespread,painful inflammationoftheinnerliningoftheabdominalwall andsepsis.[4]

Appendicitisiscausedbyablockageofthe hollowportion oftheappendix,[5][6] mostcommonlybyacalcified"stone"madeoffeces.Howeverinflamed lymphoidtissue fromaviralinfection, parasites,gallstoneor tumors mayalsocausetheblockage.[7] Thisblockageleadstoincreasedpressureswithintheappendix,decreasedbloodflowtothetissuesoftheappendix,andbacterialgrowthinsidetheappendixcausinginflammation.[7][8] Thecombinationofinflammation,reducedbloodflowtotheappendixanddistentionoftheappendixcausestissueinjuryanddeath.[9] Ifthisprocessisleftuntreated,theappendixmayburstreleasingbacteriaintotheabdominalcavity,leadingtosevereabdominalpainandincreasedcomplications.[9][10]

Thediagnosisofappendicitisislargelybasedontheperson'ssignsandsymptoms.[8] Incaseswherethediagnosiscannotbemadebasedontheperson'shistoryandphysicalexam,closeobservation,radiographicimagingandlaboratorytestscanoftenbehelpful.[11] Thetwomostcommonimagingtestsusedare ultrasoundand computertomography （CTscan）.[11] CTscanhasbeenshowntobemoreaccuratethanultrasoundindetectingacuteappendicitis.[12][13] However,ultrasoundmaybepreferredasthefirstimagingtestinchildrenandpregnantwomenduetotherisksassociatedwithradiationexposurefromCTscans.[11]

Thestandardtreatmentforacuteappendicitisis surgicalremovaloftheappendix.[7][8] Thismaybedonebyan openincisionintheabdomen orthroughafew smallerincisionswiththehelpofcameras.Surgerydecreasestheriskofsideeffectsordeathassociatedwithruptureoftheappendix.[4] Antibiotics maybeequallyeffectiveincertaincasesofnon-rupturedappendicitis.[14] Itisoneofthemostcommonandsignificantcausesofsevereabdominal pain thatcomesonquickly worldwide.In2013itresultedin72,000deathsglobally.[15] IntheUnitedStates,appendicitisisthemostcommoncauseofacuteabdominalpainrequiringsurgery.[2] EachyearintheUnitedStates,morethan300,000personswithappendicitishavetheirappendixsurgicallyremoved.[16] ReginaldFitz iscreditedwithbeingthefirstpersontodescribetheconditioninapaperpublishedin1886.[17]

Contents

  [hide] 

∙1 Signsandsymptoms

∙2 Causes

∙3 Diagnosis

o3.1 Clinical

o3.2 Bloodandurinetest

o3.3 Imaging

o3.4 Scoringsystems

o3.5 Pathology

o3.6 Differentialdiagnosis

∙4 Management

o4.1 Pain

o4.2 Surgery

∙5 Prognosis

∙6 Epidemiology

∙7 Societyandculture

o7.1 Lengthofstay

∙8 References

∙9 Externallinks

Signsandsymptoms[edit]

Locationoftheappendixinthedigestivesystem

Painfirst,nauseaandvomitingnext,andfeverlasthasbeendescribedastheclassicpresentationofacuteappendicitis.Becausetheinnervationoftheappendixentersthe spinalcord atthesamelevelasthe umbilicus（bellybutton）,thepainbeginsstomach-high.Astheappendixbecomesmoreswollenandinflamed,itbeginstoirritatetheadjoiningabdominalwall.Thisleadstothelocalizationofthepainto therightlowerquadrant.Thisclassicmigrationofpainmaynotbeseeninchildrenunderthreeyears.Thispaincanbeelicitedthroughvarioussignsandcanbesevere.Signsincludelocalizedfindingsintheright iliacfossa.Theabdominalwallbecomesverysensitivetogentlepressure（palpation）.Also,thereisseverepainonsuddenreleaseofdeeppressureinthelowerabdomen（reboundtenderness）.Iftheappendixisretrocecal（localizedbehindthe cecum）,evendeeppressureintherightlowerquadrantmayfailtoelicittenderness（silentappendix）.Thisisbecausethe cecum,distendedwithgas,protectstheinflamedappendixfrompressure.Similarly,iftheappendixliesentirelywithinthepelvis,thereisusuallycompleteabsenceofabdominalrigidity.Insuchcases,adigitalrectalexamination elicitstendernessintherectovesicalpouch.Coughingcausespointtendernessinthisarea（McBurney'spoint）.

Causes[edit]

Basedonexperimentalevidence,acuteappendicitisseemstobetheendresultofaprimaryobstructionoftheappendiceal lumen.[18][19] Oncethisobstructionoccurs,theappendixbecomesfilledwith mucus andswells.Thiscontinuedproductionofintra-lumenalmucusleadstoincreasedpressureswithinthelumenandthewallsoftheappendix.Thisincreasedpressureresultsin thrombosis and occlusion ofthesmallvessels,andstasisoflymphaticflow.Atthispointspontaneousrecoveryrarelyoccurs.Astheocclusionofbloodvesselsprogresses,theappendixbecomes ischemic andthen necrotic.As bacteria begintoleakoutthroughthedyingwalls, pus formswithinandaroundtheappendix（suppuration）.Theendresultofthiscascadeisappendicealrupture（a'burstappendix'）causing peritonitis,whichmayleadto sepsis andeventually death.Thiscascadeofeventsisresponsiblefortheslowlyevolvingabdominalpainandothercommonlyassociatedsymptoms.[9]

Thecausativeagentsinclude bezoars,foreignbodies, trauma, intestinalworms, lymphadenitis,and,mostcommonly,calcifiedfecaldepositsthatareknownasappendicolithsorfecaliths.[20] Theoccurrenceof obstructingfecaliths hasattractedattentionsincetheirpresenceinpersonswithappendicitisishigherindevelopedthanindevelopingcountries.[21] Inadditionanappendicealfecalithiscommonlyassociatedwithcomplicatedappendicitis.[22] Also,fecalstasisandarrestmayplayarole,asdemonstratedbypersonswithacuteappendicitishavingfewerbowelmovementsperweekcomparedwithhealthycontrols.[23][24] Theoccurrenceofafecalithintheappendixwasthoughttobeattributedtoaright-sidedfecalretentionreservoirinthecolonandaprolongedtransittime.Howeveraprolongedtransittimewasnotobservedinsubsequentstudies.[25] Fromepidemiologicaldata,ithasbeenstatedthatdiverticulardiseaseandadenomatouspolypswereunknownandcoloncancerexceedinglyrareincommunitiesexemptfromappendicitis.[26][27] Also,acuteappendicitishasbeenshowntooccurantecedenttocancerinthecolonandrectum.[28]Severalstudiesofferevidencethatalowfiberintakeisinvolvedinthepathogenesisofappendicitis.[29][30][31] Thislowintakeofdietaryfiberisinaccordancewiththeoccurrenceofaright-sidedfecalreservoirandthefactthatdietaryfiberreducestransittime.[32] Perihepatituscanbecausedby pelvicinflammatorydisease.[33]

Diagnosis[edit]

Diagnosisisbasedonamedicalhistory（symptoms）andphysicalexaminationwhichcanbesupportedbyanelevationof neutrophilic whitebloodcellsandimagingstudiesifneeded.（Neutrophilsaretheprimarywhitebloodcellsthatrespondtoabacterialinfection.）Historiesfallintotwocategories,typicalandatypical.Typicalappendicitisincludesseveralhoursofgeneralizedabdominalpainwhichbeginsintheregionoftheumbilicuswithassociated anorexia,nausea,orvomiting.Thepainthen"localizes"intotherightlowerquadrantwherethetendernessincreasesinintensity.Howeveritispossiblethepaincouldlocalizetothe theleftlowerquadrant inpersonswith situsinversustotalis.Thecombinationofpain,anorexia,leukocytosis,andfeverisclassic.Atypicalhistorieslackthistypicalprogressionandmayincludepainintherightlowerquadrantasaninitialsymptom.Irritationoftheperitoneum（insideliningoftheabdominalwall）canleadtoincreasedpainonmovement,orjolting,forexamplegoingoverspeedbumps.[34] Atypicalhistoriesoftenrequireimagingwithultrasoundand/orCTscanning.[35]

Clinical[edit]

∙Aure-Rozanovasign:

Increasedpainonpalpationwithfingerinright Petittriangle （canbeapositiveShchetkin-Bloomberg's）

∙Bartomier-Michelson'ssign:

Increasedpainonpalpationattherightiliacregionasthepersonbeingexaminedliesonhis/herleftsidecomparedtowhenhe/sheliesonhis/herback.

∙Dunphy'ssign:

Increasedpainintherightlowerquadrantwithcoughing.[36]

∙Kocher's（Kosher's）sign:

Fromtheperson'smedicalhistory,thestartofpainintheumbilicalregionwithasubsequentshifttotherightiliacregion.

∙Massouhsign:

DevelopedinandpopularinsouthwestEngland,theexaminerperformsafirmswishwithhis/herindexandmiddlefingeracrosstheabdomenfromthe Xiphoidprocess totheleftandtherightiliacfossa.ApositiveMassouhsignisagrimaceofthepersonbeingexamineduponarightsided（andnotleft）sweep.

∙Obturatorsign:

Thepersonbeingevaluatedliesonher/hisbackwiththehipandkneebothflexedatninetydegrees.Theexaminerholdstheperson'sanklewithonehandandkneewiththeotherhand.Theexaminerrotatesthehipbymovingtheperson'sankleawayfromthehis/herbodywhileallowingthekneetomoveonlyinward.Apositivetestispainwithinternalrotationofthehip.

∙Psoassign:

Alsoknownasthe"Obraztsova'ssign"isrightlower-quadrantpainthatisproducedwitheitherthepassiveextensionoftherighthiporbytheactiveflexionoftheperson'srighthipwhilesupine.Thepainthatiselicitedisdue