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Appendicitis is the most common abdominal surgical emergency, affecting approximately 10% of the population It occurs most commonly between the ages of 10 and 30 years It is initiated by obstruction of the appendix by a fecalith, inflammation, foreign body, or neoplasm Obstruction leads to increased intraluminal pressure, venous congestion, infection, and thrombosis of intramural vessels If untreated, gangrene and perforation develop within 36 hours
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A Symptoms and Signs
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Appendicitis usually begins with vague, often colicky periumbilical or epigastric pain Within 12 hours the pain shifts to the right lower quadrant, manifested as a steady ache that is worsened by walking or coughing Almost all patients have nausea with one or two episodes of vomiting Protracted vomiting or vomiting that begins before the onset of pain suggests another diagnosis A sense of constipation is typical, and some patients administer cathartics in an effort to relieve their symptoms though some report diarrhea Low-grade fever (< 38 C) is typical; high fever or rigors suggest another diagnosis or appendiceal perforation On physical examination, localized tenderness with guarding in the right lower quadrant can be elicited with gentle palpation with one finger When asked to cough, patients may be able to precisely localize the painful area, a sign of peritoneal irritation Light percussion may also elicit pain Although rebound tenderness is also present, it is unnecessary to elicit this finding if the above signs are present The psoas sign (pain on passive extension of the right hip) and the obturator sign (pain with passive flexion and internal rotation of the right hip) are indicative of adjacent inflammation and strongly suggestive of appendicitis
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B Laboratory Findings
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Moderate leukocytosis (10,000 20,000/mcL) with neutrophilia is common Microscopic hematuria and pyuria are present in 25% of patients
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Both abdominal ultrasound and CT scanning are useful in diagnosing appendicitis as well as excluding other diseases
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positive pregnancy test and pelvic ultrasonography are diagnostic Retrocecal or retroileal appendicitis (often associated with pyuria or hematuria) may be confused with ureteral colic or pyelonephritis Other conditions that may resemble appendicitis are diverticulitis, Meckel s diverticulitis, carcinoid of the appendix, perforated colonic cancer, Crohn s ileitis, perforated peptic ulcer, cholecystitis, and mesenteric adenitis It is virtually impossible to distinguish appendicitis from Meckel s diverticulitis, but both require surgical treatment
presenting with similar symptoms, including adnexal disease in younger women However, CT scanning appears to be more accurate (sensitivity 94%, specificity 95%, positive likelihood ratio 133, negative likelihood ratio 009) Abdominal CT scanning is also useful in cases of suspected appendiceal perforation to diagnose a periappendiceal abscess In patients in whom there is a clinically high suspicion of appendicitis, some surgeons feel that preoperative diagnostic imaging is unnecessary However, studies suggest that even in this group, imaging studies suggest an alternative diagnosis in up to 15%
1 Atypical Presentations of Appendicitis
Owing to the variable location of the appendix, there are a number of atypical presentations Because the retrocecal appendix does not touch the anterior abdominal wall, the pain remains less intense and poorly localized; abdominal tenderness is minimal and may be elicited in the right flank The psoas sign may be positive With pelvic appendicitis there is pain in the lower abdomen, often on the left, with an urge to urinate or defecate Abdominal tenderness is absent, but tenderness is evident on pelvic or rectal examination; the obturator sign may be present In the elderly, the diagnosis of appendicitis is often delayed because patients present with minimal, vague symptoms and mild abdominal tenderness Appendicitis in pregnancy may present with pain in the right lower quadrant, periumbilical area, or right subcostal area owing to displacement of the appendix by the uterus
Perforation occurs in 20% of patients and should be suspected in patients with pain persisting for over 36 hours, high fever, diffuse abdominal tenderness or peritoneal findings, a palpable abdominal mass, or marked leukocytosis Localized perforation results in a contained abscess, usually in the pelvis A free perforation leads to suppurative peritonitis with toxicity Septic thrombophlebitis (pylephlebitis) of the portal venous system is rare and suggested by high fever, chills, bacteremia, and jaundice