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The treatment of uncomplicated appendicitis is surgical appendectomy This may be performed through a laparotomy or by laparoscopy Prior to surgery, patients should be given systemic antibiotics, which reduce the incidence of postoperative wound infections Emergency appendectomy is also required in patients with perforated appendicitis with generalized peritonitis The optimal treatment of stable patients with perforated appendicitis and a contained abscess is controversial Surgery in this setting can be difficult Many recommend percutaneous CT-guided drainage of the abscess with intravenous fluids and antibiotics to allow the inflammation to subside An interval appendectomy may be performed after 6 weeks to prevent recurrent appendicitis
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Given its frequency and myriad presentations, appendicitis should be considered in the differential diagnosis of all patients with abdominal pain It is difficult to reliably diagnose the disease in some cases A several-hour period of close observation with reassessment usually clarifies the diagnosis Absence of the classic migration of pain (from the epigastrium to the right lower abdomen), right lower quadrant pain, fever, or guarding makes appendicitis less likely Ten to 20 percent of patients with suspected appendicitis have either a negative examination at laparotomy or an alternative surgical diagnosis The widespread use of ultrasonography and CT has reduced the number of incorrect diagnoses Still, in some cases diagnostic laparotomy or laparoscopy is required The most common causes of diagnostic confusion are gastroenteritis and gynecologic disorders Viral gastroenteritis presents with nausea, vomiting, low-grade fever, and diarrhea and can be difficult to distinguish from appendicitis The onset of vomiting before pain makes appendicitis less likely As a rule, the pain of gastroenteritis is more generalized and the tenderness less well localized Acute salpingitis or tubo-ovarian abscess should be considered in young, sexually active women with fever and bilateral abdominal or pelvic tenderness A twisted ovarian cyst may also cause sudden severe pain The sudden onset of lower abdominal pain in the middle of the menstrual cycle suggests mittelschmerz Sudden severe abdominal pain with diffuse pelvic tenderness and shock suggests a ruptured ectopic pregnancy A
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The mortality rate from uncomplicated appendicitis is extremely low Even with perforated appendicitis, the mortality rate in most groups is only 02%, though it approaches 15% in the elderly
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Dominguez EP et al Diagnosis and management of diverticulitis and appendicitis Gastroenterol Clin North Am 2006 Jun; 35(2):367 91 [PMID: 16880071]
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Intestinal tuberculosis is common in underdeveloped countries Previously rare in the United States, its incidence has been rising in immigrant groups and patients with AIDS It is caused by both Mycobacterium tuberculosis and M bovis Active pulmonary disease is present in less than 50% of patients The most frequent site of involvement is the ileocecal region; however, any region of the gastrointestinal tract may be involved Intestinal tuberculosis may cause mucosal ulcerations or scarring and fibrosis with narrowing of the
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Gastrointestinal Disorders
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lumen Patients may be without symptoms or complain of chronic abdominal pain, obstructive symptoms, weight loss, and diarrhea An abdominal mass may be palpable Complications include intestinal obstruction, hemorrhage, and fistula formation The purified protein derivative (PPD) skin test may be negative, especially in patients with weight loss or AIDS Barium radiography may demonstrate mucosal ulcerations, thickening, or stricture formation Colonoscopy may demonstrate an ulcerated mass, multiple ulcers with steep edges and adjacent small sessile polyps, small ulcers or erosions, or small diverticula, most commonly in the ileocecal region The differential diagnosis includes Crohn s disease, carcinoma, and intestinal amebiasis The diagnosis is established by either endoscopic or surgical biopsy revealing acid-fast bacilli, caseating granuloma, or positive cultures from the organism Detection of tubercle bacilli in biopsy specimens by PCR is now the most sensitive means of diagnosis Treatment with standard antituberculous regimens is effective
Sato S et al Colonoscopy in the diagnosis of intestinal tuberculosis Gastrointest Endosc 2004 Mar;59(3):362 8 [PMID: 14997132]
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