Kembara Xtra - Medicine - Acute Appendicitis

Kembara Xtra - Medicine - Acute Appendicitis 
​Acute inflammation of the appendix is described as simple or uncomplicated appendicitis when there are no radiologic or clinical signs of a perforation. An imaging finding of a phlegmon or abscess along with a palpable mass characterizes complicated or perforated appendicitis.
● The appendix is located in the pelvis and arises from the base of the cecum in the right lower quadrant (RLQ). It can also be anterior, posterior, medial, or lateral to the cecum.
A branch of the ileocolic artery called the appendicular artery provides vascular supply, and the superior mesenteric plexus provides nerve supply. The most typical reason for acute surgical abdomen

EPIDEMIOLOGY - Predominant age: 10 to 30 years; uncommon in infancy - Predominant sex: somewhat more men than women (3:2) - Ages 10 to 30 years
- Male = female if above 30 years old.
Lifetime incidence is 1 in every 15 persons (7%) and incidence is 1 case per 1,000 people each year. 

Pregnancy considerations include: High probability of perforation; more likely to present with peritonitis; Most common extrauterine surgical emergency; Similar incidence in pregnancy.

PATHOPHYSIOLOGY AND ETIOLOGY

Distention, ischemia, and bacterial overgrowth are hypothesized to be caused by obstruction of the appendiceal lumen. Appendicitis, if left untreated, can result in perforation and the development of an abscess or widespread peritonitis.
Fecaliths are the most frequent cause of obstruction, followed by children's lymphoid tissue hyperplasia and vegetable, fruit, and other foreign materials. 
Ascarides that live in the digestive tract Fibrosis, tumors, and strictures
Genetics No clear genetic link has been discovered, but having a first-degree relative with a history of appendicitis increases risk.

RISK ELEMENTS

male adolescents, intra-abdominal cancers, and familial predisposition

DIAGNOSIS A diagnosis is made based on a patient's medical history, physical examination, and any necessary imaging or laboratory tests.
Modified Alvarado Scoring System (MASS) scoring systems The use of MASS in the diagnosis of acute appendicitis increases diagnostic precision and lowers the incidence of complications and negative appendectomy.
- Add additional tests (such an abdominal ultrasound or laparoscopy) to MASS in female patients.
- Right iliac fossa pain that is migratory (1 point)
- Vomiting/nausea (1 point)
1 point for anorexia
- Right iliac fossa tenderness (2 pts)
- Right iliac fossa rebound tenderness (1 point)
- A point-higher temperature
2 points for leukocytosis
- Appendicitis is suggested by a MASS score >7 without the requirement for additional imaging.
A CT is not necessary if the MASS score is 3 or lower because appendicitis is thought to be less likely. A CT scan is necessary to diagnose appendicitis in people with a MASS score of 4 to 6.
The MASS score cutoff point of 6 results in increased sensitivity but is also linked to a higher rate of negative appendectomy (normal appendix).
The Pediatric Appendicitis Score aids in anticipating the possibility of acute appendicitis (diagnosis is still clinical)

HISTORY
The typical history starts with nebulous periumbilical pain and progresses to anorexia, nausea, and vomiting. In the following 4 to 48 hours, discomfort moves to the RLQ.
Only 50% of patients have a traditional history when they first arrive.
Pre-vomiting discomfort (100 percent sensitive), stomach pain (100 percent), and pain migration (50 percent). 
Obesity (100%), anorexia (100%), sickness (90%), vomiting (75%), 
A retrocecal or pelvic appendix may be the cause of unusual symptoms and pain.

Fever, temperature >100.4°F (may not be present), and tachycardia on physical examination 
Tenderness in the RLQ; greatest tenderness at McBurney point (about 1/3 of the way between the anterior superior iliac spine and the umbilicus) 
Guarding, both conscious and unconscious; Rovsing sign: RLQ pain with palpation of left lower quadrant; Psoas sign: pain with extension of the right thigh; Obturator sign: pain with internal rotation of the right thigh; local and suprapubic pain on rectal examination; 
Exams of the pelvis and the rectal region can help diagnose conditions like pelvic inflammatory disease and prostatitis that are other causes of lower abdominal pain.
Serial exams may be helpful in cases that are not yet resolved.

Differential diagnoses include: gastroenteritis, inflammatory bowel disease, diverticulitis, ileitis, cholecystitis, pancreatitis, intussusception, and volvulus; gynecologic conditions include pelvic inflammatory disease and ectopic pregnancy; endometriosis; and graafian follicle rupture; urologic conditions include testicular torsion and epididymitis

Pediatric considerations include: increased fever; increased vomiting and diarrhea; decreased history-taking and physical exam diagnostic accuracy; and

pregnant women's issues
Pregnancy makes it more challenging to diagnose appendicitis since the body's natural inflammatory response is inhibited.
Gravid uterus causes appendix to be moved out of pelvic Geriatric Considerations
decreased diagnostic precision and unusual presentation more likely 

DETECTION & INTERPRETATION OF DIAGNOSIS

Initial examinations (lab, imaging)
WBC >10,000/mm3 (Leukocytosis: 70%) 
Polymorphonuclear predominance—"left shift" (> 90%) 
Hematuria and pyuria in urine tests (30%) 
hCG (human chorionic gonadotropin) (positive results rule out ectopic pregnancy.) 
When combined with a high WBC, the nonspecific inflammatory marker C-reactive protein improves the predictability of appendicitis. 
Antibiotics and steroids may affect the outcome of lab tests.
Imaging aids in the detection of complications (abscess, perforation) if the diagnosis is unclear. 
Plain films: limited value, general findings, and potential for fecalith visualization
CT with contrast: the preferred imaging modality, with sensitivity 91-98% and specificity 95-99%. Think about the radiation dose, especially for young patients.

In cases of suspected gynecologic pathology, in children, and in pregnant women, ultrasound is an option. The expertise of the ultrasonographer varies in terms of sensitivity and specificity.
Adult populations are being used more frequently, and some studies' positive predictive value is almost 100%. can reliably rule out appendicitis but not definitively.
Start with an ultrasound and, if negative, do a CT scan if there is cause for concern.
Pregnant patients are using MRIs more frequently. renal failure individuals with contrast allergy may benefit. Cost, availability, and the amount of time needed to finish the study are all restrictions.
Radioisotope-labeled WBC scans may be utilized as an alternative to observation or surgery in individuals with ambiguous CT scans and probable appendicitis. Limitations include time needed for study and availability.
Laparotomy/laparoscopy for diagnostic purposes or other exploratory purposes. Depending on age and gender, acceptable appendectomy rates may be greater in women of childbearing age than in men.
Interpretation of Tests
Gangrene, perforation with abscess (15–30%), localized vascular congestion, blockage, and acute appendiceal irritation

GENERAL MEASURES/TREATY
The gold standard of treatment for acute, uncomplicated appendicitis has been surgery (appendectomy). Growing evidence supports the use of antibiotic medication as medical management in some situations, with appendectomy reserved for patients who do not respond to treatment.
Increased difficulties and expense are linked to postponing surgery for severe appendicitis.
For severe or perforated appendicitis with abscess formation of less than 3 cm, surgery is advised. Percutaneous drainage and antibiotics are advised for drainable abscesses that are larger than 3 cm.
The Alvarado score is unaffected by pain management, nor does it greatly enhance the likelihood of unneeded or delayed interventions.

First Line: MEDICATION
Uncomplicated acute appendicitis: single dose of cefoxitin, ampicillin/sulbactam (Unasyn), or cefazolin + metronidazole as the perioperative antibiotic
The preferred nonoperative antibiotic is ertapenem for three days, followed by seven days of oral levofloxacin and metronidazole.
Gangrenous or perforating appendicitis – Broadened antibiotic coverage for aerobic and anaerobic enteric pathogens – Piperacillin and tazobactam (Zosyn), ticarcillin and clavulanate (Timentin), or a third-generation cephalosporin plus metronidazole are initial possibilities.
- Based on intraoperative cultures, modify the antibiotic dosage and selection.
– Until the patient becomes afebrile and has a normal WBC count, antibiotics should be continued for at least 7 days following surgery.

Next Line
Clindamycin combined with ciprofloxacin, levofloxacin, gentamicin, or aztreonam for uncomplicated acute appendicitis 
Some studies indicate that the use of antibiotics alone during the first stage of conservative treatment for pediatric patients with acute appendicitis accompanied by abscess formation or phlegmon carries less risks and complications than emergency appendectomy.
Gangrenous or perforated appendicitis: ciprofloxacin or levofloxacin in combination with metronidazole, or carbapenem monotherapy (imipenem with cilastatin, meropenem, ertapenem) ISSUES FOR REFERRAL
Appendicitis calls for urgent surgical consultation in every case.

SURGICAL AND OTHER PROCEDURE
Surgery is advised as the preferred course of treatment by the American College of Surgeons, Society for Surgery of the Alimentary Tract, and others.
In some cases or when surgery is not appropriate, antibiotic therapy may be utilized instead.
The nonoperative treatment of uncomplicated acute appendicitis with antibiotics has a reported 5 year recurrence rate of up to 39%.


CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING
All appendicitis patients should be admitted.
Fluid resuscitation using lactated Ringer solution (LR) or normal saline (NS) 
Make up for electrolyte and hydration deficiencies.
Discharge upon acceptance of oral intake, restoration of bowel movements, afebrile condition, and normal WBC.

CONTINUING CARE AFTERCARE RECOMMENDATIONS
Most cases of uncomplicated appendicitis result in a return to work within 1 to 2 weeks.
Limit your activities for 4 to 6 weeks following surgery. Avoid heavy lifting (10 lbs or more) and severe exercise.
If a patient is managed non-operatively and is older than 40, a colonoscopy may be recommended to rule for cancer.

EDUCATION OF PATIENTS
Anorexia, nausea, and vomiting are post-operative warning signals, along with abdominal pain, fever, and chills.
Manifestations of a wound infection

PROGNOSIS Generally straightforward course in young adults with unruptured appendicitis Mortality and morbidity are increased by extreme ages and appendiceal rupture.
Nonperforated appendicitis morbidity rates: 3%
- Appendicitis with perforation: 47%
Mortality rates: 0.1% for appendicitis without rupture
- Appendicitis with a rupture: 3%
- Patients over 60 account for 50% of all appendicitis deaths.
- 15% of older adults with an appendix rupture
Child Safety Considerations

Early rupture; Rupture rate: 15–60%

pregnant women's issues
Fetal mortality rate: 2-8.5% Rupture rate: 40%

Aspects of Geriatrics
Ratio of rupture: 67-90%

Incisional hernia, paralytic ileus, intestinal blockage, and intestinal fistulas are among the complications. 
Stump appendicitis: recurrence of appendicitis at appendiceal stump following appendectomy; incidence 0.15%; liver abscess (rare), pyelophlebitis.