Appendicitis



Appendicitis


Bruce Minnes



Introduction



  • Most common nontraumatic condition requiring emergency abdominal surgery in children and adolescents


  • Missed appendicitis or delays to diagnosis are among the common scenarios resulting in a complaint or lawsuit regarding ED care


  • May present at any age, but most common in second and third decades (peak incidence 9-12 years)


  • ˜1 in 15 lifetime risk of developing appendicitis


  • M:F ratio is 2:1


  • Incidence of perforation at diagnosis is highest in children < 1 yr (almost 100%), 94% < 2 yrs, and 60-65% < 6 yrs


  • Mortality rate 0.1% (nonperforated), 3-5% (perforated)


  • Young children can progress to perforation rapidly within 6-12 hrs from symptom onset


  • Need a high index of suspicion


Pathophysiology



  • Lumen of the appendix vermiformis becomes obstructed


  • Less likely in infants due to primitive shape and relative lack of lymphoid tissue in appendix


  • Obstruction commonly caused by



    • Hypertrophied lymphatic tissue: seen with viral illnesses


    • Fecaliths, parasites, fruit or vegetable material


  • Obstruction leads to venous engorgement, inflammation, and eventual necrosis and perforation


  • In adolescents and adults, omentum may help to “wall-off” appendicitis


  • Omentum less developed in young children, leading to a higher likelihood of diffuse peritonitis and increased morbidity and mortality



Clinical Presentation



  • Classic symptoms: abdominal pain, low-grade fever, and vomiting


  • Abdominal pain



    • Typically dull or achy at onset, later colicky, crampy, and finally constant


    • Initially periumbilical or epigastric, later localized to right lower quadrant as parietal peritoneum becomes irritated


  • Anorexia and nonbilious emesis


  • Some degree of fever is often present


  • In many cases, atypical symptoms may occur and lead to misdiagnosis


  • Urinary frequency and dysuria if inflamed appendix is close to the ureter and bladder


  • Diarrhea (frequent, small volume, and loose stools) and tenesmus (fecal urgency) may occur in retrocecal appendicitis or if appendix is near a segment of colon


Physical Examination

Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Appendicitis

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