Acute appendicitis is inflammation of appendix. It is the most common cause of surgical emergency worldwide. It most often affect the children, teenagers and young adult but may also affect the extreme ages like infants and elderly (rare). Lifetime incidence is 6%.

If someone presented to hospital with the complaint of crampy and colicky abdominal pain then followed by severe pain at right lower abdomen, appendicitis should always be suspected if the appendix not yet been removed previously.

 How it occur? 

It usually occurs when there is an obstruction in the lumen of the appendix. The guts organism will invade the appendix wall after the obstruction occurs. This will cause the inflammation of the appendix or in other words, appendicitis.

 What can block the lumen and cause obstruction? 

• Faecolith (faecal material)
• Foreign body like filarial worms
• Enlargement of lymphoid follicles (lymphoid hyperplasia)
• Carcinoma of the caecum (rarer cause)

 Morphology: 

• Early acute appendicitis exhibits scant neutrophil exudations throughout the mucosa, submucosa and muscularis. Subserosal vessels will become congested. Perivascular emigration will occur.
• Advanced acute appendicitis exhibits more severe neutrophilic infiltration and fibropurulent serosal exudates. Luminal abscess formation with ulceration and suppurative necrosis occur. Later, gangrenous necrosis will occur followed by appendix rupture.

 Symptoms and signs: 

·        Then become central abdominal cramping or colicky pain

·        Nausea (vomiting might not present)

·        Loose stool occasionally but frank diarrhea is not common.

·        Followed by severe abdominal pain at right iliac fossa region (McBurney’s point)

·        Pain worsen by coughing or moving

·        You might have low grade fever (37.2-37.8%)

·        Flushed

·        Characteristic fetor (sweet faecal smell to breath)

·        White furred tongue

·        Tachycardia (heart rate <100 beat per minute during the first 24 hours)

·        Tender and guarding at right iliac fossa region.

·        In elderly patients, they might present with confusion and develop shock later.

·        Per rectal examination may reveal tender anteriorly in the rectovesical or rectouterine pouch.

 Variations in the clinical picture: 

• The schoolboy with vague abdominal pain who will not eat his favorite food. For example, the boy really likes burger however he refuses to eat burger at this time. (I remember we use to call it ‘burger sign’ when we were at medical school)

 Investigations: 

• Total white cell count : >10
• Ultrasound scan of abdomen : may show a mass or abscess (not useful in early appendicitis)
• Urine FEME : to rule out urinary tract infection
• Surgically removed appendix should be sent for histology investigation. It may be normal.

Usually, acute appendicitis is diagnosed clinically and ultrasound scan of abdomen is rarely done.

 Treatment: 

• Appendicectomy (removal of appendix laparascopically or by open surgery)
• Prophylactic antibiotic like metronidazole and cefuroxime should be given before the surgery to reduce the risk of wound infection.
• If appendix mass is present, the patient will be treated conservatively with antibiotic and intravenous fluid. The pain usually reduces after few days and the mass disappear within few weeks.
• Interval appendicectomy is recommended later to prevent further acute episode of appendicitis.

 Complications: 

Appendicitis may resolve spontaneously. However, some complications may happen.

• The appendix may become surrounded by adjacent small bowel and omentum and develop an appendix mass.
• The appendix might perforate and develop generalized peritonitis (the inflammation of peritoneum)
• Local adhesion may happen and give rise to appendix abscess
• If peritonitis and abscess is not treated, the patient may develop septicemia. This can lead to death.
• Other possible complications are pyelophlebitis, thrombosis of portal venous drainage and liver abscess.
• If the symptoms have been present for 48 hours and the patient has been diagnose with appendicitis, and then the patient should develop either the appendix mass or generalized peritonitis. This is what the doctor called ’48 hour rule’. If neither of these occurs, the diagnosis should be review; it might not be an acute appendicitis after all.

 So, if it is not acute appendicitis, what is it? 

Some differential diagnosis of acute appendicitis:

·        Ectopic pregnancy

·        Mesenteric adenitis

·        Food poisoning

·        Diverticulitis

·        Salpingitis

·        Cholecystitis

·        Perforated duodenal ulcer

·        Cystitis

·        Crohn’s disease

  Special conditions: 

1)   Acute appendicitis in children:

• Rare under age of 6 months
• In infants, they might only presented with vomiting and diarrhea (that might be mistaken with acute gastroenteritis)

2)   Acute appendicitis during pregnancy:

• This is no commoner than at other times
• Pain and tenderness are worse (the enlarge uterus will displace the appendix)
• There is a risk of abortion if appendicitis occurs at first trimester.
• However, treatment should not be delayed. If perforation occurs, the risk of mortality and morbidity will increase up to 25%.

 Reference:

•  
  1. Churchill’s Pocketbook of Surgery. Andrew T Raftery. Second edition.2001.
  2. Oxford Handbook of Clinical Medicine. 4^th edition. 1998.
  3. Clinical Medicine by Kumar and Clark. 4^th edition.1998.
  4. Robbins Pathologic Basis of Disease. 5^th edition. 1995.

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