What causes appendixes to burst - trivia question /questions answer / answers
Appendicitis
From Wikipedia, the free encyclopedia
(Redirected from Ruptured appendix)
Appendicitis (also called
epityphlitis[1]) is
inflammation of the
appendix. Appendicitis commonly presents with right
iliac fossa abdominal pain,
nausea,
vomiting, and
decreased appetite.
[2] However, one third to a half of persons do not have these typical signs and symptoms.
[3] Severe complications of a ruptured appendix include wide spread, painful
inflammation of the inner lining of the abdominal wall and
sepsis.
[4]
Appendicitis is caused by a blockage of the
hollow portion of the appendix,
[5][6] most commonly by a
calcified "stone" made of feces. However inflamed
lymphoid tissue from a viral infection,
parasites, gallstone or
tumors may also cause the blockage.
[7]
This blockage leads to increased pressures within the appendix,
decreased blood flow to the tissues of the appendix, and bacterial
growth inside the appendix causing inflammation.
[7][8]
The combination of inflammation, reduced blood flow to the appendix and
distention of the appendix causes tissue injury and tissue death.
[9]
If this process is left untreated, the appendix may burst, releasing
bacteria into the abdominal cavity, leading to severe abdominal pain and
increased complications.
[9][10]
The diagnosis of appendicitis is largely based on the person's signs and symptoms.
[8]
In cases where the diagnosis cannot be made based on the person's
history and physical exam, close observation, radiographic imaging and
laboratory tests can often be helpful.
[11] The two most common imaging tests used are
ultrasound and
computer tomography (CT scan).
[11] CT scan has been shown to be more accurate than ultrasound in detecting acute appendicitis.
[12][13]
However, ultrasound may be preferred as the first imaging test in
children and pregnant women due to the risks associated with radiation
exposure from CT scans.
[11]
The standard treatment for acute appendicitis is
surgical removal of the appendix.
[7][8] This may be done by an
open incision in the abdomen or through a few
smaller incisions with the help of cameras. Surgery decreases the risk of side effects or death associated with rupture of the appendix.
[4] Antibiotics may be equally effective in certain cases of non-ruptured appendicitis.
[14] It is one of the most common and significant causes of severe abdominal
pain that comes on quickly worldwide. In 2013 it resulted in 72,000 deaths globally.
[15] In the United States, appendicitis is the most common cause of acute abdominal pain requiring surgery.
[2] Each year in the United States, more than 300,000 persons with appendicitis have their appendix surgically removed.
[16] Reginald Fitz is credited with being the first person to describe the condition in a paper published in 1886.
[17]
Signs and symptoms
Pain first, nausea and vomiting next, and fever last has been
described as the classic presentation of acute appendicitis. Because the
innervation of the appendix enters the
spinal cord at the same level as the
umbilicus
(belly button), the pain begins stomach-high. As the appendix becomes
more swollen and inflamed, it begins to irritate the adjoining abdominal
wall. This leads to the localization of the pain to
the right lower quadrant.
This classic migration of pain may not be seen in children under three
years. This pain can be elicited through various signs and can be
severe. Signs include localized findings in the right
iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (
palpation). Also, there is severe pain on sudden release of deep pressure in the lower abdomen (
rebound tenderness). If the appendix is retrocecal (localized behind the
cecum), even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix). This is because the
cecum,
distended with gas, protects the inflamed appendix from pressure.
Similarly, if the appendix lies entirely within the pelvis, there is
usually complete absence of abdominal rigidity. In such cases, a digital
rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (
McBurney's point).
Causes
Based on experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendiceal
lumen.
[5][6] Once this obstruction occurs, the appendix becomes filled with
mucus
and swells. This continued production of intra-lumenal mucus leads to
increased pressures within the lumen and the walls of the appendix. This
increased pressure results in
thrombosis and
occlusion of the small vessels, and stasis of
lymphatic flow. At this point spontaneous recovery rarely occurs. As the occlusion of blood vessels progresses, the appendix becomes
ischemic and then
necrotic. As
bacteria begin to leak out through the dying walls,
pus
forms within and around the appendix (suppuration). The end result of
this cascade is appendiceal rupture (a 'burst appendix') causing
peritonitis, which may lead to
sepsis and eventually
death. This cascade of events is responsible for the slowly evolving abdominal pain and other commonly associated symptoms.
[9]
The causative agents include
bezoars, foreign bodies,
trauma,
intestinal worms,
lymphadenitis, and, most commonly, calcified fecal deposits that are known as appendicoliths or fecaliths.
[18] The occurrence of
obstructing fecaliths has attracted attention since their presence in persons with appendicitis is higher in developed than in developing countries.
[19] In addition an appendiceal fecalith is commonly associated with complicated appendicitis.
[20]
Also, fecal stasis and arrest may play a role, as demonstrated by
persons with acute appendicitis having fewer bowel movements per week
compared with healthy controls.
[21][22]
The occurrence of a fecalith in the appendix was thought to be
attributed to a right-sided fecal retention reservoir in the colon and a
prolonged transit time. However a prolonged transit time was not
observed in subsequent studies.
[23]
From epidemiological data, it has been stated that diverticular disease
and adenomatous polyps were unknown and colon cancer exceedingly rare
in communities exempt from appendicitis.
[24][25] Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum.
[26] Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis.
[27][28][29]
This low intake of dietary fiber is in accordance with the occurrence
of a right-sided fecal reservoir and the fact that dietary fiber reduces
transit time.
[30]
Diagnosis
Diagnosis is based on a medical history (symptoms) and physical examination which can be supported by an elevation of
neutrophilic
white blood cells and imaging studies if needed. (Neutrophils are the
primary white blood cells that respond to a bacterial infection.)
Histories fall into two categories, typical and atypical. Typical
appendicitis includes several hours of generalized abdominal pain which
begins in the region of the umbilicus with associated
anorexia,
nausea, or vomiting. The pain then "localizes" into the right lower
quadrant where the tenderness increases in intensity. However it is
possible the pain could localize to
the left lower quadrant in persons with
situs inversus totalis.
The combination of pain, anorexia, leukocytosis, and fever is classic.
Atypical histories lack this typical progression and may include pain in
the right lower quadrant as an initial symptom. Irritation of the
peritoneum (inside lining of the abdominal wall) can lead to increased
pain on movement, or jolting, for example going over speedbumps.
[31] Atypical histories often require imaging with ultrasound and/or CT scanning.
[32]
Clinical
- Aure-Rozanova sign: Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg's)
- Bartomier-Michelson's sign: Increased pain on palpation at the right
iliac region as the person being examined lies on his/her left side
compared to when he/she lies on his/her back.
- Dunphy's sign: Increased pain in the right lower quadrant with coughing.[33]
- Kocher's (Kosher's) sign: From the person's medical history, the
start of pain in the umbilical region with a subsequent shift to the
right iliac region.
- Massouh sign:
Developed in and popular in southwest England, the examiner performs a
firm swish with his/her index and middle finger across the abdomen from
the Xiphoid process
to the left and the right iliac fossa. A positive Massouh sign is a
grimace of the person being examined upon a right sided (and not left)
sweep.
- Obturator sign:
The person being evaluated lies on her/his back with the hip and knee
both flexed at ninety degrees. The examiner holds the person's ankle
with one hand and knee with the other hand. The examiner rotates the hip
by moving the person's ankle away from the his/her body while allowing
the knee to move only inward. A positive test is pain with internal
rotation of the hip.
- Psoas sign:
Also known as the "Obraztsova's sign" is right lower-quadrant pain that
is produced with either the passive extension of the right hip or by
the active flexion of the person's right hip while supine. The pain that
is elicited is due to inflammation of the peritoneum overlying the
iliopsoas muscles and inflammation of the psoas muscles themselves.
Straightening out the leg causes pain because it stretches these
muscles, while flexing the hip activates the iliopsoas and therefore
also causes pain.
- Rovsing's sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa
upwards (counterclockwise along the colon). The thought is there will
be increased pressure around the appendix by pushing bowel contents and
air towards the ileocaecal valve provoking right sided abdominal pain.[34]
- Sitkovskiy (Rosenstein)'s sign: Increased pain in the right iliac
region as the person is being examined lies on his/her left side.
Blood and urine test
While there is no laboratory test specific for appendicitis, a
complete blood count
(CBC) is done to check for signs of infection. Although 70-90 percent
of people with appendicitis may have an elevated white blood cell (WBC)
count, there are many other abdominal and pelvic conditions that can
cause the WBC count to be elevated.
[35]
A
urinalysis generally does not show infection but it is important for determining pregnancy status, especially the possibility of an
ectopic pregnancy
in woman of childbearing age. The urinalysis is also important for
ruling out a urinary tract infection as the cause of abdominal pain. The
presence of more than 20 WBC per high-power field in the urine is more
suggestive of a urinary tract disorder.
[35]
Imaging
In children the clinical examination is important for determination
of which children with abdominal pain should receive immediate surgical
consultation and which should receive diagnostic imaging.
[36]
Because of the health risks of exposing children to radiation,
ultrasound is the preferred first choice with CT-scan being a legitimate
follow-up if the ultrasound is inconclusive.
[37][38][39] CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a
sensitivity of 94%,
specificity of 95%. Ultrasonography had an overall
sensitivity of 86%, a
specificity of 81%.
[40]
Ultrasound
Ultrasound image of acute appendicitis
Ultrasonography and
Doppler sonography
provide useful means to detect appendicitis, especially in children.
Ultrasound can also show free fluid collection in the right iliac fossa,
along with a visible appendix without blood flow when using color
Doppler. In some cases (15% approximately), however, ultrasonography of
the
iliac fossa
does not reveal any abnormalities despite the presence of appendicitis.
This false negative finding is especially true of early appendicitis
before the appendix has become significantly distended. In addition
false negative findings are more common in adults where larger amounts
of fat and bowel gas make visualizing the appendix technically
difficult. Despite these limitations, sonographic imaging in experienced
hands can often distinguish between appendicitis and other diseases
with similar symptoms. Some of these conditions include
inflammation of
lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or fallopian tubes.
Computed tomography
A CT scan demonstrating acute appendicitis (note the appendix has a diameter of 17.1mm and there is surrounding fat stranding.)
A
fecalith marked by the arrow which has resulted in acute appendicitis.
Where it is readily available,
computed tomography
(CT scan) has become frequently used, especially in adults whose
diagnosis is not obvious on history and physical examination. Concerns
about radiation, however, tend to limit use of CT in pregnant women and
children. A properly performed CT scan with modern equipment has a
detection rate (sensitivity) of over 95%, and a similar
specificity.
Signs of appendicitis on CT scan include lack of oral contrast (oral
dye) in the appendix, direct visualization of appendiceal enlargement
(greater than 6 mm in cross-sectional diameter), and appendiceal wall
enhancement with IV contrast (IV dye). The inflammation caused by
appendicitis in the surrounding peritoneal fat (so called "fat
stranding") can also be observed on CT, providing a mechanism to detect
early appendicitis and a clue that appendicitis may be present even when
the appendix is not well seen. This is the most reliable sign for
appendicitis. Thus, diagnosis of appendicitis by CT is made more
difficult in very thin persons and in children, both of whom tend to
lack significant fat within the abdomen. The utility of CT scanning is
made clear, however, by the impact it has had on negative
appendectomy
rates. For example, use of CT for diagnosis of appendicitis in Boston,
MA has decreased the chance of finding a normal appendix at surgery from
20% in the pre-CT era to only 3% according to data from the
Massachusetts General Hospital.
X–Ray
In general, plain abdominal radiography (PAR) is not useful in making
the diagnosis of appendicitis and should not be routinely obtained in a
person being evaluated for appendicitis.
[41][42] Plain abdominal films may be useful for the detection of
ureteral calculi,
small bowel obstruction, or
perforated ulcer, but these conditions are rarely confused with appendicitis.
[43] An opaque
fecalith can be identified in the right lower quadrant in less than 5% of persons being evaluated for appendicitis.
[35] A
barium enema
has proven to be a poor diagnostic tool for appendicitis. While failure
of the appendix to fill during a barium enema has been associated with
appendicitis, up to 20% of normal appendices also do not fill.
[43]
Scoring systems
Alvarado score
A number of clinical and laboratory-based scoring systems have been devised to assist diagnosis. The most widely used is
Alvarado score. A score below 5 is strongly against a diagnosis of appendicitis,
[44]
while a score of 7 or more is strongly predictive of acute
appendicitis. In a person with an equivocal score of 5 or 6, a CT scan
is used to reduce the rate of negative appendicectomy.
Tzanakis scoring
Tzanakis scoring: Tzanakis and colleagues, in 2005 published a
simplified system, now called the Tzanakis scoring system for
appendicitis, to aid the diagnosis of appendicitis. It incorporates the
presence of four variables made up of specific signs and symptoms,
laboratory findings, as well as ultrasound findings to compute a scoring
to predict the presence of appendicitis. The maximum score is a total
score of 15. When a person with suspected appendicitis scores 8 or more
points, there is greater than 96% chance that appendicitis exists.
Tzanakis score
| Right lower abdominal tenderness |
4 points |
| Rebound tenderness |
3 points |
| White blood cells greater than 12,000 |
2 points |
| Positive ultrasound scan findings of appendicitis |
6 points |
| Total score |
15 points |
Pathology
The definitive diagnosis is based on
pathology. The
histologic finding of appendicitis is
neutrophilic infiltrate of the
muscularis propria.
Periappendicits,
inflammation of tissues around the appendix, is often found in conjunction with other abdominal pathology.
[45]
Differential diagnosis
Children:
Gastroenteritis,
mesenteric adenitis,
Meckel's diverticulitis,
intussusception,
Henoch-Schönlein purpura, lobar
pneumonia,
urinary tract infection (abdominal pain in the absence of other symptoms can occur in children with UTI), new-onset
Crohn's disease or
ulcerative colitis,
pancreatitis, and abdominal trauma from
child abuse;
distal intestinal obstruction syndrome in children with cystic fibrosis;
typhlitis in children with leukemia.
Women: A pregnancy test is important in all women of child bearing age, as
ectopic pregnancies and appendicitis present similar symptoms. Other causes
pelvic inflammatory disease,
ovarian torsion,
menarche, dysmenorrhea,
pelvic inflammatory disease,
endometriosis,
Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle).
[46]
Men:
testicular torsion;
Adults: new-onset
Crohn's disease,
ulcerative colitis, regional enteritis,
renal colic, perforated
peptic ulcer,
pancreatitis,
rectus sheath hematoma;
Elderly:
diverticulitis, intestinal obstruction,
colonic carcinoma,
mesenteric ischemia, leaking
aortic aneurysm.
The term "pseudoappendicitis" is used to describe a condition mimicking appendicitis.
[47] It can be associated with
Yersinia enterocolitica.
[48]
Management
Acute appendicitis is typically managed by
surgery however in uncomplicated cases
antibiotics are both effective and safe.
[14]
While antibiotics are effective for treating uncomplicated appendicitis
20% of people had a recurrence within a year and required eventual
appendectomy.
[14]
Pain
Pain medications (such as
morphine)
do not appear to affect the accuracy of the clinical diagnosis of
appendicitis and therefore should be given early in the person's care.
[49]
Historically there were concerns among some general surgeons that
analgesics would affect the clinical exam in children and thus some
recommended that they not be given until the surgeon in question was
able to examine the person for themselves.
[49]
Surgery
Inflamed appendix removal by open surgery
Laparoscopic appendectomy.
The
surgical procedure for the removal of the appendix is called an
appendicectomy.
Laparoscopic
removal (via three small incisions with a camera to visualize the area
of interest in the abdomen) seem to have some advantages over an open
procedures especially in young females and the obese.
[50]
Laparotomy
Laparotomy is the traditional type of surgery used for treating
appendicitis. This procedure consists in the removal of the infected
appendix through a single larger incision in the lower right area of the
abdomen.
[51]
The incision in a laparotomy is usually 2 to 3 inches (51 to 76 mm)
long. This type of surgery is used also for visualizing and examining
structures inside the
abdominal cavity and it is called exploratory laparotomy.
During a traditional appendectomy procedure, the person with suspected appendicitis is placed under general
anesthesia
to keep the muscles completely relaxed and to keep the person
unconscious. The incision is two to three inches (76 mm) long and it is
made in the right lower abdomen, several inches above the
hip bone.
[52] Once the incision opens the abdomen cavity and the appendix is identified, the
surgeon
removes the infected tissue and cuts the appendix from the surrounding
tissue. After careful and close inspection of the infected area, and
ensuring there are no signs that surrounding tissues are damaged or
infected, the surgeon will start closing the incision. This means sewing
the muscles and using
surgical staples or
stitches to close the skin up. In order to prevent infections the incision is covered with a
sterile bandage.
The entire procedure does not last longer than an hour if complications do not occur.
Laparoscopic
The newer method to treat appendicitis is the
laparoscopic surgery.
This surgical procedure consists of making three to four incisions in
the abdomen, each 0.25 to 0.5 inches (6.4 to 12.7 mm) long. This type of
appendectomy is made by inserting a special surgical tool called
laparoscope into one of the incisions. The laparoscope is connected to a
monitor outside the person's body and it is designed to help the
surgeon to inspect the infected area in the abdomen. The other two
incisions are made for the specific removal of the appendix by using
surgical instruments. Laparoscopic surgery also requires
general anesthesia and it can last up to two hours. The latest methods are
NOTES
appendectomy pioneered in Coimbatore, India where there is no incision
on the external skin and SILS (single incision laparoscopic surgery)
where a single 2.5 cm incision is made to perform the surgery.
Pre surgery
The treatment begins by
keeping the person who will be having surgery from eating or drinking for a given period of time, usually overnight. An intravenous drip is used to hydrate the person who will be having surgery.
Antibiotics given intravenously such as
cefuroxime and
metronidazole
may be administered early to help kill bacteria and thus reduce the
spread of infection in the abdomen and postoperative complications in
the abdomen or wound. Equivocal cases may become more difficult to
assess with antibiotic treatment and benefit from serial examinations.
If the stomach is empty (no food in the past six hours) general
anaesthesia is usually used. Otherwise,
spinal anaesthesia may be used.
Once the decision to perform an
appendectomy
has been made, the preparation procedure takes approximately one to two
hours. Meanwhile, the surgeon will explain the surgery procedure and
will present the risks that must be considered when performing an
appendectomy. With all surgeries there are certain risks that must be
evaluated before performing the procedures. However, the risks are
different depending on the state of the appendix. If the appendix has
not ruptured, the complication rate is only about 3% but if the appendix
has ruptured, the complication rate rises to almost 59%.
[53] The most usual complications that can occur are pneumonia,
hernia of the incision,
thrombophlebitis, bleeding or
adhesions.
Recent evidence indicates that a delay in obtaining surgery after
admission results in no measurable difference in outcomes to the person
with appendicitis.
[54]
The surgeon will also explain how long the recovery process should
take. Abdomen hair is usually removed in order to avoid complications
that may appear regarding the incision. In most of the cases persons
going in for surgery experience nausea or vomiting which requires
specific medication before surgery. Antibiotics along with pain
medication may also be administrated prior to appendectomies.
After surgery
The
stitches the day after having the appendix removed by laparoscopic surgery
Hospital lengths of stay typically range from a few hours to a few
days, but can be a few weeks if complications occur. The recovery
process may vary depending on the severity of the condition, if the
appendix had ruptured or not before surgery. Appendix surgery recovery
is generally a lot faster if the appendix did not rupture.
[55] It is important that persons undergoing surgery respect their doctor's advice and limit their physical activity so the
tissues can heal faster. Recovery after an appendectomy may not require diet changes or a lifestyle change.
After surgery occurs, the patient will be transferred to a
postanesthesia care unit
so his or her vital signs can be closely monitored to detect
anesthesia- and/or surgery-related complications. Pain medication may
also be administered if necessary. After patients are completely awake,
they are moved into a hospital room to recover. Most individuals will be
offered clear liquids the day after the surgery, then progress to a
regular diet when the intestines start to function properly. Patients
are recommended to sit up on the edge of the bed and walk short
distances for several times a day. Moving is mandatory and pain
medication may be given if necessary. Full recovery from appendectomies
takes about four to six weeks, but can be prolonged to up to eight weeks
if the appendix had ruptured.
Prognosis
Most persons with appendicitis recover easily after surgical
treatment, but complications can occur if treatment is delayed or if
peritonitis
occurs. Recovery time depends on age, condition, complications, and
other circumstances, including the amount of alcohol consumption, but
usually is between 10 and 28 days. For young children (around 10 years
old), the recovery takes three weeks.
The real possibility of life-threatening peritonitis is the reason
why acute appendicitis warrants speedy evaluation and treatment. Persons
with suspected appendicitis may have to undergo a
medical evacuation.
Appendectomies have occasionally been performed in emergency conditions
(i.e., not in a proper hospital), when a timely medical evaluation was
impossible.
Typical acute appendicitis responds quickly to appendectomy and
occasionally will resolve spontaneously. If appendicitis resolves
spontaneously, it remains controversial whether an elective interval
appendectomy should be performed to prevent a recurrent episode of
appendicitis. Atypical appendicitis (associated with suppurative
appendicitis) is more difficult to diagnose and is more apt to be
complicated even when operated early. In either condition, prompt
diagnosis and appendectomy yield the best results with full recovery in
two to four weeks usually. Mortality and severe complications are
unusual but do occur, especially if peritonitis persists and is
untreated. Another entity known as appendicular lump is talked about
quite often. It happens when the appendix is not removed early during
infection and omentum and intestine adhere to it, forming a palpable
lump. During this period, surgery is risky unless there is pus formation
evident by fever and toxicity or by USG. Medical management treats the
condition.
An unusual complication of an appendectomy is "stump appendicitis":
inflammation occurs in the remnant appendiceal stump left after a prior
incomplete appendectomy.
[56]
Epidemiology
Disability-adjusted life year for appendicitis per 100,000 inhabitants in 2004.
[57]
no data
less than 2.5
2.5-5
5-7.5
7.5-10
10-12.5
12.5-15
15-17.5
17.5-20
20-22.5
22.5-25
25-27.5
more than 27.5
Appendicitis is most common between the ages of 5 and 40;
[58]
the median age is 28. It tends to affect males, those in lower income
groups, and, for unknown reasons, people living in rural areas.
[59] In 2013 it resulted in 72,000 deaths globally down from 88,000 in 1990.
[15]
In the United States, there were nearly 293,000 hospitalizations involving appendicitis in 2010.
[10]
Appendicitis is one of the most frequent diagnoses for emergency
department visits resulting in hospitalization among children aged 5–17
years in the United States.
[60]
Society and culture
Length of stay
Length of hospital stays for appendicitis varies on the severity of
the condition. A study from the United States found that in 2010, the
average appendicitis hospital stay was 1.8 days. For stays where the
person's appendix had ruptured, the average length of stay was 5.2 days.
[10]
References
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