Acute Appendicitis & Peritonitis
Appendicitis is an acute condition that is most commonly seen in the second and third decades of life. It is relatively rare at the extremes of life and in children under the age of 4 years. The specific cause of appendicitis has not been fully clarified and luminal obstruction is present in less than 40% of cases. Even today, it is, for the most part, a clinical diagnosis.
Intestinal parasites like Pinworms (Enterobius vermicularis), Ascaris and Taenia may obstruct the lumen. In terms of cause and effect regarding pinworms has not been well established. Ascariasis (A. lumbricoides) is the largest nematode that parasitizes man and can measure over 40 cm (1 inch = 2.54 cm). Ascaris is a common infection in Mexico, Central and South America (tropical and subtropical areas).
The sequence of events in appendicitis is of great clinical importance. The initial symptom is invariably epigastric/periumbilical pain that is relatively mild. At times, the patient may report urinary frequency if the inflamed appendix lies near the bladder. Diarrhea may be reported (usually there is none) because of an urge to defecate as a result of the inflamed appendix being next to the sigmoid. If the inflamed appendix is in juxtaposition to the psoas muscle, the child may report pain with walking.
The initial visceral pain over the epigastric (E) or around the belly button progresses to somatic pain (very painful) as the inflammation spreads to the parietal peritoneal surfaces. This somatic pain is made worse (aggravated) by coughing, sneezing or motion and it is located over the right lower quadrant (asterisk).
The onset of nausea and vomiting occur after the onset of abdominal pain, rarely before. The physical exam reveals rebound tenderness. If the examiner gently pushes over the right lower quadrant (asterisk) and releases the pressure, the patient typically reports pain.
Early on, there may be no fever especially if the patient is Immunocompromised or elderly. A CBC and a KUB are rarely helpful.
Rarely are these patients hungry and at times one may note ketones in the urine because of the anorexia. If the urine reveals ketones and sugar, the clinician must consider Type I Diabetes Mellitus and properly evaluate the patient.
Kidney stones typically cause a different clinical presentation and the pain radiates from the flank down to pubic area or testicle and the urine usually shows hematuria (blood). A clinician must always consider a tubal pregnancy in the appropriate setting or pelvic inflammatory disease.
At first, typhoid fever may be confused with appendicitis, and it is often a clinical challenge. Patients with Typhoid (Enteric) fever may have diarrhea or constipation.
A ruptured ovarian cyst (graafian or corpus luteum) can present with severe pain and peritonitis. These relatively common conditions usually resolve with conservative measures and rarely is surgery required. A pregnancy test must be done.
Clinicians must consider pseudo-appendicitis (Acute Mesenteric Adenitis) due to Yersinia enterocolytica and Yersinia pseudotuberculosis. I have seen only one case of Meckel's diverticulitis.
The pathologist must report his true findings, even if they are negative for appendicitis. It is reasonable for a surgeon to have one "normal appendix" out every seven patients he operates for appendicitis. It improves our clinical skills.
In summary, the evaluation should include a urinalysis, pregnancy test and a pelvic exam in females. In males with abdominal pain, the testicles should always be checked for torsion.
Patients with the irritable bowel syndrome often think that they may have "appendicitis."
I am looking forward to writing my book on The Acute Abdomen. It will be very comprehensive and fascinating to the clinician.
This information is directed to licensed medical providers.
Luis Lomeli MD
Tags: Acute Appendicitis Tubal Pregnancy Typhoid Fever Pinworms Abdominal pain black widow Kidney Stones Luis Lomeli MD
