MBBS
In clinical practice, it is quite frequent to see cases with right iliac fossa pain. While other causes may be the culprit behind this, appendicitis stands as one common cause. Appendicitis is the most common cause of abdominal inflammation in the right lower quadrant and the most common surgical emergency.
Over 5% of the USA’s population gets appendicitis, and if left untreated, it can prove fatal. Appendicitis is more a disease of the developed world. It affects more people from developed countries than from developing ones.
Although the mechanism of the genetic link for appendicitis is yet to be discovered, people who have a family history of appendicitis are three fold at greater risk of developing appendicitis than those who have no family history of the disease.
Appendicitis is rare in children. The peak age of developing appendicitis is between 20 and 30. In the young population, men are affected twice more than women. With increasing age, both men and women have equal chances of developing appendicitis.
In this blog, I intend to discuss this disease, which occurs in an organ with apparently no known function but still makes up the most common surgical emergency.
Appendicitis, as the name implies, is an inflammation of the appendix. The appendix is a blind-ended, pouch-like projection of the cecum, which opens and closes as the intestines contract for the passage of food. The appendix has no known function, while some scientists believe it is the storehouse for various healthy bacteria in the gut, and the appendix is responsible for replenishing the normal gut flora.
Appendicitis usually occurs as a consequence of obstruction. This obstruction can be due to:
The most common symptom of appendicitis is pain. It usually starts with midabdominal pain that comes and goes. Along with this pain, patients may experience an urge to defecate and find relief upon defecating. Upon progression of the disease, the pain is more localized towards the epigastric and periumbilical regions, and eventually, the pain is localized in the right iliac fossa.
The pain of appendicitis is shifting in character. It is felt at a different site- the mid-abdomen, from where it settles and is shifted to another- the right iliac fossa. This character of pain can serve as a clue when taking history from the patient.
In the case of perforation, the pain shows up as abdominal discomfort.
Along with pain, the patient may report other symptoms like anorexia, nausea, vomiting, or constipation. Patients may also experience fever (usually 100 F to 101 F).
Upon physical assessment, observe for signs of pain like facial grimacing, clenching of the fists, increased sweating, increased heart rate, and shallow but rapid respirations.
A patient with appendicitis may guard the abdomen in a typical posture by flexing the right leg at the knee. This posture helps relax abdominal muscles, which reduces pain.
On palpation of the abdomen, you may notice diffuse tenderness around the umbilical and epigastric region with slight muscular rigidity. As the pain shifts to the right iliac fossa, tenderness may be noted at McBurney’s point. This point is located midway between the umbilicus and the right anterior iliac crest.
One clinical sign of appendicitis is the Rovsing’s sign. It is elicited by palpating the left iliac fossa. Pain on doing so in the right iliac fossa constitutes a positive Rovsing’s sign.
On palpation in a patient with appendicitis, you may also notice rebound tenderness. It is a tenderness that is experienced in relieving the pressure. Rebound tenderness is commonly seen in appendicitis.
With increasing life expectancy, appendicitis is being reported in the elderly population too. But in the very young (individuals below 18) and the elderly (people above 50), there is a higher risk of perforation. Also, the symptoms are more subtle and vague, due to which appendicitis in these individuals may not bring a patient to the hospital before developing complications.
While appendicitis is the most common cause of abdominal inflammation, there can be other causes of right iliac fossa pain. Other diseases you should keep in mind as the differential diagnosis of appendicitis are:
Appendicitis is more of a clinical diagnosis. Diagnostic tests are of secondary importance. Before sending a female patient of childbearing age for radiology, it is recommended to perform a pregnancy test.
The investigations that can help in making the diagnosis of appendicitis include:
A CBC may show elevated white blood cell count due to infection and inflammation in a patient with appendicitis. Leukocytosis may range from 10,000 to 16,000 per microliter (The normal range in adult females and males is 4,000 to 11,000 per microliter)
A CT scan may show an enlarged appendix with thickened walls and increased diameter in patients with appendicitis. This morphological change is a consequence of the underlying inflammation.
It is another parameter that is raised in inflammatory conditions. Therefore, it is also increased in appendicitis. The normal range of CRP is less than 5mg/L.
Other tests that you can send in cases of appendicitis include:
As mentioned earlier, appendicitis is a clinical and surgical emergency. If left untreated, the appendix can perforate, leading to peritonitis. An appendectomy (removal of the appendix) is the preferred method of treatment in acute appendicitis if the inflammation is localized. An appendectomy is performed within 24 to 48 hours from the onset of the symptoms. It can be done under general or spinal anesthesia.
An appendectomy can be performed both by open approach and laparoscopically. Laparoscopic appendectomy can be used in females, children, obese patients, or in those in whom diagnosis is uncertain. In a laparoscopic appendectomy, the recovery is faster.
An open appendectomy is usually performed by a transverse incision at the McBurney’s point. It is known as the McBurney-McArthur incision. Other than these, a Lanz incision or Pararectus incision may also be made to access the abdominal cavity.
In cases of a perforated appendix and evidence of peritonitis or abscess, conservative treatment with antibiotics and IV fluids is given 6 to 8 hours before an appendectomy.
The pre-operative treatment includes IV hydration, antibiotics, antipyretics, and analgesics. Analgesics are usually administered after a definitive diagnosis is made. In severe pain, opioid analgesics may be given. IV hydration can be done with normal saline or Ringer’s lactate solution.
The antibiotics can include metronidazole, gentamicin, cefotetan, cefoxitin, piperacillin, and tazobactam sodium. Any of these antibiotics offer broad antibacterial coverage, which is essential in appendicitis, especially if ruptured.
After an appendectomy, the recovery is usually smooth, and hospital discharge is possible within 24 to 48 hours of surgery. Cases may become complicated if the appendix is ruptured, prolonging the need for hospital stay to 5 to 7 days.
IV hydration is continued, and oral feed is given when the patient can tolerate it. Postoperatively, painkillers can be administered by Intramuscular route until the patient can take them orally.
Your role as a nurse is important in caring for a patient with appendicitis.
Here are a few things you should do as a nurse:
Appendicitis is a surgical emergency that requires urgent surgery. Along with surgery, conservative treatment, psychosocial support, and effective post-operative care constitute an essential role in the treatment strategy for the care of patients with appendicitis.
It makes your role as a nurse extremely significant in managing the most common surgical emergency.
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