Overview
Definition
Acute inflammation of the vermiform appendix, usually due to obstruction of its lumen.
Epidemiology
Most common surgical emergency in the world. Peaks in the 2nd and 3rd decades of life.
Etiology & Risk Factors
- Obstruction by a fecalith (most common in adults)
- Lymphoid hyperplasia (most common in children, often following a viral infection)
- Foreign body, tumor, or parasites (rare)
Clinical Symptoms
- Classic progression: Periumbilical pain (visceral, vague) migrating to the Right Lower Quadrant (RLQ) (somatic, sharp, localized) over 12-24 hours
- Anorexia (hallmark symptom - if patient is hungry, question the diagnosis)
- Nausea and vomiting
- Fever (mild)
Clinical Approach
Diagnosis
- Clinical diagnosis heavily relying on physical exam: McBurney's point tenderness, Rovsing sign (LLQ palpation causes RLQ pain), Psoas sign, Obturator sign
- Labs: Leukocytosis with left shift
- Imaging: CT Abdomen with IV contrast (Gold Standard in adults) shows enlarged appendix >6mm with periappendiceal fat stranding
- Ultrasound (Preferred in children and pregnant women)
Management
- Surgical appendectomy (usually laparoscopic) is the definitive treatment
- Pre-operative IV antibiotics (covering Gram-negatives and anaerobes, e.g., Cefoxitin or Cefazolin + Metronidazole)
- In some uncomplicated cases, non-operative management with antibiotics alone is being utilized, but recurrence risk is high
Complications
- Perforation (leading to localized abscess or generalized peritonitis)
- Sepsis
- Pylephlebitis (infective thrombosis of the portal vein)