Submitted By

PALLABI SAHOO

3rd year BHMS

Roll No. 0111BHMS021

U.H.M.C., Rourkela-769010

Under the guidance of

Dr. P. K. PATTNAIK

(H. O. D., Department of Surgery)

U.H.M.C., Rourkela-769010

CONTENTS

1. What is appendicitis?

2. Causes of appendicitis

3. Symptoms and signs of appendicitis.

4. Diagnosing appendicitis

5. Investigation

6. Differentials Diagnosis

7. Complications

8. Treatment

9. Surgical procedure

10. Medicinal Treatment

11. Conclusion

12. References

The appendix is a small dead end pouch, like a little tube, that comes off the caecum. The caecum is the first part of the large intestine (large bowel) just before the colon. The small

intestine digests and absorbs food. The parts of the food that are not digested begin to be formed into faeces (motions) in the caecum. It is normally about 5-10 cm long and quite thin and appears

to have no function.

Location of the appendix in the digestive system

Appendicitis means inflammation of the appendix. The inflamed appendix becomes infected with bacteria (germs) from the intestine. The inflamed appendix gradually swells and fills with

pus. Eventually, if not treated, the swollen appendix might perforate (burst). This is very serious, as the contents of the intestine then spill into the abdominal cavity. This can cause a serious

infection of the membrane that lines the abdomen (peritonitis), or an abscess in the abdomen. So, if appendicitis is suspected, early treatment is best before it bursts.

Mortality/Morbidity:

Overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather

than to surgical intervention.

Mortality rate rises above 20% in patients older than 70 years, primarily because of

diagnostic and therapeutic delay.

Perforation rates are higher in patients younger than 18 years and in patients older than

50 years, possibly because of delays in diagnosis. Appendiceal perforation is associated

with an increase in morbidity and mortality rates.

Sex:

Incidence of appendicitis is approximately 1.4 times greater in men than in women.

The incidence of primary appendectomy is approximately equal in both sexes.

Age:

Incidence of appendicitis gradually rises from birth, peaks in the late teen years, and

gradually declines in the geriatric years.

Although rare, cases of neonatal and even prenatal appendicitis have been reported.

Inflammation of the appendix is usually the result of blockage causing an infection. The

appendix is open at one end where it connects to the large intestine. If the open end of the

appendix gets plugged for some reason, either because of swelling or because something from

the large intestine gets stuck in the opening, then the appendix starts to swell because of the

secretions from the lining. The swelling shuts off the blood supply and the appendix tissue dies.

An operation to remove the swollen appendix (an appendectomy) is the only way to fix this

problem.

Acute appendicitis

The blockage in appendix may also occur if lymph nodes in the appendix swell. Less common

causes of blockage are vegetable and fruit seeds, stomach worms, and thickened barium from

prior X-rays. In seniors, appendicitis is occasionally caused by a tumor (cancer) of the colon.

The main symptoms of appendicitis are encrypted in the following.

Pain in the abdomen (tummy pain) is usually the main symptom. The initial typical pain

is diffuse and dull and is situated in the umbilical or lower epigastric region. Intermittent

cramping pain may also be there. Gradually the pain is localized in the right lower

quadrant.

Anorexia is complained of in case of appendicitis.

Nausea is present in 9 out 10 patients with appendicitis. Vomiting is frequently found in

children and teenagers whereas it is absent in adults.

Many patients give history of constipation before the onset of abdominal pain. Diarrhea

occurs in some patients particularly in young children.

The common physical signs are

Appendicitis may cause rise of temperatures. Temperature elevation is usually restricted

from 99˚ to 100 ˚ F (39 ˚C).

Pulse rate is usually normal or slightly elevated. Pulse rate increases in proportion with

the temperature of the patient.

Inspection

The patient looks anxious in pain and tongue is dry.

In acute condition it may disclose some limitations of the respiratory movement of the

lower half of the abdomen.

Palpation

Presence of peritoneal inflammation can be suspected if cough or percussion on the abdominal

wall elicits pain.

Systemic gentle palpation will detect an area of maximum tenderness that corresponds to

the position of the appendix and is usually located in the right lower quadrant at or near

McBurnet’s point.

Rebound tenderness:- The classic method of demonstrating peritoneal inflammation is

rebound tenderness. In this case the gentle pressure is exerted on the inflamed area and

sudden release of the hand will cause extreme pain of the patient at the inflamed area.

This is called rebound tenderness.

Rovsing’s sign:- Pain in the right lower quadrant is complicated of when palpation

pressure is exerted in the left lower quadrant. It is also called ‘referred rebound

tenderness’.

Psoas sign:- This test is performed by having the patient lie on his left side. The

examiner then slowly extends the patients right thigh, thus stretching the iliopsoas

muscle. This will produce pain to make the sign positive.

Obturator test:- Passive internal rotation of flexed right thigh with the patient in supine

position will elicit pain. This positive obturator sign is diagnostic of pelvic appendicitis.

Percussion:- Light percussion on McBurnet’s point will elicit pain in case of early

appendicitis.

Auscultation:- It will reveal mearge or no bowel movement on the right iliac fossa.

Rectal examination:- This is important and should be performed in every patient

suspected of suffering from appendicitis. In case of pelvic appendicitis there may not be

any tenderness on the anterior abdominal wall. Rectal examination is very essential to

exclude such appendicitis.

Appendicitis is usually a clinical diagnosis and needs to be determined by a doctor. The doctor

will perform a number of tests that may also provide information on the extent and location of

inflammation. After a physical examination, a blood test may be done to check for infection. A

doctor might also take a urine sample to rule out a urinary tract infection, because symptoms can

be similar to those of appendicitis.

Sometimes an ultrasound will be performed to help with the diagnosis. An abdominal CT scan is

occasionally needed for people when other tests do not give clear results.

Other diseases that can be confused with appendicitis include colitis, Crohn's disease, gastritis,

gastroenteritis, tubal pregnancy, and ovary problems.

Tests for appendicitis or peritonitis

The test for appendicitis or peritonitis may be done in the following way.

Here a person have cough and see if this causes sharp pain in the belly or slowly but forcefully,

press on the abdomen a little above the left groin until it hurts a little. Then quickly remove the

hand

If a very sharp pain (rebound pain) occurs when the hand is removed, appendices or

peritonitis is likely.

If no rebound pain occurs above the left groin, try the same test above the right groin.

80-85% of adults with appendicitis have a WBC count greater than 10,000.

Neutrophilia greater than 75% occurs in 78% of patients. Fewer than 4% of patients with appendicitis have a WBC count less than 10,000 and

neutrophilia less than 75%.

C-reactive protein (CRP) is an acute-phase reactant synthesized by the liver in response

to bacterial infection. Serum levels begin to rise within 6-12 hours of acute tissue inflammation. A rapid assay is widely available.

In adult patients who have had symptoms for longer than 24 hours, a normal CRP has a negative predictive value of approximately 100% for the presence of appendicitis.

Two other studies in adults found that a combination of a WBC count of less than 10,500,

neutrophilia less than 75%, and a normal CRP had 100% negative predictive value for the diagnosis of acute appendicitis.

Abdominal CT has become the most important imaging study in the evaluation of

patients with atypical presentations of appendicitis. Several studies have shown a decrease in negative laparotomy rate and appendiceal perforation rate when abdominal CT is used in selected patients with suspected appendicitis.

Advantages of CT scanning include superior sensitivity and accuracy compared with other imaging techniques, ready availability, noninvasiveness, and potential to reveal

alternative diagnoses.

If graded compression ultrasonography of the right lower quadrant is positive for appendicitis, appendectomy should be performed.

If negative, this finding is not sufficiently sensitive to rule out the possibility of appendicitis. Consideration should be given to further observation and focused helical CT with rectal contrast.

Kidneys-ureters-bladder (KUB) view used typically.

Visualization of an appendicolith in a patient with symptoms consistent with appendicitis is highly suggestive of appendicitis, but this occurs in fewer than 10% of cases.

The consensus in the literature is that plain radiography is insensitive, nonspecific, and not cost-effective.

A single contrast study can be performed on an unprepared bowel.

Non-filling or incomplete filling of the appendix coupled with pressure effect or spasm in the cecum suggests appendicitis.

Except for high specific gravity due to dehydration, routine urine examination will usually reveal normal result in case of appendicitis.

Acute cholecystitis

Enterocolitis

Amoebic colitis

Meckel’s diverticulitis

Acute pancreatitis

Intestinal obstruction

Crohn’s disease

Perforated peptic ulcer

Carcinoma of the caecum

Salpingitis

Ectopic gestation

Ruptured ovarian follicle

Twisted right ovarian cyst

Right ureteric colic

Right sided acute pyelonephritis

Torsion of testis

Haematoma

Basal pneumonia

Pleurisy

Appendicular rupture

Appendicular mass (Phlegmon)

Appendicular abscess

Supportive pylephlebitis

Wound infection

Intra-abdominal abscess

Treatment guidelines for patients with suspected acute appendicitis include the following:

Establish IV access and administer aggressive crystalloid therapy to patients with

clinical signs of dehydration or septicemia.

Do not give anything by mouth to patients with suspected appendicitis.

Consider ectopic pregnancy in women of childbearing age and obtain a qualitative

beta-hCG in all cases.

This may be useful when appendectomy is not accessible or when it is temporarily a

high-risk procedure.

Preoperative antibiotics.

An operation to remove the inflamed appendix is usually done quite quickly once the

diagnosis is made. It is much better to remove an inflamed appendix before it bursts. The

inflamed appendix is found and cut off the caecum. The hole left in the caecum is stitched up

to stop any contents from the gut leaking out. Antibiotic medicine is given just before the

operation to reduce the risk of an infection developing at the site of the operation.

In most cases, the operation is done before the appendix perforates. This is usually a

straightforward and successful operation needing just a short recovery. However, surgery can

be more difficult and you will take longer to recover if the appendix has perforated.

Surgery is commonly done by a keyhole operation, as the recovery is quicker compared to

having an open operation. The keyhole operation is performed through three tiny cuts, the

largest of which is only around 1.5 cm in size. There are usually no long-term complications

after the operation. As with any operation, there is a small risk of complications from the

operation itself and from the anesthetic. However, if you don't have an operation, an inflamed

appendix is likely to perforate and cause a serious infection in the abdomen (peritonitis)

which can be life-threatening.

Open surgery Laparoscopic appendectomy

The goals of therapy are to eradicate the infection and prevent complications.

Medicine acute intest. conditions, colic

Abdominal pains, violent; come and disappear suddenly. Are squeezing; clawing; as if griped by nails; violent pinchings. "Violent colic, intense cramping pain, face red as fire." Tenderness of abdomen, worst least jar. Frequent urging to stool, little or no

result (Nux).

Spasmodic contraction of sphincter ani. Great pain in ileo-caecal region: cannot bear slightest touch, even of bedclothes (early appendicitis. Local external applications to abort). Typical Bell. has red, hot face; big pupils: is sensitive to pressure draughts, jar.

Special remedies of appendix and caecum

Years ago, when making diagrams to show the action of remedies on parts of the body, one grasped the fact that two drugs seemed to share the honours in this area-

Belladonna and Mercurius corrosivus. And one knows that Bell. has earned a great reputation for early, simple inflammation of appendix. Among its symtoms are: Great pain in right ileo-caecal region.

Cannot bear the slightest touch, not even of bed covers. Tenderness aggravated by

least jar. (KENT says, "The jar of the bed will often reveal to you the remedy"). Bell. has much swelling. Its inflammations throb : feel bursting. Kent also says, "There are instances where Bell. :is the remedy of all remedies in appendicitis".

There are instances where Bell. is the remedy in appendicitis. Belladonna has

dysenteric troubles. Pain in the region of the caecum.

Medicine acute intest. conditions, colic.

Peculiar bruised sensation about caecum and along transverse colon. Tender to pressure. Appendicitis. (Bell). Painful bloody discharges (from rectum) with vomiting. Tenesmus,

persistent, incessant, with insupportable cutting, colicky pains. Diarrhoea dysentery with terrible straining before, with, and after stool. Merc. cor. is almost specific for dysentery. Very distressing tenesmus, getting worse and worse: nothing blood.

Special remedies of appendix and caecum

This drug down in black type for appendicitis. Merc. corr. is violent and active. Has far more

activity, excitement and burning. Caecal region and transverse colon painful. Bloated abdomen. Characteristic : Great tenesmus of rectum, the "never-get-done" remedy. Abdomen

bruised, bloated, tender to least touch. Tenesmus of bladder, also. Hot urine passed drop by

drop. Clinical.

Appendicitis.

A girl, 16, had perforating appendicitis, operation having been delayed too long in consequence of opposition of friends.

Special remedies of appendix and caecum

Appendicitis : peritonitis. Must keep very still; stools hard, dry, as if burnt. Pain in a

limited spot: dull, throbbing or sticking. Bry. is better lying on painful side, for pressure and to limit movement. Lies knees drawn up. Better for heat to inflamed part.

Sensitive abdomen; appendicitis. Constipation; hard, dry stool.

Special remedies of appendix and caecum

"It acts on appendix and has been used for appendicitis. But remember, it promotes suppuration, and a neglected appendix with pus formation would probably rupture sooner under its use". -Another condition to which Natrum sulph. patients are prone is

a fairly acute attack of appendicitis, with extreme pains in the cecal region. Lymphatic inflammation; crushing injuries. Compare: Iris florentina-Orris-root-

(delirium, convulsions, and paralysis); Iris factissima (headache and hernia); Iris germanica-Blue Garden Iris-(dropsy and freckles); Iris tenax -1.minor-(dry mouth; deathly sensation at point of stomach, pain in ileo-caecal region; appendicitis. Pain

from adhesions after). Echinacea angustifolia - Clinical - Appendicitis.

Digestive drugs

Apparently, it is a retro-cecal appendix, because they always complain of extreme pain going right round to the back, rather than of pain ore McBurney's Point. It is the

type of appendix which is associated with a degree of jaundice. Some of the most striking results from Natrum sulph. have been in cases of appendix abscesses, where there has been a retro-cecal appendix and a tendency for the inflammation to track up

and conditions suggesting a sub-phrenic. There is one other rather interesting point about this remedy, and it has no connection with the digestive system. Natrum sulph.

is sometimes very well indicated in acute his joints, particularly when it is the right hip which is affected. The pain is very similar in character to that experienced in cases of appendicitis, and if there are any Natrum sulph. indications, it is worthwhile to

consider its use. Two cases in hospital cleared up remarkably well on Natrum sulph., and it is apt to be forgotten for this condition.

It has cured many cases resembling the first stage of appendicitis. Pain and tenderness in the whole abdomen. Flatulence; colic; rending, tearing, cutting pains throughout the abdomen; stitching pains in the abdomen; violent neuralgic pains in the abdomen;

inflammation of the bowels, of the peritoneum; appendicitis.

Abdomen

Flatulence with distention. Shifting, flatulent pain along colon several hours after meals. Frequent, loose, yellow, painful stools, with burning of flatulence. Chronic appendicitis.

Relationship

Compare: Hyd.; Nux.; Rhamnus Californica (tincture for constipation; tympanites and appendicitis and especially rheumatism).

Acts on vermiform appendix thus has been used for appendicitis, but remember it promotes suppuration and a neglected appendicitis with pus formation would

probably rupture sooner under its use.

clinical

Appendicitis. Stitches in the caecum at 7 p.m., alternating with pains elsewhere.

Characteristics

This should make it appropriate in some cases of appendicitis. Appendicitis. As an external

application in the form of compresses, Lime-water has an ancient repute in allaying inflammation of many kinds.

Characteristics

It has rapidly dispelled all inflammatory action in cases of appendicitis; and has removed all suffering in an aggravated case of phagedaenic piles.

Clinical

Appendicitis. Acute pain in liver extending towards stomach," though contrary to the

general "left to right" direction, is characteristic, as I can testify. Lach. is also one of the most prominent remedies in appendicitis.

Clinical

Appendicitis.

Characteristics

Although he deemed it useless he was persuaded to operate, and found a large abscess behind the colon, freely communicating with the peritoneal cavity.

Clinical

Appendicitis.

Clinical

Appendicitis. Colic. Constipation Diarrhoea. Tympanites. Typhlitis. The ileo-caecal

symptoms seem to point to it as a possible remedy in cases of appendicitis.

Clinical

Anus, itching of. Appendicitis.

Clinical

Appendicitis. Appetite, lost.

Clinical

Appendicitis. Breast, tumours of. Colic. Colic just below navel and some griping in the side in afternoon. Griping below navel, 7 a.m. (after a slight vexation). Pain in sigmoid flexure.

Dull, heavy, periodic pain < when abdomen compressed, legs extended. (Appendicitis as a local remedy. -R. T. C.). Several stools daily with tenesmus. Albuminuria.

Clinical

Appendicitis. "Sensitive to music" was observed in one of Nebel's patients; another had pains in the region of the appendix vermiformis, which should lead to serviceable action in

appendicitis cases.

Clinical

Albuminuria. Appendicitis.

Do not forget the symptoms of Arnica in appendicitis if we know Bryonia, Rhus tox., Belladonna, Arnica and similar remedies. The homoeopathic remedy will cure these cases, and, if we know it, you need never run after the surgeon in appendicitis except in recurrent

attacks.If we do not know remedies, we will succumb to the prevailing notion that it is necessary to

open the abdomen and remove the appendix. It is only deplorable ignorance that causes appendicitis to be surrendered to the knife. "Great pain in the ileo-caecal region; cannot bear the slightest touch, even the bed clothes."

Yellow, brown spots on the abdomen; petechiae over the abdomen during typhoid fever. Pale face in pleura/peritoneum-disease, red face in articular affections.

Belladonna Echinacea Purpurea

Bryonia alba Alfalfa plant

In this project the appendicitis disease is presented. Here various sections viz. what is appendicitis, causes, symptoms and sign of appendicitis are given, which may give the

overall understanding of the disease. Further investigation of the disease and its diagnosis are given. Both the surgical and medicinal treatment of this disease is broadly discussed.

1. S. Craig, Appendicitis, Medscape, Jul 2011.

2. D. J. Humes, J. Simpson; Acute appendicitis. BMJ. 2006 Sep 9. 3. A. Kentsis, Y. Y. Lin, K. Kurek, Discovery and Validation of Urine Markers of Acute

Pediatric Appendicitis Using High-Accuracy Mass Spectrometry, Ann Emerg Med. 2009, Jun 25.

4. http://chealth.canoe.ca

5. http://en.wikipedia.org/wiki/Appendicitis