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Topics: Appendicitis, Vermiform appendix, Appendicectomy Pages: 18 (6060 words) Published: January 1, 2013
APPENDICITIS is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis and shock.[1] Reginald Fitz first described acute and chronic appendicitis in 1886,[2] and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".[3] The term "pseudoappendicitis" is used to describe a condition mimicking appendicitis.[4] It can be associated with Yersinia enterocolitica.[5] * |

Signs and symptoms

Location of the appendix in the digestive system
Pain first, vomiting next and fever last has been described as the classic presentation of acute appendicitis. Since the innervation of the appendix enters the spinal cord at the level T10, the same level as the umbilicus (belly button), the pain begins mid-abdomen. Later, as the appendix becomes more inflamed and irritates the adjoining abdominal wall, it tends to localize over several hours into the right lower quadrant, except 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). In case of a retrocecal appendix (appendix localized behind the cecum), however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, protects the inflamed appendix from the 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) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis, requiring urgent surgical intervention.[6] Causes

On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen (the inside space of a tubular structure).[7][8] Once this obstruction occurs, the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former 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 septicemia and eventually death. The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis, and, most commonly, calcified fecal deposits known as appendicoliths or fecaliths[9] The occurrence of obstructing fecaliths has attracted attention since their presence in patients with appendicitis is significantly higher in developed than in developing countries,[10] and an appendiceal fecalith is commonly associated with complicated appendicitis.[11] Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls.[12] The occurrence of a fecalith in the appendix seems to be attributed to a right-sided fecal retention reservoir in the colon and a prolonged transit time.[13] From...

References: 1. ^ Hobler, K. (Spring 1998). "Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement" (– Scholar search). Permanente Medical Journal 2 (2).[dead link]
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5. ^ Zheng H, Sun Y, Lin S, Mao Z, Jiang B (August 2008). "Yersinia enterocolitica infection in diarrheal patients". Eur. J. Clin. Microbiol. Infect. Dis. 27 (8): 741–52. doi:10.1007/s10096-008-0562-y. ISBN 0-9600805-6-2. PMID 18575909.
7. ^ Wangensteen OH, Bowers WF (1937). "Significance of the obstructive factor in the genesis of acute appendicitis". Arch Surg 34 (3): 496–526. doi:10.1001/archsurg.1937.01190090121006.
9. ^ Hollerman J. et al. (1988). "Acute recurrent appendicitis with appendicolith". Am J Emerg Med 6 (6): 614–7.
11. ^ Nitecki S, Karmeli R, Sarr MG (1990). "Appendiceal calculi and fecaliths as indications for appendectomy". Surg Gynecol Obstet 171 (3): 185–8. PMID 2385810.
12. ^ Arnbjörnsson E (1985). "Acute appendicitis related to faecal stasis". Ann Chir Gynaecol 74 (2): 90–3. PMID 2992354.
13. ^ Raahave D, Christensen E, Moeller H, Kirkeby LT, Loud FB, Knudsen LL (2007). "Origin of acute appendicitis: fecal retention in colonic reservoirs: a case control study". Surg Infect (Larchmt) 8 (1): 55–62. doi:10.1089/sur.2005.04250. PMID 17381397.
14. ^ Burkitt DP (1971). "The aetiology of appendicitis". Br J Surg 58 (9): 695–9. doi:10.1002/bjs.1800580916. PMID 4937032.
15. ^ Segal I, Walker AR (1982). "Diverticular disease in urban Africans in South Africa". Digestion 24 (1): 42–6. doi:10.1159/000198773. PMID 6813167.
16. ^ Arnbjörnsson E (1982). "Acute appendicitis as a sign of a colorectal carcinoma". J Surg Oncol 20 (1): 17–20. doi:10.1002/jso.2930200105. PMID 7078180.
17. ^ Burkitt DP, Walker AR, Painter NS (1972). "Effect of dietary fibre on stools and the transit-times, and its role in the causation of disease". Lancet 2 (7792): 1408–12. doi:10.1016/S0140-6736(72)92974-1. PMID 4118696.
18. ^ Adamis D, Roma-Giannikou E, Karamolegou K (2000). "Fiber intake and childhood appendicitis". Int J Food Sci Nutr 51 (3): 153–7. doi:10.1080/09637480050029647. PMID 10945110.
19. ^ Hugh TB, Hugh TJ (2001). "Appendicectomy--becoming a rare event?". Med. J. Aust. 175 (1): 7–8. PMID 11476215.
20. ^ Gear JS, Brodribb AJ, Ware A, Mann JI (1981). "Fibre and bowel transit times". Br. J. Nutr. 45 (1): 77–82. doi:10.1079/BJN19810078. PMID 6258626.
21. ^ Hobler, K. (Spring 1998). "Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement" (– Scholar search). Permanente Medical Journal 2 (2).[dead link]
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23. ^ Small V (2008) Surgical emergencies. In Dolan B and Holt L (eds) Accident and Emergency: Theory into Practice, 2nd edition. Elsevier.
29. ^ Terasawa T, Blackmore CC, Bent S, Kohlwes RJ (2004). "Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents". Ann. Intern. Med. 141 (7): 537–46. PMID 15466771.
31. ^ Fink, AS.; Kosakowski, CA.; Hiatt, JR.; Cochran, AJ. (Jun 1990). "Periappendicitis is a significant clinical finding". Am J Surg 159 (6): 564–8. doi:10.1016/S0002-9610(06)80067-X. PMID 2349982.
33. ^ Sauerland S, Lefering R, Neugebauer EA (2004). Sauerland, Stefan. ed. "Laparoscopic versus open surgery for suspected appendicitis". Cochrane Database Syst Rev (4): CD001546. doi:10.1002/14651858.CD001546.pub2. PMID 15495014.
39. ^ " 'Emergency ' appendix surgery can wait: MDs". CBC News. 2010-09-21.
42. ^ "WHO Disease and injury country estimates". World Health Organization. 2009. Archived from the original on 11 November 2009. Retrieved Nov. 11, 2009.
43. ^ "Health Care as a 'Market Good '? Appendicitis as a Case Study". JournalistsResource.org, retrieved April 25, 2012
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