- Acute abdominal pain is defined as previously undiagnosed pain of
<72 hours duration
- Accounts for about 2% of hospital admissions
- In only 50% of patients is the preoperative diagnosis correct
- Right iliac fossa pain accounts for about half of all cases of acute
abdominal pain
Causes of right iliac fossa pain
- Appendicitis
- Urinary tract infection
- Non-specific abdominal pain
- Pelvic inflammatory disease
- Renal colic
- Ectopic pregnancy
- Constipation
Causes of right iliac fossa mass
- Appendix mass
- Crohn's disease
- Caecal carcinoma
- Mucocele of the gallbladder
- Psoas abscess
- Pelvic kidney
- Ovarian cyst
Appendicitis
- About 10% of the population will develop acute appendicitis
- The incidence is falling
- 70,000 appendicectomies are performed each year in the UK
- Appendicitis is more common in men
- Appendicectomy is performed more often in women
- At 10-20% appendicectomies a normal appendix is removed
- The risk of perforation is:
- Less than 10 years old = 50%
- 10-50 years old = 10%
- Over 50 years old = 30%
- A women is more likely to have a 'normal' appendix removed
Clinical features of appendicitis
- Central abdominal pain moving to right iliac fossa
- Nausea, vomiting, anorexia
- Low-grade pyrexia
- Localised tenderness in right iliac fossa
- Right iliac fossa peritonism
- Percussion tenderness is a kinder sign of peritonism than rebound
- Rovsing's sign = pain in right iliac fossa on palpation of the left
iliac fossa
Investigations
- Appendicitis is essentially a clinical diagnosis
- The following may be useful:
- Urinalysis may exclude urinary tract infection
- Pregnancy test to exclude ectopic pregnancy
- Abdominal x-ray is of little value
- A normal white cell count does not exclude appendicitis
- Ultrasound may be helpful in the assessment of an appendix mass or
abscess
- Ultrasound adds little to the clinical diagnosis of acute
appendicitis
- Scoring systems and computer-aided diagnosis my be helpful
- Meta-analysis suggest the following to be useful predictors of
appendicitis in patients with abdominal pain
- Raised inflammatory markers
- Clinical signs of peritoneal irritation
- Migration of abdominal pain
Picture provided by Fahid Abu-Zant, Neblus Speciality
Hospital, Neblus, Palestine
Management
- In cases of diagnostic doubt a period of 'active observation' is
useful
- Active observation reduces negative appendicectomy rate without
increased risk of perforation
- Intravenous fluids and analgesia should be given
- Opiate analgesia does not mask the signs of peritonism
- Antibiotics should not be given until a decision to operate has been
made
- Diagnostic laparoscopy should be considered particularly in young
women
- Whether a 'normal' appendix should be removed following laparoscopy
is unclear
Appendicectomy
- Early appendicectomy for non-perforated appendicitis was first
performed in 1880s
- Open appendicectomy is usually performed via a Lanz incision and
muscle splitting approach
- No evidence that burying the stump reduces the infection rate
- Consider a midline incision in elderly patients
- If normal appendix removed need to look for:
- Meckel's diverticulum
- Acute salpingitis
- Crohn's disease
- Laparoscopic appendicectomy may be associated with:
- reduced hospital stay
- rapid return to normal activity
- Overall benefits of laparoscopic approach not as great as for
cholecystectomy
Appendix mass
- Usually presents with a several day history
- Inflammation localised to the right iliac fossa by the omentum
- Patient is usually pyrexial with a palpable mass
- Initial treatment should be conservative
- Fluids, analgesia and antibiotics
- Observe the patient and mass
- Continue conservative whilst there is clinical improvement
Appendix abscess
- Results from localised perforation
- Abscess should be surgically or percutaneously drained
- Appendicectomy at initial operation can be difficult
- Need for appendicectomy after abscess drainage is unclear
Picture provided by Dr Florencia Castro,
Hospital Juan de San Martin, Buenos Aires, Argentina
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