ATYPICAL CLINICAL FEATURES OF APPENDICITIS

5^th International conference “Surgery 4 All”. Moscow. Published in the “SURGERY made simple” Magazine

ATYPICAL CLINICAL FEATURES OF APPENDICITIS

Presented by: I.M. Kapuwa; M.A. Chinikov , MD, PhD

Extract...

Appendicitis is an inflammation of the appendix that causes the organ to fill with fluid. In classic descriptions of appendicitis, patients will experience a progressively worsening amount of periumbilical (near the navel) pain in the abdominal region followed by nausea, right lower quadrant pain, and later, vomiting with fever. However, some people, especially pregnant women, the elderly, children and people with situs inversus totalis (mirrored positions of internal organs), may suffer from atypical symptoms, making a proper diagnosis more difficult.
Acute appendicitis is one of the most common surgical emergencies encountered by general surgeons. When appendicitis manifests in its classic form, it is easily diagnosed and treated. Unfortunately, these classic symptoms occur in just over half of patients with acute appendicitis therefore, an accurate and timely diagnosis of atypical appendicitis remains clinically challenging and is one of the most commonly missed problems in the emergency department. Furthermore, the consequence of missing appendicitis, leading to perforation, significantly increases morbidity and prolongs hospitalization.

WHAT YOU NEED TO KNOW: Anatomy - 

Normal Appendix anatomy

• Blind pouch off of cecum

• Contains lymphoid tissue which peaks in adolescence, atrophies with age

• Function still unclear

• Appendix can be anywhere within peritoneal cavity

• One study showed 65 % retrocecal, 31 % pelvic

APPENDICITIS INCIDENCE & COMPLICATIONS

o 6 % lifetime incidence, Slightly more common in men

o 69 % are ages 10 to 30

o 1 in 6 of the population will have an appendectomy.

o More common in European societies (Diet); less common in vegetarians

o Only 55% have classical features.

o Atypical 45%

o Up to 30 % misdiagnosed initially

o Mortality : 0.1 to 0.2 % unruptured, 3 to 5 % ruptured Significant morbidity

Various positions of the Appendix

PRESENTATION: Atypical presentation of appendicitis may occur because of the position of the appendix, the age of the patient, or coexisting conditions such as pregnancy. In such cases the diagnosis may be particularly challenging. The position of the appendix as related to the caecum may also influence the clinical presentation and the differential diagnosis. When the inflamed appendix is in retroacecal and retroileal position it is shielded from the anterior abdominal wall by the overlying caecum and ileum. The pain, therefore, seems less severe with a mild to moderate manifestation that doesn't worsen or shift.

The classic shift of pain from the epigastrium to the right lower quadrant may not occur. Tenderness or sensitivity to touch will be slight and not worsen. In some cases, there is no tenderness at all. Another atypical symptom of appendicitis is a change in bowel movements, including a reduction in frequency or a change in the consistency, with harder and drier stools. Without the presence of pain and tenderness, appendicitis is likely to be misdiagnosed as constipation.

Urinary frequency may result from direct irritation of the ureter. Muscular rigidity is absent and abdominal tenderness is minimal in these cases. With inflamed appendix in pelvic position, pain is often localized to the lower abdomen. The absence of abdominal signs can be deceiving, but tenderness is usually elicited on rectal examination.

DIAGNOSIS:  Diagnosis is clinical; for there is no specific test to confirm the diagnosis of acute appendicitis. The Alvarado score can be used in the diagnosis of appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total of 10 points.

THE ALVARADO CLINICAL  ‘MANTRELS’ SCORE.                                                               Established in 1986

Characteristic	Point
Migration of pain to right lower quadrant (RLQ)	1
Anorexia	1
Nausea / vomiting	1
Tenderness in RLQ	2
Rebound pain	1
Elevated temperature	1
Leukocytosis	2
Shift of white blood cell count to left	1
Total	10

Diagnosis of appendicitis in the elderly is often delayed. Even with advanced inflammation, pain may be minimal and fever is absent. Appendicitis in pregnancy is also difficult to diagnose. Patients usually seek obstetric advice for their symptoms.  Area of maximal abdominal tenderness may be adjacent to the umbilicus or in the right subcostal area because of upward displacement of caecum. 

Imaging diagnostics:

 Ultrasonography

 Computed tomography/ magnetic resonance imaging

 X-ray 

 Laparoscopy 

 Vaginal/rectal examination