Appendicitis is inflammation of the appendix. It is a small pouch-like structure located in the small and large intestines. It is a medical emergency and needs diagnosis and treatment to prevent complications like infection and rupture.

Appendicitis can occur in individuals at any age. It is common in teenagers and young adults. It is a common surgical emergency. The main cause of appendicitis is not clear. It happens because of an obstruction in the appendix. A small piece of fecal matter which can lead to overgrowth of bacteria and infection.

This disease causes abdominal pain, which starts near the belly button and moves to the lower right side of the abdomen. Other symptoms are nausea, vomiting, loss of appetite, low-grade fever, and changes in bowel movements.

Appendicitis is the most common surgical emergency globally. It affects people in all ages. It is most common for the age of 10 to 30 years. The risk of developing this disease is about 7 to 8%. The incidence may vary from different populations and areas. It is more common in men than women. The men-to-women ratio is about 1.4:1.

The incidence of this disease may vary geographically. It has a higher rate in developed countries than in developing countries. Some other factors like environmental factors, lifestyle and dietary habits can contribute to this disease.

Appendicitis can affect all individuals of all the ethnicities. Higher rate of appendicitis in people of Caucasian ethnicity than the other groups. It can occur to all socioeconomic backgrounds.

Obstruction: Appendicitis starts with the obstruction of appendix. The most common obstructions are hardened stool, lymphoid hyperplasia, or a tumor. This can lead to accumulation of bacteria and mucus in the appendix.

Increased intraluminal pressure: The obstruction can lead to increased pressure in the appendix. This can lead to impaired venous and lymphatic drainage.

Bacterial overgrowth and infection: Bacteria in the appendix can grow and lead to infection. The common pathogens are enterobacteria and E.coli.

Inflammation: The infection triggers an inflammatory response. Neutrophil infiltrate the body and produce the inflammatory mediators. This can lead to inflammation in the wall of appendix.

Ischemia and necrosis: The appendix can become ischemic because of the low supply of blood in the inflammation progresses. Necrosis of the appendix wall can happen in severe cases.

Perforation: The necrotic appendix can rupture if it is left untreated. It can lead to the release of infectious material in the abdominal cavity. It results in peritonitis.

Obstruction: The main cause of appendicitis is blockage of the appendiceal lumen. This blockage can happen because of the presence of fecaliths, lymphoid hyperplasia, or, in rare cases, tumors.

Infection: Blockage of appendix can lead to accumulation of the mucus and bacteria in the appendix. It can cause infection. The bacteria which are included from the GI tract like E. coli, Bacteroides species.

Inflammation: The immune response of the body causes inflammation in the appendix after the infection. The release of inflammatory mediators can cause swelling and inflammation.

Time of intervention: Early recognition of the disease and surgical intervention in time for appendicitis are linked with the good results. Delayed diagnosis and surgical treatment may lead to complications like perforation and abscess formation.

Age: Young children and older adults may have a higher risk of complications from this disease than the other age groups.

Severity of inflammation: The severity of the inflammation and presence of complications like perforation or abscess formation can impact the prognosis of the disease.

Comorbidities: Some specific diseases like diabetes or immunodeficiency may elevate the risk of complications in patient who have appendicitis.

Surgical approach: The surgical method which is used, either open appendectomy or laparoscopic appendectomy, may affect the result and recovery of the patients.

Activity: Appendicitis can happen in people of all physical activity. There is no link between activity level and the onset of appendicitis.

Inspection:

General appearance: Check the overall appearance of patient, any sign of stress or discomfort.

Abdominal distension: Check for any visible distention or swelling of the abdomen.

Palpation:

Tenderness: Examine the abdomen softly to check the areas of tenderness, specifically in the right side of the abdomen or McBurney’s point.

Guarding: Check for voluntary or involuntary protection as a defensive contraction of the abdominal muscles in response to palpation.

Rebound tenderness: Perform an intensive examination to look for any sign of rebound tenderness, which is intense pain after the release of pressure after palpation.

Rigidity: Check for any rigidity which is continuous, heard in the abdominal muscles.

Percussion: Percuss the abdomen to check for any areas which are dull or tympany and indicate inflammation or accumulation of fluid.

Auscultation: Check the bowel sounds in all quarters of the abdomen to see if they are normal, reduced, or absent.

Special Tests:

Rovsing’s sign: Apply gentle pressure to the left side of lower quadrant and check for any pain in the right side of lower quadrant.

Psoas sign: Extend the right leg while the patient lies on their left side and check for any pain in the right side of lower quadrant.

Obturator sign: Flex the right hip and knee, then internally rotate the hip, and check for any pain in the right side of lower quadrant.

Associated comorbidity: There are no particular comorbidities linked with appendicitis. Specific conditions like inflammatory bowel disease, cystic fibrosis, and pelvic inflammatory disease may elevate the risk of appendicitis.

Acuity of presentation: The symptoms of appendicitis are like:

• Abdominal pain: The common symptom is abdominal pain which occur to the right side of the lower abdomen.
• Nausea and vomiting: Nausea and vomiting come along with the abdominal pain.
• Loss of appetite: Many patients who have appendicitis also have a loss of appetite.
• Low-grade fever: Some patients may have minor elevation in the body temperature.
• Change in bowel habits: Diarrhea or constipation may occur.

Activity: Appendicitis can happen in people of all physical activity. There is no link between activity level and the onset of appendicitis.

Diagnosis: The diagnosis of appendicitis depends on clinical evaluation, which includes symptoms, physical examination, and imaging studies like CT scan or ultrasound.

Fluid Resuscitation: IV fluid resuscitation is started to balance any dehydration or electrolyte imbalance, specifically in cases of severe appendicitis.

Antibiotic Therapy: Broad-spectrum antibiotics are administrated to prevent the infection and reduce the risk of complications, which is linked with appendicitis. The choice of antibiotics can vary depending on the local antibiotic resistance.

Surgical Intervention: The primary treatment of appendicitis is surgical removal of inflamed appendix. It is known as an appendectomy. There are 2 main methods:

Laparoscopic Appendectomy: It is a minimally invasive technique. It includes an insertion of small incisions and use of laparoscope to see and remove the appendix.

Open Appendectomy: An open surgical method may be needed. It includes a large incision to remove the appendix.

Post-operative Care: The patient is monitored closely for any symptoms of complications like wound infection, abscess formation, or ileus after the surgery. Management of pain, oral intake, and mobilization are continued.

Follow-up: Take follow up visits from the healthcare provider to check the recovery of patient, wound healing and post-operative concerns. They may give additional instructions to resume the normal activity and lifestyle modifications.

Emergency Medicine

Gastroenterology

Healthy Diet: Follow a balanced diet which is rich in fruits, whole grains, vegetables and lean proteins can help to maintain the good digestive health. Avoid excessive consumption of processed foods, fatty or greasy foods, and sugary drinks can help to reduce the risk of GI problems.

Adequate Hydration: Drink more water and stay hydrated can improve the regular bowel movements and prevent constipation. It can lead to appendicitis.

Regular Exercise: Regular physical activity may improve the overall GI health, improve digestion, and help to maintain a healthy body weight. It is necessary to take follow up from a healthcare providers regarding the proper level of physical activity during the recovery period.

Stress Management: Chronic stress can affect the immune system. Mediation, deep breathing exercises, or engaging in hobbies and activities are the techniques which can implement to improve the relaxation.

Good Hygiene Practices: Practice with good hygiene like regular handwash can reduce the risk of infection which can lead to appendicitis.

Emergency Medicine

Gastroenterology

• Surgery is a standard treatment to treat appendicitis. The use of antibiotics can manage non-perforated appendicitis. Different antibiotics are studied to manage non-perforated appendicitis.
• Ceftriaxone: It is a 3^rd generation cephalosporin. It has a broad-spectrum activity against bacteria. It is used with other antibiotics.
• Metronidazole: It has an activity against anaerobic bacteria. It is used with other antibiotics to give broad coverage.
• Fluoroquinolones (ciprofloxacin or levofloxacin): These antibiotics have broad-spectrum activity against many bacteria which are linked with appendicitis.
• 3^rd generation cephalosporins (cefdinir): These antibiotics have broad spectrum activity. It is used along with metronidazole.
• Amoxicillin & clavulanate: These antibiotics have a wide coverage against the bacteria which are linked with appendicitis.

Emergency Medicine

Gastroenterology

• Cefoxitin: It is a 2^nd generation cephalosporin. It has a broad spectrum activity against many bacteria. It is used as a single agent for prophylaxis.
• Cefotetan: It is a 2^nd generation cephalosporin. It has a broad spectrum activity against many bacteria. It is used as a single agent for prophylaxis.
• Cefazolin & metronidazole: This combination drugs gives activity against gram + and gran _ bacteria. It is 1^st generation cephalosporin. Metronidazole has activity against anaerobic bacteria.
• Allergic to penicillin & cephalosporins: Patients who are allergic to penicillin and cephalosporins, alternative medication is used. Clindamycin is used as a main agent. It is used with other drugs like levofloxacin, gentamicin, or aztreonam. The choice of drug is depend on the allergy of patient, local resistance pattern and preference of surgeon.

Emergency Medicine

Gastroenterology

• Aspirin or clopidogrel: These are anti-platelet medications. It is used to prevent clot formation in patients who have cardiovascular disease. It depends on the risk of thrombosis and surgical bleeding of patient. The risk of surgical bleeding is low from an appendectomy.
• Direct oral anticoagulants (DOACs): DOACs like dabigatran, rivaroxaban, apixaban, or edoxaban are used to prevent blood clot formation in patients who have conditions like atrial fibrillation or venous thromboembolism. The choice to hold or continue to take DOAC treatment before the surgery is based on the bleeding risk of patient and immediate risk of surgery. The appendectomy is optional, and bleeding risk is low. It can be acceptable to delay DOAC for a particular time before the surgery.
• Warfarin: Warfarin is a vitamin K antagonist. It is used as an anticoagulant. The management of warfarin treatment is based on the INR of patient and the immediate need of the surgery. If the INR is in the normal range. The surgery is optional. It can be necessary to hold warfarin and take other alternative anticoagulant drugs like heparin.

Emergency Medicine

Gastroenterology

• Perforated appendicitis is a serious condition. It needs surgical intervention. If the patient is stable and localized peritonitis is present, non-operative management with antibiotics can be given. The choice of antibiotics must target pathogens like aerobic and anaerobic bacteria. The antibiotics which are used for non-operative management of perforated appendicitis are:
• Broad-spectrum antibiotics: IV antibiotics who have both aerobic and anaerobic bacteria are suggested like combination of ceftriaxone and metronidazole or ampicillin and sulbactam.
• Duration of antibiotic therapy: The duration of antibiotics to treat non-operative perforated appendicitis may vary but the time is about 7 to 14 days. The exact time is determined on the basis of clinical response, any improvement of symptoms, and inflammatory markers.

Emergency Medicine

Gastroenterology

• Appendectomy is surgical removal of appendix and is the standard treatment for perforated appendicitis.
• Emergency appendectomy: This is the immediate surgical intervention performed once the diagnosis of perforated appendicitis is confirmed. It is typically indicated in cases with signs of generalized peritonitis, hemodynamic instability, or clinical deterioration.
• Rescue appendectomy: In some cases, initial nonoperative management with antibiotics may be attempted to stabilize the patient and control the infection. However, if there is inadequate response or clinical deterioration, a rescue appendectomy is performed as a secondary intervention to remove the appendix.
• Upfront appendectomy: This refers to the immediate surgical removal of the appendix without attempting nonoperative management. It may be chosen in certain situations, such as when there is a high suspicion of perforation based on clinical and imaging findings, or when the patient’s condition warrants prompt intervention.

Emergency Medicine

Gastroenterology

• Laparoscopic Appendectomy: It is a minimally invasive procedure. It includes a small incision in the abdomen and inserts a laparoscope and surgical instrument. The surgeon can see the appendix and nearby structures and can remove the appendix by a small incision. Laparoscopic appendectomy is linked with advantages like short stay at the hospital, decreased post-operative pain, and fast recovery.
• Open Appendectomy: A large incision is made in the lower right side of the abdomen. It can give the direct access to the appendix. The surgeon can see the appendix and remove it by incision. It allows for better visualization of the abdominal cavity. It is performed in specific cases like complicated or advanced cases of appendicitis, suspected perforation, or patients who have obesity or abdominal surgery.

Emergency Medicine

Gastroenterology

Radiology

Acute Phase:

• It starts with the onset of symptoms and medical need of the patient. A physical examination and diagnostic test like blood tests, imaging tests like CT scan and ultrasound are performed to confirm the disease.

Perioperative Phase:

• The surgery is performed. It included fasting, administration of IV fluid, and antibiotics to prevent infection. The open or laparoscopic appendectomy is performed to remove the appendix. The surgical method is dependent on different factors like severity of appendicitis and choice of surgeon. The vital sign of patient and anaesthesia are monitored to make sure the safety and surgical result during the surgery.

Post-operative Phase:

• The patient is monitored in a recovery area. Pain management, vital signs, and wound care are monitored. Oral intake and mobilization is started on the basis of the condition of patient. Pain medications are suggested to manage post-operative discomfort and pain. Complications like wound infection, deep vein thrombosis, and pneumonia are measured. This includes early mobilization, deep breathing exercises, and administration of prophylactic medications. Once the patient is stabilized, they can be discharged with some instructions about the wound care, medication and follow up appointments.