Appendicitis ,What causes appendix? typical and Atypical Symptoms of appendicitus,signs , Alvarado scoring ,Differential diagonosis and investigations

Appendicitis is swelling (inflammation) of the appendix. The appendix is a small pouch attached to the beginning of your large intestine .. that pouch is known as caecum.



What causes appendix?
Appendicitis occurs when the appendix becomes blocked, often by stool, a foreign body, or cancer. Blockage may also occur from infection, since the appendix swells in response to any infection in the body.



The cause of appendicitis isn't always clear. Sometimes appendicitis can occur as a result of:
An obstruction. Food waste or a hard piece of stool (fecal stone) can block the opening of the cavity that runs the length of your appendix.
An infection. Appendicitis may also follow an infection, such as a gastrointestinal viral infection, or it may result from other types of inflammation.
In both cases, bacteria inside the appendix multiply rapidly, causing the appendix to become inflamed, swollen and filled with pus. If not treated promptly, the appendix can rupture.

Symptoms of appendicitus:
typical presentation:

• pain in periumblical region which later migrate to right illeac fossa. (periumblical means around umblicus. illiac fossa is the right lower coner of abdomen above the boony protuberance)

• Vomitting

• loss of appetite

• mild fever

• abdominal swelling

• inability to pass gas

Atypical presentation:

• pain in right illiac fossa which does nt migrate

• dairrhea 

• constipation 

• frequency of micturation if lies in close contact with bladder

Signs:

Pointing sign
Rovsing sign
soas sign
obturator sign

Pointing sign:
                  Patient points the region where pain occured and where it is migrated
Rovsing sign:
                when deep palpation is tried in left illiac fossa patient feels pain in right illiac fossa
soas sign:
              patient with this sign ususally keep their leg flex due to involvement of soas muscle and feels comfortable.. later they are seen with hyperflexion of leg due to spasm of soas muscle.
obturator sign
                  when leg is flexed and is rotated at hip joint the patient feel pain in hypogastrim .

Alvarado scoring sysytem for appendicitus:

symptoms:
migratory pain                 1
anorexia                          1
nausea and vommiting      1

signs:
tenderness                    2
rebound tenderness       1
elevated temperature     1
laboratory
  leucocytosis                                                                  2
shift to left(increase in segmented neutrophils)                  1

score less than 5 no appendicitis
score 5 to 6 is suspicious and require contrast enhanced CT
Score 7 or above means  acute apendicitis

Differential diagonosis:
Children:

• gastroentritis

• mesenteric adenitis

• meckel diverticulum

• henoch scholein purpura

• lobar pneumonia

Adults:

•  acute pancreatitis

• acute   cystitis

• ureteric colic

• pyelonephritis

• perforation due to ulcer

• testicular torsion

• rectus sheath haematoma

women:

• pelvic inflammatory disease

• mittleschmerz

• ectopic pregnancy

• torsion or haemorrhage of ovarian cyst

elders:

• intsetinal obstruction

• cancer of caecum

• sigmoid diverticulitis

• laeking aortic aneurysm

• soas abcess

• mesenteric infarction

Invetigations:

• Complete blood count

(white cell count more than 14000 is an indicative of appendicitis)

• urine test

• pregnancy test

• X-rays

• ultrasound

 

• diagnostic laprascopy: