We're gonna be talking about appendicitis
and how you’re gonna diagnosis this
and treat it in the Emergency Department.
So first of all,
let’s start out by thinking about what the appendix is.
So the appendix is a hollow, muscular, closed-end tube.
The average is about 10 centimeters in length
and it arises from the posteromedial cecum
about 3 centimeters from the ileocecal valve.
The appendix is a little bit of a mysterious structure
so it has unclear function and for the most part,
it can just cause problems in people
and lead to appendicitis.
Historically, it potentially may have been thought
to be related to enzyme secretion of some sort,
but now, we’re not really totally sure exactly what it does.
So what does appendicitis mean and how does it develop?
Essentially what happens is you have the appendix
which is a hollow structure that has a blind end essentially.
So what happens is you have the appendix
and then the lumen gets obstructed by various things
that we’ll talk about in a moment,
and that essentially leads to appendicitis.
Itis generally in medicine equals inflammation,
so when we’re thinking about the word itis
at the end of anything,
that’s what it means.
It means inflammation.
So what obstructs the lumen?
What dooes gets in there that causes the problem?
An appendicolith is the most common thing
and what that essentially is,
is it’s some very small piece of stool
that gets stuck at the opening to the appendix.
And when it gets stuck there,
there is bacteria that can breed
in the structure of the appendix.
Other things that can cause problems would be a stone,
an enlarged lymph node, or possibly a tumor.
There are a few case reports of a foreign body,
so some kind of you know,
foreign body that’s in the intestinal structure
that gets stuck in that intestinal opening
which then in turn will lead to that inflammation.
Now, who gets appendicitis and how frequent
or how regular of a condition is this?
So approximately 7% of people will develop appendicitis
at some point in their lifetime,
so that’s approximately 1 in 10 people.
So of ten people,
one of them will get it,
maybe a little bit less than that.
Predominantly, men more than women
and this is generally a condition
that happens mainly to young people,
but old people can still very much get appendicitis.
So this is a condition
where although we think of it classically
in those people who are 20, 30, 40 years old,
you definitely don’t wanna discount this in an elderly patient.
This is definitely something that can still happen
as time goes on.
In the United States,
this condition is about 250.000-300.000 appendectomies,
so that’s the number of people
who get their appendix removed every year,
and in Europe it’s about 700.000 in a year.
When people come in to the Emergency Department,
what’s gonna make you start thinking that they have appendicitis
or make you concerned about appendicitis?
The big thing here is the location of the pain.
For the most part in a majority of people,
the appendix lives in the right lower quadrant of the abdomen,
so in the right lower portion of the belly.
Oftentimes, the pain begins though around the umbilicus,
so around the belly button
is where people will describe that their pain first starts.
An important landmark here is McBurney’s point,
so this is where we approximate that the appendix
should lie in a majority of people.
And what this is,
is that it’s two centimeters
from the anterior superior iliac spine
going towards the umbilicus.
Now, pain can be felt in other locations.
Patients don’t always read the textbook and the truth
is that patients can have various locations of the appendix.
So while we discuss the most common location,
patients can also have retrocecal appendices,
which can sometimes cause pain more in the rectal area.
Patients can have appendices that point — appendices to the left,
and the pain can be more felt on the left side
or closer to the umbilicus.
So just because the patient isn’t presenting
in a totally clear way
with pain specifically in the right lower quadrant,
it’s possible that it’s just that
they have an oddly located appendix.
Now, if a patient all of a sudden
has a significant increase in pain
that may be due to rupture of the appendix.
So what sometimes happens as if the inflammation builds up
so greatly in that area of the appendix,
the appendix can in turn burst or rupture,
and those patients may initially experience
a significant increase in pain in those situations.
Now, sometimes though,
rupture of the appendix actually
can then lead to over a period of time a decrease in pain
because essentially that structure has burst
and released some of that inflammation into the abdominal cavity.
What other associated symptoms?
So we talked about where the pain is
and where the pain is located.
The other associated symptoms
would be a subjective or a measured fever.
So patients might say they felt fevers or chills.
They may have a temperature
when they present to the Emergency Department.
Another classic thing that people think about
and talk about a lot is nausea or vomiting after the pain starts.
So we use this sometimes to help us distinguish this from a cause
such as like a viral illness.
So in a viral illness classically,
you would have vomiting and then the pain.
Here you have the pain and then vomiting.
So those are kind of in a different direction
and this is a classic thing
that people talk about and ask about.
Anorexia or not feeling hungry for food.
Oftentimes, in the Emergency Department
when I’m concerned that someone may have appendicitis,
I ask them if they’re feeling hungry
and I oftentimes ask them,
if I had your most favorite food here,
whatever that might be,
for me it’s pizza, or chocolate, or ice cream,
would you wanna eat that?
And if someone says, "No",
that sometimes definitely points to me more in this direction.
Now, it’s definitely not a 100% thing,
but I do like to ask that question
and I think that sometimes it does
help support a diagnosis of appendicitis.
Lastly, patients can sometimes report pain with driving in a car,
jumping up and down,
and this is another thing that I definitely do
classically ask patients.
The other thing you can do sometimes on physical exam is
kind of give the bed a little bit of a nudge
and see if that increases the patient’s pain.
So asking someone if they had pain
while driving to the Emergency Department
or if they took an ambulance right in
and if that increases the pain going over the bumps.
Sometimes, you’ll have people jump up and down on one foot
and we’ll talk about that when we get to physical exam.
There are some other special exam maneuvers
that can be done to further support a diagnosis of appendicitis.
For the most part, these are non-specific signs.
One of them is Rovsing's sign.
Rovsing's sign is when you palpate
the abdomen in the left lower quadrant,
so in the left lower portion of the abdomen,
they feel pain over on the right side of the abdomen.
is another potential physical exam maneuver that you can do.
What you basically do in that situation
is you have a patient laying flat in bed
and you rotate their leg in and out,
so you have the hip rotate
and that can potentially increase pain in the abdomen.
Psoas sign is a similar kind of a maneuver
where you extend to the right hip
and when you do that,
you assess for guarding and rebound in the abdomen
and the patient may experience increased pain.
Obturator sign and Psoas sign as well as Rovsing's sign
are not super sensitive or specific
but it just can potentially provide you with increased evidence.
What these are basically saying
is that you have irritation of the peritoneum.
Rebound or involuntary guarding also can cause peritoneal signs
or support peritoneal signs and what that basically means
is that the abdominal cavity is irritated.
There is inflammation there.
Rebound tenderness can be assessed by asking a patient,
does it hurt more when I push down or more when I let go?
Rebound tenderness is when it hurts more when you let go
of pushing down on a patient’s abdomen.
So trying to get a patient to focus on that
and see when it hurts more.
Does it hurt more when you push or more when you let go?
is when the patient has a rigid abdomen
or that the abdomen is very tense on the surface.
That indicates that potentially,
there may have been rupture of the appendix
and lots of inflammation within the abdominal cavity.