Appendicitis (Emergency Medicine)

by Sharon Bord, MD

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    00:02 Hi.

    00:02 We're gonna be talking about appendicitis and how you’re gonna diagnosis this and treat it in the Emergency Department.

    00:09 So first of all, let’s start out by thinking about what the appendix is.

    00:14 So the appendix is a hollow, muscular, closed-end tube.

    00:18 The average is about 10 centimeters in length and it arises from the posteromedial cecum about 3 centimeters from the ileocecal valve.

    00:27 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.

    00:36 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.

    00:47 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.

    00:59 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.

    01:10 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.

    01:18 It means inflammation.

    01:20 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.

    01:34 And when it gets stuck there, there is bacteria that can breed in the structure of the appendix.

    01:42 Other things that can cause problems would be a stone, an enlarged lymph node, or possibly a tumor.

    01:49 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.

    02:03 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.

    02:18 So of ten people, one of them will get it, maybe a little bit less than that.

    02:22 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.

    02:33 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.

    02:43 This is definitely something that can still happen as time goes on.

    02:48 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.

    03:03 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.

    03:14 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.

    03:23 Oftentimes, the pain begins though around the umbilicus, so around the belly button is where people will describe that their pain first starts.

    03:32 An important landmark here is McBurney’s point, so this is where we approximate that the appendix should lie in a majority of people.

    03:39 And what this is, is that it’s two centimeters from the anterior superior iliac spine going towards the umbilicus.

    03:48 Now, pain can be felt in other locations.

    03:50 Patients don’t always read the textbook and the truth is that patients can have various locations of the appendix.

    03:57 So while we discuss the most common location, patients can also have retrocecal appendices, which can sometimes cause pain more in the rectal area.

    04:05 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.

    04:13 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.

    04:26 Now, if a patient all of a sudden has a significant increase in pain that may be due to rupture of the appendix.

    04:31 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.

    04:46 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.

    05:01 What other associated symptoms? So we talked about where the pain is and where the pain is located.

    05:06 The other associated symptoms would be a subjective or a measured fever.

    05:11 So patients might say they felt fevers or chills.

    05:13 They may have a temperature when they present to the Emergency Department.

    05:18 Another classic thing that people think about and talk about a lot is nausea or vomiting after the pain starts.

    05:24 So we use this sometimes to help us distinguish this from a cause such as like a viral illness.

    05:30 So in a viral illness classically, you would have vomiting and then the pain.

    05:35 Here you have the pain and then vomiting.

    05:38 So those are kind of in a different direction and this is a classic thing that people talk about and ask about.

    05:45 Anorexia or not feeling hungry for food.

    05:48 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.

    06:09 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.

    06:19 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.

    06:29 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.

    06:37 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.

    06:45 Sometimes, you’ll have people jump up and down on one foot and we’ll talk about that when we get to physical exam.

    06:52 There are some other special exam maneuvers that can be done to further support a diagnosis of appendicitis.

    06:59 For the most part, these are non-specific signs.

    07:02 One of them is Rovsing's sign.

    07:04 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.

    07:15 Obturator’s sign is another potential physical exam maneuver that you can do.

    07:20 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.

    07:31 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.

    07:45 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.

    07:54 What these are basically saying is that you have irritation of the peritoneum.

    08:00 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.

    08:11 There is inflammation there.

    08:12 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.

    08:24 So trying to get a patient to focus on that and see when it hurts more.

    08:28 Does it hurt more when you push or more when you let go? Involuntary guarding is when the patient has a rigid abdomen or that the abdomen is very tense on the surface.

    08:38 That indicates that potentially, there may have been rupture of the appendix and lots of inflammation within the abdominal cavity.

    About the Lecture

    The lecture Appendicitis (Emergency Medicine) by Sharon Bord, MD is from the course Abdominal and Genitourinary Emergencies. It contains the following chapters:

    • Appendicitis
    • Appendicitis: Signs and Symptoms
    • Appendicitis Examination

    Included Quiz Questions

    1. It can occur at any age.
    2. The lifetime prevalence is 1%.
    3. It occurs more often in women.
    4. It occurs more often in the elderly.
    5. Pain is limited to the right lower quadrant.
    1. 2 cm from the right anterior superior iliac spine on a line leading to the umbilicus
    2. 2 cm from the left anterior superior iliac spine on a line leading to the umbilicus
    3. 2 cm from the right ilium on a line leading to the umbilicus
    4. 2 cm from the left ilium on a line leading to the umbilicus
    5. 2 cm from the right ischium on a line leading the umbilicus
    1. Pain in the right lower quadrant occurring with palpation of the left lower quadrant
    2. Periumbilical pain radiating to the right lower quadrant
    3. Right lower quadrant pain with extension of the right hip
    4. Right lower quadrant pain with flexion of the right hip against resistance
    5. Sharp right lower quadrant pain elicited by coughing
    1. Obturator sign
    2. Rovsing's sign
    3. Psoas sign
    4. Dunphy sign
    5. Markle sign

    Author of lecture Appendicitis (Emergency Medicine)

     Sharon Bord, MD

    Sharon Bord, MD

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