9

Appendix

Appendicitis

Overview

Most common in teenage years and patients in their 20s

Rate of appendectomy for appendicitis is 10 per 10,000 patients per year

Usually due to lymphoid hyperplasia or fecalith causing luminal obstruction

Signs and Symptoms

Anorexia (90%)

Abdominal pain: Periumbilical migrating to RLQ

Nausea and vomiting (70%)

Low-grade fever

Physical Examination Findings

Point tenderness typically over McBurney point

Psoas sign: Pain with extension of right thigh while in left lateral decubitus position

Obturator sign: Pain with passive rotation of flexed right hip

Rovsing’s sign: Pain in RLQ while palpating LLQ

Rectal examination may reveal a pelvic mass or abscess

Laboratory Findings

Patients can have a normal WBC count, but usually mild leukocytosis in the range of 10,000 to 18,000/mm³

Urinalysis may be positive with pyuria, hematuria, and albuminuria

Treatment

IV fluid resuscitation and peri-operative antibiotics

Laparoscopic or open appendectomy

For perforated appendix, may undergo appendectomy if there is no inflammatory phlegmon. If there is an inflammatory phlegmon, conservative management with IV antibiotic, with percutaneous drainage of any associated abscess

RADIOLOGY

Appendicitis

Plain film findings

• Usually normal

• Adynamic ileus may be seen

• Sometimes, a calcified appendicolith in the right lower quadrant is seen

US findings

• Blind-ending tubular structure that is noncompressible, outer wall to outer wall diameter greater than 6 mm

• If identified, an appendicolith casts a clean posterior acoustic shadow

• Tenderness over appendix

• False negative can result from retrocecal appendicitis, gangrenous or perforated appendicitis, gas-filled appendix, and massively enlarged appendix

CT findings (Fig. 9.1)

• Appendix measuring greater than 6 mm in diameter, failure of appendix to fill with oral contrast or air up to its tip

• Adjacent cecal thickening due to edema at the origin of the appendix

• Inflammation/fatty stranding/fluid in the retroperitoneum/frank abscess

• Appendicolith

MRI findings

• Dilated, thickened appendix with adjacent inflammation seen on contrast-enhanced T1-weighted and T2-weighted images

FIGURE 9.1 A,B

A. Vertebra

B. Psoas muscle

C. Colon

D. Stomach

E. Spleen

F. Bladder

FIGURE 9.1 A

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