Appendicite

Question 1

Diagnosi

Answer 1

Clinico-Lab

• Rovsing
• Mc Burney (già alla fase catarrale)
• Psoas (appendice retrocecale), Obturator (inlfamed pelvic appendix)
• Leucocitosi
• Febbre

The characteristic features of acute appendicitis are periumbilical abdominal pain that migrates to the right lower quadrant (RLQ), anorexia, nausea, fever, and RLQ tenderness. In association with neutrophilic leukocytosis, these features are sufficient to make a clinical diagnosis of acute appendicitis

Question 2

Imaging

Answer 2

Eco ( non è necessario alla diagnosi, ma è l’esame specifico)

• non-compressible and enlarged appendix (> 6–8 mm)
• Target sign
• Loss or absence of appendix in advanced or phlegmonous appendicitis
• Wall thickening
• Edema surrounding the appendix
• Appendix not compressible
• In perforation → intra-abdominal free fluid
• Abdominal CT scan (∼ 98% sensitivity): periappendiceal streaking and enlarged appendix: this may be considered when clinical findings are unclear or when clinical examination proves difficult (e.g., in cases of obesity). Other advantages include identification of an abscess and estimating the extent of appendiceal involvement.

Question 3

General findings

Answer 3

• The most common cause of acute abdomen requiring emergency surgical intervention.
• Anche nei bambini dai tre anni in su (al di sotto è l’invaginazione intestinale)
• anche nelle gestanti (non c’è incidenza maggiore, è solo la urgenza chirurgica più frequente

Question 4

Eziologia

Answer 4

Caused by obstruction of the appendiceal lumen due to:
-Lymphoid tissue hyperplasia (60% of cases): most common cause in children and young adults

• Fecalith and fecal stasis (35% of cases): most common cause in adult
• Neoplasm (uncommon): more likely in patients > 50 years of age [4]
• Parasitic infestation (uncommon): e.g., Enterobius vermicularis, Ascaris lumbricoides, and species of the Taenia and Schistosoma genera [5]

Question 5

Clinica

Answer 5

-Migrating abdominal pain: most common and specific symptom
Typically constant and rapidly worsens
Most patients present within 48 hours of symptom onset.

• Initial diffuse periumbilical pain: caused by the irritation of the visceral peritoneum (pain is referred to T8–T10 dermatomes)
• Localizes to the RLQ within ∼ 12–24 hours: caused by the irritation of the parietal peritoneum

Question 6

Piuria !

Answer 6

Pyuria may present in a patient with appendicitis because of the close proximity of the right ureter and appendix. Urine analysis is ultimately important for ruling out the differential diagnoses of an acute urinary tract infection or kidney stones. However, appendicitis and a right urinary tract infection may present simultaneously; any pathological findings consistent with a urinary tract infection should therefore not exclude appendicitis.

Abnormal urine analysis does not necessarily rule out appendicitis!

Question 7

Trattamento : suspected appendicitis warrants surgical intervention!

Gli unici due casi che orevedono prima trattamento conservativo/drenaggio e poi chirurgia dipo 6 settimane sono il piastrone appendicolare e ascesso appendicolare (ovviamente se non c’è peritonismo, altrimenti sempre e surgery)

Answer 7

SURGERY : Appendectomy

• Conservative therapy is considered in exceptional cases or if findings are unclear (“soft” signs).
• Bowel rest (keep patient NPO), IV fluid therapy, and observation
• Analgesia
• Antibiotics with anaerobic and gram negative cover (e.g., cefazolin and metronidazole)

Question 8

Inflammatory appendiceal mass (appendiceal phlegmon)

Answer 8

Piastrone appendicolare

• Description: an ill-defined mass of inflammatory periappendiceal tissue
• Clinical features: manifests as a tender mass in the RLQ in a patient who is not acutely ill
• Management: conservative (bowel rest, IV fluids, IV antibiotics, with/without interval appendectomy)

Question 9

Appendiceal abscess

Answer 9

-Description: localized collection of pus and necrotic tissue that forms around an inflamed appendix, which typically follows an untreated perforated appendix

• Clinical features: manifests as a tender mass in the RLQ in an acutely ill patient (i.e., high-grade fever, with/without paralytic ileus, leukocytosis, signs of sepsis)
• Management: IV antibiotics, CT-guided drainage of the abscess if > 4 cm, and interval appendectomy [1

Question 10

Pylephlebitis (in generale le flebiti sono complicanze tardive delle operazioni chirurgiche, dopo 48/72 ore)

Answer 10

Trombosi della vena porta, gestisci con antibiotici