Management of Acute Appendicitis

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Appendiceal Abscess

Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a surgical emergency and many cases require removal of the inflamed appendix, either by laparotomy/laparoscopy or open approach in some developing countries.

The disease is slightly far more popular in males, with a male:female ratio of 1.4:1. In a lifetime, 8.6% of males and 6.7% of females could be expected to create acute appendicitis. Young age can be a risk factor, as nearly 70% of individuals with acute appendicitis are much less than 30 many years of age. The highest incidence of appendicitis in males is from the 10- to 14-year-old age group (27.6 instances per 10,000 population), although the highest female incidence is inside the 15- to 19-year-old age group (20.5 instances per 10,000 population). Individuals at extremes of age are additional likely to develop perforated appendicitis. Overall, perforation was present in 19.2% of circumstances of acute appendicitis. This number was considerably higher, even so, in sufferers under 5 and over 65 many years of age. Though much less typical in people more than 65 many years old, acute appendicitis inside elderly progresses to perforation more than 50% of the time.

History

  • Pain (site, onset, duration, character, radiation, shifting, association with cough & movement).
  • Nausea, vomiting, anorexia, fever, diarrhea.
  • Urinary symptoms.
  • OB/GYN History (Specially LMP).

 

Physical Examination:

 

  1. Pulse, blood pressure, temperature, respiratory rate, coated tongue.
  2. Tenderness & rebound tenderness in RIF.
  3. Rovsing’s Sign, Psoas Sign & Obturator Sign.
  4. P/R Examination & P/V Examination,
  5. Alvarado score

[table id=2 /]

 

Investigations:

 

  1. Blood for Hb%, TLC. & DLC.
  2. Urinalysis.
  3. Urine for pregnancy test in all females of child bearing age.
  4. Abdomino pelvic ultrasound in all females
  5. Abdominal ultrasound in males with complex signs (e.g. Palpable mass in RIF)
  6. X-Rays Abdomen Erect and supine Posture (Complex cases).

Management:

When diagnosed start

  • Analgesia: Inj. diclofenac sodium 75 mg deep intragluteal/ Inj Nalbufin 5-10mg I/V.
  • Inj. ampicillin 15 mg/Kg I/V ATD.
  • Inj. gentamycin 1-1.5 mg I/V stat.
  • Inj. metronidazole 7.5 –10 mg Kg I/V stat.
  1. No need of preoperative I/V fluids.
  2. Keep the pt. NPO.
  3. Inform the anaesthetist & theatre staff.
  4. Take the consent for operation, arrange medicines & pile up the patient’s chart.
  5. Shift the patient to theatre for

 

Guidelines for Appendicectomy:

 

  1. Palpate the anesthetized patient for Caecal gurgle and appendicular mass.
  2. Incision 2cm medial to anterior superior iliac spine at line joining from umbilicus to anterior superior iliac spine.
  3. Separate the internal oblique and transverses abdominal muscles. Abdominous close to rectus sheath.
  4. Ligate the appendix at base flush with Caecum avoiding the Caecal wall.
  5. Cut appendix where the conical curvature ends.
  6. Cauterize the mucosa pouting.
  7. Delayed primary closure of skin perforated appendix.

 

Appendicular Mass

  1. Exploration of the mass by senior registrar
  2. Exclude ileocecal tuberculosis and carcinoma cecum.

Postoperative Period:

  1. NPO for 2 hours then 2 oz fluids ½ hourly.
  2. NO I/V fluids.
  3. Two doses of I/V antibiotics (Gram +ve cover) in simple acute appendicitis.
  4. In case of perforated appendix,   continue IV triple regimen for 48 hours and then continue oral antibiotics for 3 days

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