Appendicitis

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Carolyn Little & Ginny Tibbs from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Genevieve Tibbs, Carolyn Hall, Leana Louw, Elaine Lonnemann, Wendy Walker, Kim Jackson, Lucinda hampton and WikiSysop  

Definition/Description

Appendicitis is described as the inflammation of the vermiform appendix that results in necrosis and perforation². The appendix is a small finger-shaped pouch that projects out from your colon on the lower right side of your abdomen and has no known essential purpose3. Obstruction, inflammation, or infection can cause the appendix to rupture leading to peritonitis¹. This condition usually requires surgery as its medical management due to the fact that acute appendicitis can often be life threatening. Thus, appendicitis is the leading cause of emergency abdominal operations.⁶ Upon histiological review, acute appendicitis can be divided into simple, gangrenous, or perforated categories².

Prevalence/Incidence²

The lifetime risk of appendicitis in the Unitied States is 9% for males and 7% for females. It is most commonly diagnosed in adolescents and younger adults¹. Overall incidence of this condition is declining for reasons not well known. It is suggested that increased dietary fiber intake and improved hygiene could be contributing factors to the decrease in appendicitis cases. 

Characteristics/Clinical Presentation

The following list outlines some of the common signs and symptoms of typical acute appendicitis: 

•     Pain preceding nausea and vomiting
•     Low grade fever
•     Dysuria
•     Pain in umbilical region that localizes in RLQ
•     Pain referral to groin or thigh
•     Pain comes in waves and is aggravated by movement
•     Patients bend over, tense abdominal muscles, lie down, or flex hips to relieve tension over abdomen
•     Anorexia
•     Tense, rigid abdomen²
  
•     Aggravating factors: movements that increase abdominal pressure (cough, walk, laughing)² 
  
•     Positve McBurney's point
•     Positive Rebound Tenderness test
•     Constipation
•     Inability to pass gas³
•     Diarrhea
•     Loss of appetite³
•     Pain typically increases over a period of 12 to 18 hours and eventually becomes very severe.³

The location of pain may vary, depending on age and the position of the appendix. For example, young children or pregnant women may have appendicitis pain in different places.³

Atypical appendicitis may not presnt with the classical signs and symptoms listed above. These abnormal symptoms could present with decreased pain intensity and localization, less discomfort experienced when coughing or walking, and/or pain that localizes to the left side of the body². In older adults, confusion may be the first sign of an acute event².

Associated Co-morbidities

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Medications

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Diagnostic Tests/Lab Tests/Lab Values²

Diagnostic testing is often indicated for individuals suspected of having appendicitis. Medical imaging such as CT scans or sonograms are used to help confirm possible appendicitis. Additional laboratory tests utilzed are urine analyses or complete blood counts. Patients who present with typical appendicitis will have an elevated WBC count > 20,000 mm³. Physicians will also perform a histological examination of the resected appendix for further confirmation of the condition. Iliopsoas and obturator muscle tests are administered to rule out potential abcesses or insults to muscle integrity.

Etiology/Causes²

Appendicitis is thought to be caused by a combination of obstruction and bacterial infection. In 50% of appendicitis cases, there is no known cause. Approximately 1/3 of appendicitis cases are obstruction related (tumors, fecaliths, parasites, or lymphoid hyperplasia). Obstruction of the appendix causes inflammation of the mucosa lining. Swelling of the glandular tissue leads to distention of the appendix and increased intraluminal pressure. When the intraluminal pressure excessed venous pressure ischemia to the local tissue occurs. As neutrophils accumulate, microabscesses produce additional ischemia increasing the likelihood of perforation within 24-48 hours. Ulceration of the mucosa allows invasion of intestinal bacteria and infection of the peritoneal cavity can occur.

Other causes of this condition include Chron's disease of the terminal ileum, ulcerative cholitis, and tuberculous enteritis.

Systemic Involvement

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Medical Management (current best evidence)²

The most common treatment for appendicitis is an appendectomy with some patients receiving antibiotics preoperatively. Early surgical removal decreases the risk of mortality and morbidity to < 1%. Prognosis for these patients who undergo surgery is typically good unless accurate diagnosis is delayed and perforation occurs. Poor prognostic indicators for this condition include hypovolemia, peritonitis, and septic shock.

Currently, reaserch on antibiotic therapy alone has increased in popularity across the world. In 1997, 1 million hospitalizations for acute appendicitis were reported and roughly three billion dollars were spent on patient care. A recent systematic review published in 2011 compared the effects of antibiotic treatment to appendectomies on success rate and overall complications experienced after treatment. Researchers found that 73.4% of those treatet with antibiotic therapy (415/901) were free of abdominal pain, fever, inflammatory markers within two weeks and were without major complications and recurrance within one year. On the other hand, 97.4% of those who had an appendectomy (486/901) had similar outcomes. It was noted that patients who had surgery had a shorter duration of hospital stay. Due to the fact that the 5 RCTs analyzed in this review were low to moderate quality, the authors could not make direct conculsions about the effectiveness of antibiotic therapy over traditional surgery.

Another systematic review published in 2011 also found similar inconclusive results regarding the efficacy of antibiotic therapy on acute appendicitis. In this study, 489/741 patients underwent antibiotic therapy. Although the number of individuals who developed complications were significantly higher in the surgery group, the percentage of experiencing acute appendicitis within the first year follow up and immediate 48 hour surgery varried from 10.5 to 36.8% and 5 to 47.5%, respectively.

Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

Due to the high success rate of surgical management for acute appendicitis, there is limited evidence on alternative or holistic managment. A recent case study by Gershfeld, Sultana, and Goldhamer in 2011 reported positive outcomes for a patient with subacute appendicitis. In this study a 46 year old man was medically supervised on a water only fasting program for seven days. The patient then followed a strict low sodium and low fat diet after he was reintroduced to foods. He was further advised to contiune the diet after leaving medical facility. The participant reported decreaed right lower quadrant pain at three months, one year, and two year follow ups. The exact mechanism for how the fasting regimine worked are not well understood. Fasting protocols have reported some success in inflammatory conditions like SLE, RA, and IBS.

Differential Diagnosis

The following diseases can present with similar signs and symptoms as appendicitis¹: 

• Chron's disease
• Duodenal ulcer
• Gallballder attacks
• Kidney infection
• Right lower lobe pneumonia
• Ruptured ectopic pregnancy
• Twisted ovarian cyst
• Intestinal Obstruction
• Pelvic Inflammatory Disease
• Abdominal Adhesions
• Constipation

Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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Mayo Clinic. Appendicitis. http://www.mayoclinic.org/diseases-conditions/appendicitis/basics/definition/CON-20023582. (accessed 18 Mar 2014).