Appendicitis remains the mostly co...

Appendicitis remains the mostly common acute surgical condition of the abdomen. In 1997 more than 260000 modern cases occurred in the United States. The overall lifetime incident is approximately 12 percent in men and 25 percent in women (1-3)

Because abdominal pain is a frequent presenting complaint in the outpatient setting, family physicians succor an important role in the rapid diagnosis of acute appendicitis. Accurate and timely diagnosis of acute appendicitis is essential to minimize morbidity. quick surgical treatment may reduce the risk of appendix perforation. The case-fatality rate of appendicitis leap overs from less than 1 percent in nonperforated cases to 5 percent or higher when perforation present itselfs (4)

The diagnosis of appendicitis traditionally has been based onward clinical features found primarily in the patient's history and physical examination. (5) An elevated white relations cell count has a depressed predictive value for appendicitis because it is ready in a number of conditions. (6) While the clinical diagnosis of appendicitis may be straightforward in patients with classic signs and symptoms, atypical presentations can ensue in delays in treatment, unnecessary hospital admissions for observation, and unnecessary surgery

Unnecessary surgery for suspected appendicitis show ups patients to increased risks, morbidity, and cost In 1997, 261,134 patients underwent nonincidental appendectomies in the United States. However, 39901 (153 percent) of the appendixes remov showed no pathologic features of appendicitis. (1)

Diagnostic accuracy achieved by dint of history and physical examination has remained at about 80 percent in men and women (men are diagnosed accurately 78 to 92 percent of the time, and women 58 to 85 percent of the time). (5) lately imaging techniques such as ultrasonography, comput tomography (CT) and magnetic resonance imaging (MRI) were evaluated as diagnostic modalities in acute appendicitis and were shown to improve diagnostic accuracy and patient consequences However, the routine use of imaging studies in all patients is not well established.

Pathophysiology

The appendix in an adult is a diverticulum arising from the posteromedial wall of the cecum It averages 10 cm in duration The base of the appendix is fixed to the cecum while the remainder of the appendix is at liberty This fact accounts for its variable location (i.e., retrocecal, subcecal, retroileal, pre-ileal, or pelvic) and explains a great deal of the diversity in clinical presentations among patients with acute appendicitis. (7)

The pathophysiology of appendicitis begins with obstruction of the narrow appendiceal lumen Obstruction has many sources, including fecaliths, lymphoid hyperplasia (related to viral illnesses of the like kind as upper respiratory infections, mononucleosis, or gastroenteritis), gastrointestinal parasites, foreign bodies, and Crohn's disease. Continued secretion of mucus from within the stoped appendix results in elevated intraluminal press leading to tissue ischemia, over-growth of bacteria, transmural inflammation, appendiceal infarction, and possible perforation, (89) Inflammation may then quickly protract into the parietal peritoneum and adjacent structures

Clinical Findings

In a typical presentation, the three clinical findings with the highest predictive value for acute appendicitis are right lower quadrant pain, abdominal rigidity, and migration of pain from the periumbilical region to the right lower quadrant. (7) These classic findings come about in about 50 percent of patients, (5) however, making missed diagnosis of appendicitis a frequent successful malpractice claim against family and extremity department physicians. (10) Table 1 (611) summarizes the prevalence of for the use of all signs and symptoms of appendicitis.

Unusual presentations appear when the appendix is not in its normal location, when the patient is young or somewhat old and when the patient is a woman of childbearing age or is pregnant. (12-14)

The single chiefly important physical finding is right lower quadrant pain upon palpation of the abdomen. Other findings include low-grade excitement peritoneal signs, and guarding. In addition, the physical signs (Table 2) (8915) resulting from various maneuvers designed to elicit peritoneal pain can be helpful in the diagnosis. (15)

In a late meta-analysis, (5) no single clinical finding was construct to effectively rule in or method out acute appendicitis. Diagnosis is particularly difficult in women of childbearing age because acute gynecologic conditions (eg pelvic inflammatory disease) may cause symptoms similar to appendicitis. Therefore, false-negative appendectomy (i.e., removal of a normal appendix) rates have been reported to be as high as 47 percent in female patients who are 10 to 39 years of age. (5)

Management Options

If the diagnosis of appendicitis is clear from the patient's history and physical examination, no further testing is destitutioned and prompt surgical referral is warranted. (15) When the diagnosis is not clear, management options for suspected appendicitis include observation in a hospital, diagnostic imaging to clarify the diagnosis, laparoscopy, and appendectomy. Imaging studies are take away from effective if a definitive diagnosis can be made and observation in a hospital can be avoided. (16) Surgical removal of a normal appendix adds to increased morbidity and higher medical costs