Appendicitis in the adult, pediatric, and pregnant population

1. Appendicitis in the adult, pediatric, and pregnant population Kimberly Henry, RNC, FNP-S SUNY Institute of Technology Nursing 652

2. Pathophysiology Thought to be obstruction of appendiceal lumen ↓ Inflammation ↓ Ischemia ↓ Perforation ↓ Abscess formation or Generalized Peritonitis

3. Etiology of the obstruction Pediatrics • Lymphoid hyperplasia due to infections Adults • Fecaliths (hard fecal masses) • Calculi • Benign or malignant tumors

4. Risk Factors • 1st degree relative with history of appendicitis • 10-19 year old age group • Male (2:1) • Intra-abdominal tumors • Parasites

5. Adult Patient Presentation:Subjective data • Classic presentation consists of vague periumbilical pain which later migrates to RLQ as inflammation progresses (within 4-48hrs) • May or may not have a fever • Anorexia • Nausea or/or vomiting (after the onset of pain) • Pain which is exacerbated by walking or coughing • Nonspecific signs: indigestion, flatulence, bowel irregularity, diarrhea, generalized malaise

6. Objective data • May have tachycardia and hypertension r/t pain and fever • May display shallow breathing in an attempt to not cause pain • Psoas sign: Pain when right thigh is extended (retrocecal appendix) as a result, patient may lie with knee bent to relieve tension on ilopsoas muscle • Positive rebound tenderness

7. Rovsing sign: RLQ pain when palpating LLQ • Obturator sign: Right hip and knee flexed, then rotated internally stretching obturator muscle (pelvic appendix) • McBurney’s sign: Pressure applied to McBurney’s Point • Bowels sounds can be present, absent, or decreased

8. Symptoms can be dependent on location of the tip of appendix

9. Retrocecal appendix: may only produce dull abdominal tenderness but marked pain during rectal/pelvic exam • Anterior appendix: Produces marked, localized pain in the right lower quadrant • Pelvic appendix: Causes tenderness below McBurney’s point. Also will have pain during rectal/pevic exam

10. Differential Dx • GI: Gastroenteritis, IBD, Divertulitis, Ileitis, Cholecystitis, Pancreatitis, bowel obstruction, Intussusception, Crohn’s Disease, • Gynecological: PID, Ectopic Pregnancy, Ruptured Ovarian Cyst, Tubo-Ovarian Cyst, Ovarian and Fallopian Torsion, Mittelschmerz, Endometriosis, Acute Endometritis • Urological: Testicular Torsion, Epididymitis, Renal Colic, kidney stones, Prostatitis, Cystitis, Pylenephritis

11. Laboratory Tests and Diagnostic Imaging • CBC with Diff: mild to moderate leukocytosis (10-20,000mcg/L) with a left shift of immature neutrophils • U/A: may show hematuria and/or pyuria • C-Reactive Protein (CPR)- elevation in CPR coupled with leukocytosis can be an indicator of appendicitis • CT scan is the most widely used imaging modality, but should be used only when diagnosis is uncertain • Ultrasound is reliable to confirm, not exclude, the diagnosis

12. Alvarado Scoring System • Migratory right iliac fossa pain 1pt • Anorexia 1pt • Nausea/Vomiting 1pt • Tenderness in RLQ 2pts • Rebound tenderness 1 pt • Fever >37.3 1 pt • Leukocytosis 2pts • Shift to the left 1 pt 1-4 discharge 5-6 observation/admission >7 surgery

13. Management/Treatment Guidelines The standard of care for treating appendicitis is appendectomy Preop: NPO, IV fluids, IV antibiotics Cefoxitin (1-2gms) Cefazolin (2g if <120kg 3g if >120kg) PCN and Cephalosporin allergy Clindamycin 900mg plus Gentamycin 5mg/kg

14. Different subjective and objective data of the pregnant patient • Less likely to present with classic appendicitis signs • Due to the enlarging uterus, McBurney’s Point may be located more toward the mid or upper right side of the abdomen • Rebound tenderness and guarding may not be present (due to uterus size) • An increased WBC is a normal finding in pregnancy, with the count rising to ~25,000 during labor

15. Different subjective and objective data of the pediatric patient • Lack of migratory pain in 50% of patients • Absent of anorexia, with 50% reporting they are hungry • Infants may be lethargic, have increased irritability with movement, and may flex their hips for comfort • Hoping on one foot or coughing usually elicits abdominal pain • Neonates display temperature instability • May limp or have right hip pain • May have right sided pelvic pain or mass on palpation or rectal exam

16. Differential Diagnosis in the Pediatric Patient The adult list plus: • Intussusception • Intestinal Malrotation • Torsion of the Omentum • Hemolytic Uremic Sydrome • Primary Peritonitis • Henoch-SchonleinPurpura • Sickle cell-disease • UTI

17. Complications of Appendicitis • Perforation • Sepsis • Shock • Death Peds: Rupture earlier and have a rupture rate of 15-60% Pregnant patients: 40% rupture rate and fetal mortality rate of 2-8.5% Geriatrics: Rupture rate of 67-90%

18. Complications of Surgery • Wound infection (increased risk if no prophylactic antibiotics) • Intestinal obstruction • Paralytic Ileus • Incisional Hernia • Preterm labor

19. Follow-up/counseling/education • No heavy lifting (>10 lbs) or strenuous physical activity for 4-6 weeks • May return to work 1-2 weeks • S/S infection

20. References: