Appendicitis in the adult, pediatric, and pregnant population

Kimberly Henry, RNC, FNP-SSUNY Institute of Technology

Nursing 652

Thought to be obstruction of appendiceal lumen↓

Inflammation ↓

Ischemia↓

Perforation↓

Abscess formation or Generalized Peritonitis

Pathophysiology

Etiology of the obstructionPediatrics

Lymphoid hyperplasia due to infections

Adults

Fecaliths (hard fecal masses)

Calculi Benign or malignant

tumors

1st degree relative with history of appendicitis

10-19 year old age group

Male (2:1)

Intra-abdominal tumors

Parasites

Risk Factors

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

Adult Patient Presentation:Subjective 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

Objective data

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

Symptoms can be dependent on location of

the tip of appendix

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

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

Differential Dx

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

Laboratory Tests and Diagnostic Imaging

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

Alvarado Scoring System

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

Management/Treatment Guidelines

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

Different subjective and objective data of the pregnant 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

Different subjective and objective data of the pediatric patient

The adult list plus: Intussusception Intestinal Malrotation Torsion of the Omentum Hemolytic Uremic Sydrome Primary Peritonitis Henoch-Schonlein Purpura Sickle cell-disease UTI

Differential Diagnosis in the Pediatric Patient

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%

Complications of Appendicitis

Wound infection (increased risk if no prophylactic antibiotics)

Intestinal obstruction Paralytic Ileus Incisional Hernia Preterm labor

Complications of Surgery

No heavy lifting (>10 lbs) or strenuous physical activity for 4-6 weeks

May return to work 1-2 weeks S/S infection

Follow-up/counseling/education

References: