Definition and Pathophysiology:
Acute appendicitis is the inflammation of the vermiform appendix, typically caused by an obstruction due to fecaliths, lymphoid hyperplasia, tumors, or foreign bodies. If untreated, it can lead to perforation, peritonitis, and sepsis, making it a medical emergency that often requires surgical intervention.
Pathophysiology
The obstruction in the appendix leads to:
- Increased intraluminal pressure → Venous congestion and ischemia.
- Bacterial overgrowth → Inflammation and purulent infection.
- Necrosis and perforation → Peritonitis and sepsis if untreated.
Etiology and Risk Factors:
- Obstruction (fecaliths, lymphoid hyperplasia, parasites)
- Infections (gastrointestinal or systemic)
- Genetic predisposition
- Low-fiber, high-fat diet (linked to fecalith formation)
- Adolescents and young adults (10–30 years)
Signs and Symptoms
Early symptoms:
- Periumbilical pain (vague, dull)
- Anorexia, nausea, vomiting
- Mild fever
Classic presentation:
- Localized pain at McBurney’s point (RLQ)
- Rebound tenderness (Blumberg’s sign)
- Rovsing’s sign (RLQ pain when pressing on LLQ)
- Psoas sign (pain on hip extension)
- Obturator sign (pain with internal hip rotation)
Complications:
- Perforation → Severe, sudden relief of pain followed by generalized peritonitis
- Sepsis → Tachycardia, hypotension, high fever
Diagnosis:
- Physical examination (tenderness, positive special signs)
- Imaging:
- Ultrasound (preferred in children and pregnant patients)
- CT scan (gold standard for diagnosis)
- Laboratory tests:
- ↑ WBC count (>10,000/mm³ with left shift)
- ↑ CRP (C-reactive protein, indicates inflammation)
Treatment and Management
Preoperative Care
- NPO status
- IV fluids (prevent dehydration)
- Pain management (avoid strong opioids until diagnosis confirmed)
- Avoid laxatives or enemas (may cause rupture)
- Antibiotics (cephalosporins, metronidazole) if perforation is suspected
Surgical Intervention
- Laparoscopic appendectomy (preferred) → Less pain, faster recovery
- Open appendectomy if perforation or complications present
Postoperative Care
- Monitor for infection, bleeding, and bowel function return
- Encourage early ambulation
- Pain management (NSAIDs, acetaminophen
- Monitor for signs of peritonitis (fever, tachycardia, abdominal rigidity)
Complications:
- Perforation → Can lead to peritonitis or abscess formation
- Peritonitis → Generalized abdominal pain, fever, sepsis
- Abscess formation → May require drainage before surgery
Nursing Considerations (NCLEX Focus)
✅ Assess pain characteristics (location, intensity, progression)
✅ Monitor for signs of perforation (sudden relief of pain followed by worsening symptoms)
✅ Postoperative care (monitor VS, assess wound, promote mobility)
✅ Education on recovery (diet, wound care, avoiding heavy lifting)
References (APA 7th Edition):
- Andersson, R. E. (2020). The natural history and traditional management of appendicitis revisited. World Journal of Surgery, 44(9), 2890–2893. https://doi.org/10.1007/s00268-020-05551-1
- Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: Modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278–1287. https://doi.org/10.1016/S0140-6736(15)00275-5
- D’Souza, N., & Nugent, K. (2016). Appendicitis. American Family Physician, 93(2), 142–143. Retrieved from https://www.aafp.org
- Ferris, M., Quan, S., Kaplan, B. S., Molodecky, N., Ball, C. G., Lobo, D. N., & Gmora, S. (2017). The global incidence of appendicitis: A systematic review of population-based studies. Annals of Surgery, 266(2), 237–241. https://doi.org/10.1097/SLA.0000000000002188
- Humes, D. J., & Simpson, J. (2019). Acute appendicitis. BMJ, 333(7567), 530–534. https://doi.org/10.1136/bmj.333.7567.530
- Körner, H., Söreide, J. A., Pedersen, G., Bru, T. B., Søreide, K., & Vatten, L. (2019). Risk factors for perforation in acute appendicitis in adults. Annals of Surgery, 267(5), 1036–1041. https://doi.org/10.1097/SLA.0000000000002878
- Masoomi, H., Nguyen, N. T., Dolich, M. O., Kim, E. G., Mills, S., Carmichael, J. C., & Stamos, M. J. (2018). Laparoscopic versus open appendectomy: A population-based analysis. Journal of the American College of Surgeons, 215(3), 403–410. https://doi.org/10.1016/j.jamcollsurg.2012.05.007
- Sartelli, M., Baiocchi, G. L., Di Saverio, S., Ferrara, F., Labricciosa, F. M., Ansaloni, L., … & Catena, F. (2020). Prospective evaluation of patients with acute appendicitis: A multicenter observational study (ANNEX study). World Journal of Emergency Surgery, 15(1), 45. https://doi.org/10.1186/s13017-020-00321-3
- Varadhan, K. K., Humes, D. J., Neal, K. R., Lobo, D. N., & Simpson, J. (2019). Antibiotic therapy versus appendectomy for acute appendicitis: A meta-analysis. World Journal of Surgery, 34(2), 199–209. https://doi.org/10.1007/s00268-009-0294-6
- Walker, S. J., West, R., & Colmer, M. R. (2019). Pediatric appendicitis: Trends in diagnosis and management. The Journal of Pediatrics, 204, 97–102. https://doi.org/10.1016/j.jpeds.2018.07.041