Appendicitis

52 Appendicitis




Overview/pathophysiology


Appendicitis is the most commonly occurring inflammatory lesion of the bowel and one of the most common reasons for abdominal surgery. Appendicitis occurs most often in adolescents and young adults, and is more common in males than females. The appendix is a blind, narrow tube that extends from the inferior portion of the cecum and does not serve any known useful function. Appendicitis can be caused by obstruction of the appendiceal lumen by a fecalith (hardened bit of fecal material), inflammation, a foreign body, or a neoplasm. Obstruction prevents drainage of secretions that are produced by epithelial cells in the lumen, thereby increasing intraluminal pressure and compressing mucosal blood vessels. This tension eventually impairs local blood flow, which can lead to necrosis and perforation. Inflammation and infection result from normal bacteria invading the devitalized wall. Mild cases of appendicitis can heal spontaneously, but severe inflammation can lead to a ruptured appendix, which can cause local or generalized peritonitis.



Health care setting


Acute care surgical unit. Inpatient status for ruptured appendix with peritonitis; 1-day length of stay for suspected acute appendicitis without complications.



Assessment


Signs and symptoms vary because of differences in anatomy, size, and age. The sequence of symptoms can be significant in the differential diagnosis. Abdominal discomfort, indigestion, and bowel irregularity occur first.




Early stage:


Pain usually occurs in either the epigastric or umbilical area and may be vague and diffuse or associated with mild cramping. Nausea and vomiting are not always present, but if they occur, they follow the onset of pain. Fever and leukocytosis occur later.



Intermediate (acute) stage:


Over a period of a few hours, pain shifts from the midabdomen or epigastrium to the right lower quadrant (RLQ) at McBurney’s point (approximately 2 inches from the anterior superior iliac spine on a line drawn from the umbilicus) and is aggravated by walking, coughing, and movement. Pain may be accompanied by a sensation of constipation (gas-stoppage sensation). Anorexia, malaise, occasionally diarrhea, and diminished peristalsis also can occur.


On physical assessment, patient may experience pain in the RLQ elicited by light palpation of the abdomen; presence of rebound tenderness; RLQ guarding, rigidity, and muscle spasms; tachycardia; low-grade fever; and pain elicited with rectal examination. A palpable, tender mass may be felt in the peritoneal pouch if the appendix lies within the pelvis. Note: Physical assessment is performed in four steps—inspection, auscultation, percussion, and palpation—in that order, to avoid stimulating the abdomen by palpation and percussion, which can affect bowel sounds.



Acute appendicitis with perforation:


Increasing, generalized pain; recurrence of vomiting. On physical assessment, patient usually exhibits temperature increases to more than 38.5° C (101.4° F) and generalized abdominal rigidity. Typically, patient remains rigid with flexed knees. Presence of abscess can result in a tender, palpable mass. The abdomen may be distended.



Diagnostic tests




Abdominal computed tomography (CT) scan:


Has accuracy rate of 95% overall and should be performed before a laparotomy.



White blood cell count with differential:


Reveals presence of leukocytosis and an increase in neutrophils. A shift to the left with more than 75% neutrophils is a consistent finding in later stages of appendicitis.



Abdominal ultrasound:


May be done to rule out appendicitis or conditions that mimic it, such as Crohn’s disease, diverticulitis, or gastroenteritis. Higher success rate for diagnosis is found in children.



Abdominal x-ray examination:


May reveal presence of a fecalith. About half of these patients may have x-ray findings of localized air-fluid levels, increased soft tissue density in the RLQ, and indications of localized ileus. If perforation has occurred, the presence of free air is noted.

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Jul 18, 2016 | Posted by in NURSING | Comments Off on Appendicitis

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