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Appendicitis: Patients
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Appendicitis is the most common cause of acute abdominal pain that necessitates surgical intervention in the Western world (1). Clinical diagnosis of acute appendicitis is based primarily on symptoms and physical findings. However, this diagnosis is often difficult, and up to 50% of patients hospitalized for possible appendicitis do not actually have this disorder. Authors of large prospective studies report a 22%–30% removal rate of normal appendices at surgery (2–5). To reduce the frequency of unnecessary appendectomy, the importance of laboratory findings that include both white blood cell (WBC) counts and C-reactive protein (CRP) values has been stressed (6–8), and the use of ultrasonography (US) as a diagnostic tool for appendicitis has been widely evaluated (9–13). Reported US signs of appendicitis can be grouped into the two categories of (a) appendiceal findings and (b) periappendiceal findings, which mainly include inflammatory changes in the right lower abdominal quadrant.
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Appendicitis in the elderly may be difficult to diagnose because they don't experience the typical symptoms of the illness. Appendicitis should be considered... in any elderly patient who still has an appendix and who develops sudden abdominal pain.
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Appendicitis can be classified into two types, typical and atypicical. The painof typical acute appendicitis usually starts centrally (periumbilical) before localising to the right iliac fossa(the lower right side of the abdomen). There is usually associated loss of appetite and fever. Nausea, or vomitingmay or may not occur. These classic signs and symptoms are more likely the younger the patient. Older patients (beyond their teenage years) may present with only one or two.
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Appendicitis is usually sudden in its onset and progresses rapidly. After a diagnosis of appendicitis, most people have immediate surgery to remove the appendix, an operation called an appendectomy. Sometimes surgeons drain the abdominal cavity and put the patient on antibiotic therapy, then do the appendectomy 6 weeks to 3 months later.
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This retrospective, case-control study in a large HMO in northern California examined hospitalizations for pathology-confirmed appendicitis in HIV-positive men (age 20-74 years) and in controls not known to be HIV-positive. Between January 1991 and December 1995, prior to the advent of potent antiretroviral therapy in this population, the rate of hospitalization for appendicitis was approximately 3-fold higher in the HIV-infected group: 2.9 versus 0.92 events/1,000 patient-years in cases and controls, respectively. The study ... included over 18,000 person-years of follow-up among HIV-infected men in an era of effective antiretroviral therapy (January 1996-February 2001). Among these patients, the rate of hospitalization for appendicitis was 3.1 per 1,000 patient-years, compared with 0.73 per 1,000 patient-years among patients not known to be HIV positive (p < .01). Interestingly, during the same time period (1996-2001) the percentage of appendicitis admissions with initial white blood cell count >12,500 /mm 3 was 70% among HIV-negative controls but only 26% among HIV-infected patients (p < .0001). CD4-cell count was not predictive of risk for perforation, which was not statistically different between HIV-infected and -uninfected patients (although a trend towards increased frequency of perforation in HIV-positive patients was noted).
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It is important to get treatment for appendicitis before the wall of the appendix breaks down because of progressive inflammation and infection. In advanced stages of inflammation when the wall of the appendix begins to break down, it is sometimes called “gangrenous appendicitis”. When this happens, you could develop an abscess or spread of this infection into the abdomen causing peritonitis, which is a dangerous infection of the lining of the belly. This is ... sometimes called “perforated” or “ruptured” appendicitis. Because of the risk of this happening if appendicitis is untreated, the treatment of appendicitis is considered an emergency. Because of the unusual location of the appendix or other reasons, about 20% of patients with appendicitis are unaware of their symptoms until the inflammation in the appendix has progressed through the wall or “perforated” and early diagnosis is not possible.
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