Appendicitis: Diagnosis and Management

Acute appendicitis is the MOST COMMON SURGICAL EMERGENCY worldwide. For Zambian students, it is a DAILY PRESENTATION. Delayed diagnosis increases morbidity (perforation, abscess, peritonitis). PATHOPHYSIOLOGY: Luminal obstruction (faecolith, lymphoid hyperplasia, parasites, tumour) → bacterial overgrowth, distension, venous congestion, ischemia, necrosis, PERFORATION (24-36h). CLINICAL: CLASSIC: PERIUMBILICAL PAIN (visceral) → MIGRATES to RLQ (parietal), ANOREXIA, NAUSEA, VOMITING, LOW-GRADE FEVER. ATYPICAL: retrocecal (flank pain), pelvic (suprapubic, urinary frequency), subhepatic, pregnancy (pain location higher). PHYSICAL EXAM: RLQ TENDERNESS (McBurney's point), REBOUND, GUARDING, ROVSING'S SIGN (palpation LLQ → RLQ pain), PSOAS SIGN (retrocecal), OBTURATOR SIGN (pelvic). DIAGNOSIS: CLINICAL (history, exam). LABS: LEUKOCYTOSIS (left shift). CRP elevated. ALVARADO SCORE (MANTRELS): Migratory pain, Anorexia, Nausea/vomiting, Tenderness RLQ, Rebound, Elevated temp, Leukocytosis, Shift (left shift). Score 1-4: low risk, observe. 5-6: equivocal, imaging. 7-10: high risk, surgery. IMAGING: ULTRASOUND (first-line, non-ionizing, operator-dependent): non-compressible, dilated appendix (>6mm), appendicolith, periappendiceal fluid, increased Doppler flow. CT ABDOMEN (with IV contrast): GOLD STANDARD, highest accuracy (95-98%). Findings: dilated appendix (>6mm), wall thickening, fat stranding, appendicolith, abscess. MRI: pregnancy, children. MANAGEMENT: UNCOMPLICATED (early, non-perforated): APPENDECTOMY (LAPAROSCOPIC or OPEN). Laparoscopic: faster recovery, less pain, lower wound infection. NON-OPERATIVE MANAGEMENT (antibiotics only) in SELECTED PATIENTS: uncomplicated, no faecolith, mild symptoms. IV antibiotics (piperacillin-tazobactam, ceftriaxone+metronidazole) → oral antibiotics (7-10d). Failure rate 20-30%, recurrence 10-20%. COMPLICATED (perforated, abscess, phlegmon): PERCUTANEOUS DRAINAGE of abscess (if accessible) + IV antibiotics → INTERVAL APPENDECTOMY (6-12 weeks). EMERGENCY SURGERY if diffuse peritonitis, uncontrolled sepsis. Prognosis: EXCELLENT. Mortality <0.5% (uncomplicated). Perforation increases morbidity. Zambian context: APPENDICITIS IS COMMON. DIAGNOSIS: CLINICAL (Alvarado score). ULTRASOUND available, operator skill variable. CT limited. SURGERY: OPEN APPENDECTOMY (standard, widely available). LAPAROSCOPIC APPENDECTOMY (tertiary centres). ANTIBIOTICS: ceftriaxone, metronidazole, piperacillin-tazobactam available. PERCUTANEOUS DRAINAGE: limited. INTERVAL APPENDECTOMY: performed. FOCUS: CLINICAL DIAGNOSIS, TIMELY SURGERY (uncomplicated), PERCUTANEOUS DRAINAGE + INTERVAL APPENDECTOMY (complicated), AVOID DELAY (perforation).