Acute appendicitis (Ukázka, strana 99)

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Acute Appendicitis

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Diagnostic laparoscopy Vitezslav Marek

Diagnostic laparoscopy is the most effective diagnostic tool for AA. It exceeds the sensitivity and specificity of sonographic, CT and MRI examinations (1). In addition, it has therapeutic potential.

Diagnostic laparoscopy is indicated for an uncertain, suspected clinical diagnosis of AA in: • children, • elderly patients (over 65 years of age), • obese patients, • women before menopause.

During the examination itself, the surgeon classifies the laparoscopic finding on the appendix and considers a laparoscopic appendectomy. It indicates appendectomy in: • a macroscopic image of acute appendicitis, • a negative finding on the appendix, with pain in the right hypogastrium and a negative macroscopic image of the abdominal organs.

In the case of a negative finding on appendix and the identification of another representative source of abdominal pain (extrauterine pregnancy, ovarian bleeding...), appendectomy is not indicated (2).

References 1. Hershko DD, Sroka G, Bahouth H, et al. The role of selective computed tomography in the diagnosis and management of suspected acute appendicitis. Am Surg 2002; 68: 1003–1007.

2. Larsson PG, Henriksson G, Olsson M, et al. Laparoscopy reduces unnecessary appendicectomies and improves diagnosis in fertile women. A randomized study. Surg Endosc 2001; 15: 200–202.

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Diagnostic laparoscopy

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Tab. 12.1 Structured format for diagnosis of acute appendicitis Patient identification

First Second examination examination

Previous laparotomy Previous RLQ pain 1st degree relative with history of acute appendicitis Gynaecological history and last period (date): Patient´s position Facial expression Behaviour Patient mood Pulse/Breath/Body temperature History of pain – development, nature, localization, radiation Migration of pain to the lower right quadrant Protective spasm of the abdominal muscles (defense musculaire) Laboratory examination: • leukocytes • NLR • CRP • urine examination • B-HCG Imaging examination: • sonographic • CT • MRI Indication for surgery: • clear indications • uncertain indications Operation: • date • duration of the operation • postoperative diagnosis Lessons learned:

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Acute Appendicitis

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Differential diagnostics of AA Vitezslav Marek

As part of differential diagnostics, we must differentiate between AA and abdominal and thoracic diseases imitating the image of AA.

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Diseases of the abdominal cavity

1. Acute mesenteric lymphadenitis – a disease is preceded or accompanied by a banal “virosis”. Abdominal pain is indeterminate, mild, rather diffuse. The protective spasm of the abdominal muscles is not present. The number of heartbeats and breaths is not increased.

2. Perforation of the gastroduodenal ulcer – The perforation of gastroduodenal ulcer – if a personal history of ulcer disease is known, and there is a sharp (like a flash from clear sky) onset of somatic pain in the epigastrium, the diagnosis is conclusive. The problem arises when the stomach and duodenal contents flow along the ascending part of the colon into the right hypogastrium. Differential diagnostics is significantly difficult. A CT examination of the abdomen is helpful.

3. Acute pancreatitis – is characterized by acute, acute epigastric pain radiating to the lumbar region and left scapula. The patient vomits suddenly, and dehydration occurs rapidly. Abdominal pain is diffuse, with no signs of peritoneal irritation (oedematous form). Peristalsis is inaudible. An examination of serum amylases and CT examination of the abdomen are helpful in the differential diagnostics.

4. Acute gastroenteritis – there is dietary defect in the history. The patient vomits undigested remains of food. Diarrhoea is present, the tongue is coated, an indigestion smell in breath Similar to AA, pain is present in the epigastrium. Palpation pain is rather of a diffuse nature; there is no gradation of pain when pushing the right hypogastrium, unlike with AA. Rectal examination is negative. Repeated clinical examination of the abdomen and the use of imaging examinations have an exceptional place in differential diagnostics.

5. Right-sided ureterolithiasis – it is difficult to distinguish from retrocaecal AA. The urge to urinate or a feeling of incomplete urination are frequent. The pain is localized in the right mesogastrium – at the umbilical level. It is of colic nature and radiates to the right iliac. Cough intensifies the pain in AA, but not with ureterolithiasis.

Palpation pain and muscular protective spasm are present along the entire length of the right side of the abdomen and extend laterally to the lumbar region. There is percussion pain in the right lumbar region. Blood is present in the urine. With differential diagnosis of difficulties with retrocaecal AA, a CT examination of the abdomen is appropriate.

6. Acute hydronephrosis – it mimics the image of a periappendicular abscess. It is manifested by a pain in the right meso-hypogastrium. We palpate a spherical shape formation, freely movable, painful at the touch. We palpate the formation in the right meso-hypogastrium and in the right lumbar region. Unlike AA, there is a frequent urge to urinate, burning when urinating, and colic-like pain without protective muscle spasm of the abdominal muscles.

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