Acute Appendicitis

The appendix, also known as the vermiform appendix, is a narrow, tubular structure attached to the cecum at the confluence of the taeniae coli, which converge at the base of the appendix. It is located in the right lower quadrant of the abdomen, commonly in the retrocecal position (65%–70% of cases), though pelvic, subcecal, retroileal, preileal, and paracecal positions are also possible.

Dimensions and Vascular Supply

• The appendix is approximately 6–9 cm in length in adults but can vary significantly.
• It derives arterial supply primarily from the appendicular artery, a branch of the ileocolic artery (off the superior mesenteric artery).
• Venous drainage parallels the arterial supply, terminating in the superior mesenteric vein.
• Lymphatic drainage follows the mesoappendix, eventually draining into the ileocolic lymph nodes.
• Its innervation includes sympathetic fibers from the T10 spinal segment and parasympathetic fibers via the vagus nerve.

Histology

The appendix contains abundant lymphoid tissue in its submucosa, playing a role in immune response, particularly during early life. Its mucosa resembles that of the colon, consisting of simple columnar epithelium with goblet cells.

Appendicitis is an inflammatory condition of the appendix, often resulting from luminal obstruction. This obstruction can arise from various etiologies:

1. Fecaliths or Appendicoliths: Hardened fecal material occluding the lumen.
2. Lymphoid Hyperplasia: Common in younger individuals, typically due to infections.
3. Foreign Bodies or Neoplasms: Less common causes.

Pathophysiological Sequence

1. Obstruction: Obstruction of the appendiceal lumen leads to mucosal secretions accumulating within the appendix, increasing intraluminal pressure.
2. Venous Congestion: Elevated pressure compresses venous outflow, leading to vascular congestion and ischemia.
3. Bacterial Overgrowth: Ischemia facilitates bacterial proliferation, predominantly involving Escherichia coli and Bacteroides fragilis.
4. Inflammation and Necrosis: The inflamed mucosa can ulcerate, allowing translocation of bacteria, resulting in further inflammation and eventual necrosis.
5. Perforation: Untreated necrosis can lead to perforation, with spillage of appendiceal contents into the peritoneal cavity, causing localized abscess or generalized peritonitis.

Clinical Correlation

• Early appendicitis presents as visceral pain referred to the periumbilical region due to T10 dermatome innervation. As the inflammatory process involves the parietal peritoneum, pain localizes to the right lower quadrant (McBurney’s point).
• Associated symptoms include nausea, vomiting, fever, and anorexia.

I. Patient Information

• Biodata: Name, age, sex, occupation, religion, tribe, marital status, address, etc.

II. Presenting Complaint

• Abdominal Pain

III. History of Presenting Complaint (Detailed Analysis)

1. Symptom Analysis

• Characterization:
  • Duration: Specify onset, progression, and current state.
  • Initial Pain: Periumbilical, moderate intensity, colicky or dull-aching (due to visceral pain).
  • Later Pain: Shifts to the right iliac fossa (RIF), becomes severe, sharp, and constant (due to irritation of parietal peritoneum).
  • Aggravating Factors: Exacerbated by coughing or sudden movements.
  • Alleviating Factors: Temporary relief with analgesics.
  • Progression: May become generalized with the onset of peritonitis.

2. Associated Symptoms

• Common:
  • Anorexia: Invariable in most cases.
  • Nausea: Prominent, with vomiting (1–2 episodes, non-bilious) due to gastrocolic reflex.
• Less Common:
  • Bowel Habits: Constipation common; diarrhea may occur with pelvic appendix or appendiceal abscess.
  • Suprapubic pain or discomfort.
  • Dysuria: Especially with pelvic appendix.
  • Fever: Low-grade fever, no chills or rigors.
• Rare:
  • Jaundice.
  • Right lower abdominal swelling.

3. Analysis of Aetiology

• Dietary Factors: Low dietary fiber, high refined carbohydrate intake.
• Recurrent Episodes: Previous episodes of similar pain may suggest recurrent appendicitis.
• Family History: Enquire about family history of appendicitis or related conditions.

4. Differential Diagnoses (Rule Out Other Conditions)

• Adult Females:
  • Ruptured Ectopic Pregnancy:
    • History of sexual activity, LMP, amenorrhea.
    • Lower abdominal pain, sometimes vaginal bleeding.
    • Rarely causes vomiting or fever.
  • Pelvic Inflammatory Disease (PID):
    • Vaginal discharge, lower abdominal pain ± fever.
    • No anorexia.
  • Torsion/Ruptured Ovarian Cyst:
    • Recurrent lower abdominal pain, no fever or anorexia.
• Adult Males & Females:
  • Urinary Tract Infection (UTI):
    • Dysuria, fever, vomiting, suprapubic pain.
  • Peptic Ulcer Disease (PUD):
    • Epigastric pain, vomiting.
    • No fever or anorexia.
  • Right Ureteric Colic (Stones):
    • Pain radiating to groin/pelvis.
    • Vomiting often present.
• Children:
  • Mesenteric Adenitis and Gastroenteritis: Features of a recent viral infection.
• Elderly/Middle-aged:
  • Caecal Pole Tumor: Weight loss, RIF colicky abdominal pain.

5. Past Medical and Surgical History

• Abdominal Surgeries: History of previous abdominal surgeries (important as adhesions can complicate acute appendicitis).
• Medical History: Rule out chronic illnesses (e.g., diabetes, immunosuppression) or previous abdominal infections.

General Examination

• Appearance: The patient may appear febrile, uncomfortable, and in distress due to abdominal pain.
• Posture: The patient often lies supine with the right hip flexed, which helps reduce irritation from the inflamed appendix on the parietal peritoneum.

Vital Signs

• Pulse: Typically normal, but tachycardia may indicate complications such as sepsis or perforation.
• Blood Pressure (BP) and Respiratory Rate (RR): Usually normal, unless there is significant systemic involvement (e.g., septic shock or peritonitis).

Abdominal Examination

• Inspection:
  • Reduced abdominal movement with respiration: This is common in cases of peritonitis, where muscle guarding and rigidity limit abdominal motion.
• Palpation:
  • Pointing Sign: The patient points to McBurney's point (located 1/3 of the distance from the anterior superior iliac spine to the umbilicus) as the site of maximal pain.
  • Localized Tenderness: Often found in the Right Iliac Fossa (RIF), specifically at McBurney’s point.
  • Muscle Guarding: Involuntary tensing of abdominal muscles upon palpation, indicating peritoneal irritation.
  • Rebound Tenderness: Increased pain when pressure is suddenly released after palpation of the RIF.
  • Rovsing’s Sign: Deep palpation of the Left Iliac Fossa (LIF) causes pain in the RIF, suggesting peritoneal irritation in the right side.
• Special Tests:
  • Psoas Sign: Pain in the RIF when the patient lies on the left side and extends the right hip. This is suggestive of retrocecal appendicitis.
  • Obturator Sign: Pain in the RIF when the right hip is flexed and internally rotated, often seen in pelvic appendicitis.
  • Dunphy’s Sign: Pain in the RIF worsened by coughing, often associated with retrocecal appendicitis.

Digital Rectal Examination (DRE)

• Tenderness of the Right Rectal Wall: This suggests pelvic appendicitis or lower abdominal peritonitis. It may indicate the appendix is located low in the pelvis or that there is extensive inflammation.

Note:

• When performing the examination, it is important to document the exact location, severity, and nature of tenderness as well as the presence of specific signs.
• Careful assessment for signs of complications such as generalized peritonitis or appendiceal abscess should be made. This includes checking for systemic signs of sepsis like tachycardia, fever, and hypotension.

Overview

The diagnosis of appendicitis is primarily clinical. However, laboratory and imaging studies support the diagnosis, especially in atypical presentations or when ruling out differential diagnoses.

I. Laboratory Investigations

1. Full Blood Count (FBC):
   • Leukocytosis: WBC > 10,000/mm³ is typical in appendicitis.
   • Neutrophilia: Elevated neutrophils (shift to the left) suggest bacterial infection.
   • PCV: May be normal in the early stages.
2. Pregnancy Test (β-hCG):
   • Conducted in females of reproductive age to exclude ectopic pregnancy and other pregnancy-related conditions.
3. Urinalysis:
   • WBC/RBC or Protein: May indicate irritation of the bladder or ureter by a pelvic or retrocecal appendix.
   • Nitrites/Protein: Helps exclude urinary tract infection (UTI).
4. Inflammatory Markers:
   • C-Reactive Protein (CRP): Elevated in inflammatory states.
   • Procalcitonin and APPY1 biomarker: May provide additional diagnostic support in atypical cases.
5. Serum Electrolytes and Urea:
   • Evaluate for dehydration or electrolyte imbalances, especially in cases with vomiting or systemic complications.

II. Imaging Studies

1. Ultrasonography (USG):
   • Findings:
     • Non-compressible tubular structure (>6 mm in diameter).
     • Increased echogenicity of periappendiceal fat.
     • Appendicolith or periappendiceal fluid.
     • Sentinel loop: Dilated terminal ileum.
   • Advantages:
     • Safe, non-invasive, and radiation-free.
     • Ideal for children and pregnant women.
   • Limitations:
     • Operator-dependent and less reliable in obese patients.
     • The appendix may not always be visualized.
2. Contrast-Enhanced CT (CECT):
   • Findings:
     • Appendiceal dilatation (>6 mm).
     • Wall thickening (>3 mm) with enhanced wall.
     • Periappendiceal fluid or fat stranding.
     • Cecal bar sign: Thickened cecal apex.
   • Purpose: High sensitivity and specificity (96%), useful in elderly or complicated cases.
   • Disadvantages: Expensive, radiation exposure.
3. Magnetic Resonance Imaging (MRI):
   • Useful in pregnant women as an alternative to CT.
   • Findings:
     • Thickened, dilated appendix.
     • Periappendiceal fluid.
     • Thickened terminal ileum or cecum.
4. Plain Abdominal X-Ray:
   • Findings:
     • Fecolith in the right iliac fossa.
     • Scoliosis with concavity toward the right.
     • Loss of psoas shadow or air-fluid levels in obstruction.
   • Purpose: Limited utility but may identify complications like obstruction or perforation.
5. Barium Enema:
   • Shows non-filling of the appendix lumen (arrowhead sign).
   • Rarely used today due to advancements in imaging.

III. Scoring Systems

1. Alvarado Score (MANTRELS):
   • Migratory RIF pain (1 point).
   • Anorexia (1 point).
   • Nausea/vomiting (1 point).
   • Tenderness in RIF (2 points).
   • Rebound tenderness (1 point).
   • Elevated temperature (1 point).
   • Leukocytosis (2 points).
   • Left shift of neutrophils (1 point).

   Interpretation:

   • Score ≥7: Likely appendicitis.
   • Score 5-6: Equivocal; further investigations needed.
   • Score <5: Unlikely appendicitis.
2. Other Scoring Systems:
   • Modified Alvarado Score.
   • Acute Inflammatory Response (AIR) Score.
   • RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) Score.
   • Appendicitis Inflammatory Response (APPEND) Score.

Note

• Investigations are critical in atypical presentations and populations with high diagnostic uncertainty (e.g., women, elderly, children).
• Combining clinical findings with targeted investigations ensures accurate diagnosis and minimizes unnecessary surgical interventions.

1. Stomach/Duodenum
   • Perforated Peptic Ulcer Disease (PUD):

     Characterized by severe, sudden-onset abdominal pain with signs of peritonitis and free air on X-ray. May mimic appendicitis, especially when perforation is in the right lower quadrant.

2. Intestine
   • Acute Intestinal Obstruction:

     Often presents with colicky pain, vomiting, and abdominal distension. X-rays may show air-fluid levels and dilated bowel loops.

   • Perforated Typhoid Enteritis:

     Seen in endemic areas, with prolonged fever, abdominal pain, and history of recent enteric fever. May present with similar signs of peritonitis.

   • Meckel's Diverticulitis:

     Inflammation of a congenital diverticulum in the ileum, often mimicking appendicitis. It can present with RLQ pain, but typically with less systemic involvement.

   • Regional Ileitis (Crohn's Disease):

     Inflammatory bowel disease affecting the terminal ileum. May present with chronic RLQ pain, diarrhea, and weight loss. Imaging shows bowel thickening or strictures.

3. Colon
   • Right-sided Diverticulitis:

     Common in older adults, presenting with fever, tenderness in the right abdomen, and often with changes in bowel habits. CT scan can help differentiate it from appendicitis.

   • Caecal Cancer (Caecal Tumor):

     Often presents with chronic right abdominal pain, changes in bowel habits, and weight loss. A colonoscopy or CT scan is needed to differentiate.

   • Perforated Colon:

     Can mimic appendicitis when there is perforation in the right colon, often due to diverticulitis or malignancy.

4. Hepatobiliary
   • Acute Cholecystitis:

     RUQ pain, fever, and positive Murphy’s sign. Ultrasound is helpful in distinguishing this from appendicitis.

   • Amoebiasis:

     Can present with right lower quadrant pain and fever, especially in endemic regions. Stool examination or serology is used to confirm.

5. Kidneys
   • Acute Pyelonephritis:

     Fever, dysuria, and CVA tenderness. Urine analysis typically shows pyuria and bacteriuria, distinguishing it from appendicitis.

   • Renal Colic/Ureteric Colic:

     Severe colicky pain radiating to the groin. Urinalysis may show hematuria, and imaging (e.g., ultrasound or CT) will reveal kidney stones.

6. Pancreas
   • Acute Pancreatitis:

     Severe epigastric pain radiating to the back, with elevated serum amylase and lipase levels. CT or ultrasound confirms the diagnosis.

7. Intra-abdominal Lymph Nodes
   • Mesenteric Adenitis:

     Inflammation of the mesenteric lymph nodes, typically in children. It can mimic appendicitis with right lower quadrant pain, fever, and tenderness.

8. Gynaecological Cases
   • Right Ectopic Pregnancy (ruptured):

     History of missed periods, positive pregnancy test, and severe unilateral abdominal pain with signs of shock and peritonitis.

   • Accidented Right Ovarian Cyst (Torsion):

     Sudden-onset severe lower abdominal pain, often with nausea and vomiting. Ultrasound is helpful for diagnosis.

   • Accidented Right Pedunculated Fibroid:

     Twisted fibroid presenting with acute lower abdominal pain. Imaging shows the fibroid with torsion.

   • Acute Pelvic Inflammatory Disease (PID):

     Lower abdominal pain, fever, and vaginal discharge. Pelvic examination and ultrasound are useful for diagnosis.

   • Mittelschmerz:

     Mid-cycle pain associated with ovulation. Typically a mild, self-limiting pain.

   • Endometriosis:

     Chronic pelvic pain, dysmenorrhea, and dyspareunia. Laparoscopy is required for diagnosis.

9. Medical Conditions
   • Right Basal Pneumonia:

     Presents with chest pain, fever, and cough. X-ray will show infiltrates in the lower lobe of the lung.

   • Gastroenteritis:

     Diarrhea, vomiting, and diffuse abdominal pain. Stool tests may help identify the pathogen.

   • Abdominal Crisis in Hemoglobin SS (Sickle Cell Disease):

     Acute severe abdominal pain due to vaso-occlusion in the mesenteric vessels. Hemoglobin electrophoresis confirms the diagnosis.

Differential Diagnoses Peculiar to Children

• Gastroenteritis:

  Often presents with vomiting, diarrhea, and diffuse abdominal pain, without localized tenderness.

• Mesenteric Adenitis:

  Often seen in children, presenting with right-sided abdominal pain, fever, and tenderness. History of recent viral infection is often present.

• Lobar Pneumonia:

  May present with abdominal pain, fever, and respiratory symptoms. Chest X-ray helps differentiate it.

• Meckel’s Diverticulitis:

  As with adults, it can present with RLQ pain, mimicking appendicitis.

• Intussusception:

  Severe abdominal pain, vomiting, and the passage of "currant jelly" stools. Ultrasound or air enema is diagnostic.

• Henoch-Schönlein Purpura:

  A vasculitis with abdominal pain, purpura, and renal involvement. History of recent viral infection and skin changes help differentiate.

1. Definitive Treatment
The definitive treatment for acute appendicitis is an appendectomy. This can be performed as either an open or laparoscopic procedure:

A. Open Appendectomy

• Incision: McBurney’s incision.
• Indications:
  • Resource-limited settings.
  • Complications such as perforation or abscess.
  • Advanced peritonitis.

B. Laparoscopic Appendectomy

• Advantages:
  • Shorter recovery time.
  • Reduced postoperative pain.
  • Smaller scars.
• Limitations:
  • Not ideal for advanced peritonitis.
  • Not suitable for resource-constrained facilities.

Types of Appendicectomy:

• Emergency Appendicectomy: Performed when a diagnosis of acute appendicitis is made.
• Elective Appendicectomy: Done for subacute appendicitis, recurrent, or chronic appendicitis. This is planned surgery and not urgent.
• Incidental Appendicectomy: Occurs when the appendix is removed during another abdominal surgery by chance. It is no longer recommended as a routine practice unless the surgery is for a contaminated procedure.
• Interval Appendicectomy: Done 6–8 weeks after the resolution of complicated appendicitis (e.g., appendix mass or abscess) to prevent recurrent episodes of appendicitis.
• Laparoscopic Appendicectomy: A minimally invasive approach where small incisions are made, and the appendix is removed using a camera and specialized instruments. It is associated with quicker recovery times and less scarring compared to open appendicectomy.

2. Preoperative Management

• NPO (Nil Per Os): The patient is kept fasting in preparation for surgery.
• Intravenous Fluids (IVF): Correct dehydration and electrolyte imbalance.
• Analgesia: Pain relief using IV paracetamol or opioids (e.g., morphine). Avoid excessive analgesia if the diagnosis is uncertain.
• Antibiotics: Administer broad-spectrum IV antibiotics to cover gram-negative and anaerobic bacteria (e.g., ceftriaxone + metronidazole). Reduces postoperative infection risks.

3. Postoperative Management

• Monitoring: Watch for complications such as infection, bowel obstruction, or intra-abdominal abscess. Regular assessment of vitals and surgical wound site.
• Diet: Gradual reintroduction of oral intake, beginning with clear fluids.
• Antibiotics: Continue for 5–7 days if appendicitis was complicated (e.g., perforation or abscess).
• Pain Management: Oral analgesics as required.

4. Treatment of Uncomplicated Appendicitis

• Surgical Management: Emergency Appendectomy: Primary treatment to prevent rupture and complications such as peritonitis. Performed under general anesthesia.

5. Incision Types for Appendectomy

• Lanz Incision: Transverse incision at McBurney’s point. Preferred for better cosmetic outcomes (follows natural skin creases).
• Gridiron Incision: Muscle-splitting incision at McBurney’s point. Effective but less cosmetically appealing.
• Other Incisions:
  • Right Lower Paramedian: Common for complicated cases.
  • Rutherford Morrison Incision: Extends laterally, useful in abscess or perforation.
  • Battle’s and Rocky-Davies Incisions: Rarely used.

1. Appendix Gangrene:

   The appendix may become necrotic and gangrenous due to lack of blood supply, often associated with delayed diagnosis or treatment. This can lead to perforation if not addressed promptly.

2. Appendix Mass:

   The inflamed appendix may become surrounded by omentum, ileum, and cecum, forming a mass. This can occur when the appendix is inflamed but not perforated. It can be treated conservatively initially but may require surgical intervention later.

3. Appendix Abscess:

   A localized collection of pus around the appendix, often resulting from perforation or gangrene. It can present with fever, worsening abdominal pain, and may require drainage (either percutaneously or surgically) and/or appendectomy.

4. Perforation (Ruptured Appendicitis):

   If the appendicitis is not treated in a timely manner, the appendix can rupture, leading to contamination of the peritoneal cavity with infectious material. This can result in widespread peritonitis, a life-threatening condition.

5. Spreading Peritonitis:

   The rupture of the appendix releases bacteria into the peritoneal cavity, causing generalized peritonitis. This leads to severe abdominal pain, distension, fever, and a risk of septic shock. It requires prompt surgical intervention (lavage and appendectomy) and intensive care management.

6. Intra-abdominal Abscess:

   Abscess formation can occur in different locations, including:

   1. Pelvic abscess
   2. Retrocecal abscess
   3. Subhepatic abscess
   4. Subphrenic abscess

   These abscesses can be difficult to diagnose and often require imaging (ultrasound or CT) and drainage, along with antibiotics.

7. Recurrent Appendicitis/Chronic Appendicitis:

   Recurrent episodes of appendicitis or chronic inflammation of the appendix can occur in some patients. The clinical presentation may be less acute, with intermittent pain, anorexia, and nausea. It may not be immediately diagnosed and could eventually require an appendectomy.

1. Extremes of Age:

   Both very young and elderly patients may present with atypical symptoms or delayed diagnosis, increasing the risk of perforation. In children, misdiagnosis may lead to a delay in treatment, while in the elderly, atypical presentations can result in delayed recognition.

2. Immunosuppression:

   Patients who are immunocompromised (due to conditions like HIV/AIDS, cancer treatment, or organ transplantation) are at higher risk for severe appendicitis and complications like perforation due to reduced immune response.

3. Diabetes Mellitus:

   Diabetes can impair immune function, increase the risk of infection, and delay the diagnosis of appendicitis, raising the risk of perforation and associated complications.

4. Faecolith Obstruction:

   A faecolith (hardened stool or foreign body) can obstruct the lumen of the appendix, leading to increased pressure, decreased blood flow, and a higher likelihood of perforation.

5. Pelvic Appendix:

   An appendix located in the pelvic region can present with more atypical symptoms, making diagnosis more difficult. This can result in delays in treatment and an increased risk of perforation.

6. Previous Abdominal Surgery:

   Adhesions from previous surgeries (e.g., cesarean section, laparotomy) can obscure the clinical presentation and delay diagnosis. Scar tissue may also make surgery more challenging if the appendix is located near adhesions.

1. Early Postoperative Complications

1. Paralytic Ileus:

   Definition: Temporary bowel paralysis post-surgery.

   Symptoms: Abdominal bloating, nausea, and vomiting.

   Management: Supportive care with IV fluids and nasogastric decompression.

2. Hemorrhage:

   Definition: Bleeding from the surgical site or intra-abdominally.

   Management: Monitoring; surgical intervention if severe.

3. Wound Infection:

   Risk Factors: Perforated appendix or poor aseptic technique.

   Symptoms: Redness, swelling, discharge, fever.

   Management: Wound care and antibiotics.

4. Intra-abdominal Abscess:

   Definition: Pus collection within the abdomen.

   Management: Percutaneous or surgical drainage with antibiotics.

5. Enterocutaneous Fistula:

   Definition: Abnormal connection between the intestine and the skin.

   Management: Conservative care or surgical repair if persistent.

6. Septicemia:

   Definition: Systemic infection spreading from the surgical site.

   Management: Aggressive antibiotics and supportive care.

7. Pylephlebitis (Portal Vein Thrombophlebitis):

   Definition: Infection of the portal venous system, often leading to liver abscesses.

   Management: IV antibiotics and drainage of abscesses if present.

2. Late Postoperative Complications

1. Adhesive Intestinal Obstruction:

   Definition: Bowel blockage due to intra-abdominal adhesions.

   Symptoms: Cramping abdominal pain, vomiting, and distension.

   Management: Conservative or surgical intervention in severe cases.

2. Incisional Hernia:

   Definition: Protrusion of abdominal contents through a weakened surgical site.

   Management: Elective surgical repair if symptomatic.

Key Points:

• Paralytic Ileus: Common in early postoperative phase.
• Wound Infections & Abscesses: Higher risk in perforated appendicitis cases.
• Long-term Risks: Adhesions leading to bowel obstruction are the most common late complication.

An appendiceal mass is a localized inflammatory conglomerate that includes:

• The inflamed appendix.
• Cecum.
• Terminal ileum.
• Greater omentum.

This forms as a physiologic response to wall off the infection, preventing it from spreading within the peritoneal cavity.

Treatment Approach

The primary management strategy for an appendiceal mass is conservative (non-surgical) treatment, also known as the Ochsner-Sherren regimen. Immediate surgery is avoided to minimize risks such as iatrogenic injury to surrounding structures or fistula formation.

Ochsner-Sherren Regimen for Appendiceal Mass

A. Initial Conservative Management

1. Nil Per Os (NPO):
   • Patient is kept fasting to rest the bowel.
   • If vomiting occurs, insert a nasogastric tube to decompress the stomach.
2. Intravenous (IV) Fluids:
   • Ensure adequate hydration and correct any electrolyte imbalances.
3. IV Antibiotics:
   • Administer broad-spectrum antibiotics (e.g., ciprofloxacin + metronidazole) to cover gram-negative and anaerobic organisms.
4. IV Analgesics:
   • Provide pain relief without masking diagnostic signs (e.g., IV paracetamol or pentazocine).
5. Vital Sign Monitoring:
   • Regular monitoring of:
   • Pulse rate (hourly).
   • Temperature (every 4 hours).
   • Blood pressure and respiratory rate.
6. Mass Size Assessment:
   • Mark the borders of the mass on the skin with a marker and measure twice daily to track changes.
7. Assess Abdominal Tenderness:
   • Monitor for improvement or worsening of tenderness and guarding.

B. Outcomes and Next Steps

1. If Improvement is Observed:
   • Criteria for Success:
   • Normal pulse and temperature.
   • Reduction or resolution of the mass.
   • No abdominal tenderness.
   • Plan:
   • Gradually reintroduce oral intake once symptoms improve.
   • Schedule an interval appendectomy in 6–8 weeks to prevent recurrence.
2. If No Improvement or Worsening Occurs:
   • Indicators of Failure:
   • Persistent or increasing size of the mass.
   • Rising pulse rate and temperature (especially if >39°C).
   • Persistent or worsening abdominal pain and tenderness.
   • Features of intestinal obstruction, perforation, or generalized peritonitis.
   • Plan:
   • Immediate surgical exploration to manage complications, such as abscess formation or peritonitis.

Contraindications to Ochsner-Sherren Regimen

• Children under 5 years.
• Adults above 40 years with suspicion of cecal pole malignancy.
• Presence of generalized peritonitis.
• Diagnostic uncertainty or atypical presentation.

Rationale for Conservative Management

Conservative management allows the inflammation to subside, reducing the risk of complications during surgery. This approach typically leads to symptom resolution within 3–5 days. Surgery is deferred to allow safer removal of the appendix once the inflammatory process has resolved.

1. Drainage of Abscess:
   • Percutaneous Drainage:
     • Preferred in stable patients when the abscess is accessible under ultrasound or CT guidance.
   • Surgical Drainage:
     • Performed when percutaneous drainage is not feasible or the patient is unstable.
2. With or Without Appendectomy:
   • If the appendix can be safely identified during drainage, immediate appendectomy may be performed.
   • If the appendix cannot be excised due to inflammation or unclear anatomy, plan for an interval appendectomy 6–8 weeks after abscess resolution.
3. Peritoneal Lavage (If Required):
   • Irrigation of the peritoneal cavity with saline is performed if there is evidence of peritoneal contamination.

1. Exploratory Laparotomy:
   • A lower midline abdominal incision is preferred for better access and exposure to the abdominal cavity.
   • Steps in Surgery:
     • Identification and removal of the appendix (if visible).
     • Thorough peritoneal lavage with warm saline to clear infected fluid, pus, or debris.
     • If the appendix stump cannot be found, control the source of infection and manage the peritoneal cavity appropriately.
2. Use of Abdominal Drain:
   • Placing a drain is considered at the surgeon’s discretion:
   • Used when there is a concern for residual infection or fluid collection.
   • Typically removed once drainage reduces and there are no signs of infection.

Follow-Up for Appendicitis

1. Post-Treatment Follow-Up
   1. Uncomplicated Appendectomy (Non-Perforated Cases):
      • Hospital Stay:
        • Laparoscopic appendectomy: Discharge within 24-48 hours.
        • Open appendectomy: Discharge within 48-72 hours.
      • Wound Care:
        • Monitor the surgical site for redness, swelling, discharge, or signs of infection.
        • Instruct the patient on proper wound hygiene and dressing changes.
      • Pain Management:
        • Prescribe oral analgesics (e.g., paracetamol or NSAIDs). Avoid opioids if not necessary.
      • Activity Restrictions:
        • Avoid strenuous activities for 2-4 weeks after open surgery and 1-2 weeks after laparoscopy.
      • Dietary Advice:
        • Gradually reintroduce regular foods as tolerated.
   2. Complicated Appendicitis (Perforated Cases):
      • Hospital Stay:
        • Prolonged hospitalization for observation and IV antibiotics (5-7 days).
      • Monitoring:
        • Regularly monitor for signs of residual infection, abscess formation, or bowel obstruction.
      • Wound Care:
        • Watch for delayed healing or surgical site infection.
2. Interval Appendectomy (After Appendiceal Mass or Abscess):
   • Timing:
     • Perform appendectomy 6-8 weeks after conservative treatment of an appendiceal mass or abscess.
     • This reduces the risk of recurrent appendicitis.
   • Pre-Operative Evaluation:
     • Ensure complete resolution of the mass and absence of infection before surgery.
3. Late Complications Monitoring:
   1. Adhesive Intestinal Obstruction:
      • Symptoms: Colicky abdominal pain, distension, or vomiting.
      • Intervention: May require imaging (e.g., abdominal X-ray) and potential surgical correction if severe.
   2. Incisional Hernia:
      • Symptoms: Bulging or discomfort at the incision site.
      • Intervention: Surgical repair if symptomatic or large.