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Referral and warning signs
When to refer
Urgent surgical referral (Hospital level) required for all suspected cases for appendectomy.
Red flags
- Localized RIF pain with tenderness/guarding/rebound
- Signs of peritonitis (generalized rigidity, high fever, tachycardia, absent bowel sounds)
- High fever
- Persistent vomiting
Signs and symptoms
- Peri-umbilical pain initially (often crampy, increasing intensity)
- Pain migrating to and localizing in the Right Iliac Fossa (RIF)
- RIF pain becomes continuous
- Nausea, vomiting
- Anorexia (loss of appetite)
- Low-grade fever (initially)
- Constipation (common)
- Tenderness in RIF (McBurney's point)
- Guarding (muscle rigidity) in RIF
- Rebound tenderness in RIF
- Signs of peritonitis (generalized pain/rigidity) if ruptured.
Risk factors
- Blockage of appendix lumen (faecolith, lymphoid hyperplasia, parasites, tumour - rare)
Diagnosis
Clinical assessment
Diagnosis is primarily clinical based on history (migrating pain, anorexia, nausea) and physical examination findings (localized RIF tenderness, guarding, rebound). Differential diagnosis: Salpingitis, Ovarian cyst, Ectopic pregnancy (females), Pyelonephritis, Ureteric colic, Gastroenteritis, Mesenteric adenitis, Intestinal obstruction.
Investigations
- Clinical assessment is key; investigations are supportive.
- Complete Blood Count (CBC): Leucocytosis (raised white blood cell count) often present.
- Transabdominal Ultrasound: May show thickened, non-compressible appendix, appendicolith, periappendiceal fluid (operator dependent).
- Abdominal X-ray: Usually non-specific, may show faecolith, signs of perforation (free air) or obstruction (ileus).
- CT Scan (Abdomen/Pelvis): High accuracy, used if diagnosis uncertain (less available).
Diagnostic criteria
Clinical diagnosis based on characteristic history and examination findings, supported by investigations like CBC and ultrasound.
Management
Non-pharmacological management
- Emergency surgical appendectomy (laparoscopic or open) is the definitive treatment.
- Nil by mouth (NPO).
- Intravenous fluids for hydration.
- Monitor vital signs.
Pharmacological treatment
- Analgesia (e.g., Opioids).
- Antibiotics (Pre-operative and potentially post-operative):
- - If surgery delayed or for pre-operative prophylaxis: Ceftriaxone 2g IV daily (Child: 80mg/kg IV daily) PLUS Metronidazole 500mg IV Q8H (Child: 10mg/kg IV Q8H).
- - Duration depends on findings: <24h for unperforated, ≥5 days for perforated/gangrenous appendix.
Monitoring
- Post-operative monitoring for complications (infection, abscess, ileus).
Complications
- Perforation
- Peritonitis (generalized or localized abscess)
- Appendiceal abscess/phlegmon
- Sepsis
- Wound infection
- Intra-abdominal abscess (post-op)
- Ileus (post-op)
- Adhesive small bowel obstruction (late)
Prevention
- Not generally preventable, though high-fibre diet may theoretically reduce faecolith formation.
Patient education
- Explanation of appendicitis and the need for urgent surgery.
- Post-operative care instructions (wound care, activity, diet).
- Signs of post-operative complications to watch for.
Uganda-specific notes
Clinical diagnosis is paramount due to often limited access to advanced imaging. Early referral for surgery is crucial to prevent perforation and peritonitis.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 6, Section 6.1.1