Appendicitis is the commonest cause of acute abdomen and may appear as catarrhal appendicitis or as obstructive appendicitis and sometimes it may present as an appendicular lump or appendicular abscess or as burst appendix with peritonitis.

Salient features

•           Acute central abdominal pain, followed by nausea, vomiting and fever, with the pain after a variable period, shifting to right lower abdomen localized tenderness maximum at the Mc Burney's point, rebound tenderness and guarding in the right iliac fossa,

•           An inflammatory lump in the right lower abdomen or signs of peritonitis.

•           A polymorph nuclear leukocytosis and ultrasonography appearances may help to corroborate the clinical diagnosis.

•           Investigations are primarily undertaken to exclude other conditions like ectopic gestation or ureteric calculus.

Management

A.  Definitive treatment

•           Appendectomy within 48 hours before the lump formation.

•           An interval appendicectomy may be performed where a lump has formed or when attack has already resolved or circumstances make surgery not feasible.

•           Laparotomy is to be done in cases of generalized peritonitis.

•           Stop oral feeding.

B.  Pharmacological (Expectant management)

1.     Intravenous fluids (R.L/N.S/Dextrose) to maintain hydration. Requirement of fluids would be more if the patient has peritonitis and septicemia.

2.     Inj Ceftriaxone 1gm + Salbactum 500mg, iv twice daily or

3.     Inj. Ciprofloxacin infusion (100mg/50 ml) 100 ml twice a day for 5 days or

4.     Inj. Gentamicin (40 mg/ml), 80 mg IV 8 hourly. Or

5.     lnj. Amikacin (500 mg/2 ml), 2 ml lVfwice a day.

6.     Inj. Metronidazole infusion (500 mg/i 00 ml) 100 ml IV 8 hourly. lnj. Diclofenac sodium (25 mg/ml) 50 ml IM SOS.

(Caution: Purgation and enema are contraindicated)

Pain subsides first, followed by relaxation of the abdomen and control of fever. Tenderness disappears later. Polymorph nuclear leukocytosis tends to settle down.

Failure of signs and symptoms to subside or the appearance of new signs and symptoms during expectant treatment, calls for surgical intervention.

C.  Postoperative management

•           Oral feeding is started when abdomen is soft, the patient has passed flatus/ stools and bowel sounds have appeared. Start with liquids, gradually permitting semi solid and solid diet over a period of 2-3 days.

•           Antibiotics should continue for 5 days or more if the condition demands.

•           Initially antibiotics are given by parenteral route and later switched to oral route when the patient starts tolerating semi solid diet.

•           Patient is discharged usually between 3rd and 5th postoperative day, if comfortable, ambulatory, tolerating semi solid or solid food, afebrile and has a healthy wound.

•           Sutures are removed around 7th postoperative day.

D.  Patient education

•           Normal routine physical work can be permitted in 10-15 days (5-7 days after laparoscopic appendectomy).

•           Moderate physical work is permitted after 4-6 weeks (2 weeks after laparoscopic appendectomy).

•           Heavy physical work is permitted after 2-3 months (4-6 weeks after laparoscopic appendectomy).