Appendicitis Nursing Guide

Definition & Pathophysiology

Appendicitis is inflammation of the vermiform appendix, typically caused by obstruction of the appendiceal lumen by a faecolith, lymphoid hyperplasia, or foreign body. It is the most common cause of emergency abdominal surgery worldwide, with lifetime risk of ~7–8%.

Progression

Obstruction → bacterial overgrowth → mucosal inflammation
Distension → venous obstruction → ischaemia → gangrenous appendicitis
Perforation → faecal peritonitis or peri-appendiceal abscess

Perforation rate: 20–30% overall; up to 80% in children <5 years and elderly patients, due to delayed presentation and atypical symptoms.

Differential Diagnoses

Mesenteric adenitis (children)
Meckel's diverticulitis
Right-sided renal/ureteric colic
Ectopic pregnancy (women of reproductive age)
Ovarian cyst / torsion

Pelvic inflammatory disease (PID)
Caecal carcinoma (elderly)
Crohn's ileitis
Psoas abscess
Right-sided diverticulitis

Clinical Assessment

Classic Presentation

Central/periumbilical abdominal pain — onset, dull/colicky
Pain migrates to right iliac fossa (RIF) — typically over 12–24 hours; constant, worsened by movement
Anorexia — very common (~95%); absence should raise doubt
Nausea and vomiting — usually after pain onset
Low-grade fever 37.5–38.5°C (high fever suggests perforation)

Classic sequence: Pain → Anorexia → Nausea/Vomiting. In appendicitis, pain ALWAYS precedes vomiting. If vomiting occurs before pain, consider other diagnoses (e.g., gastroenteritis, bowel obstruction).

Clinical Signs

Sign	How to Elicit	Significance
McBurney's point tenderness	1/3 along line from ASIS to umbilicus	Most reliable sign; maximum tenderness in classic appendicitis
Rovsing's sign	Palpate LIF — causes pain in RIF	Positive = peritoneal irritation in RIF from transmitted pressure
Psoas sign	Extend right hip against resistance (patient lying left lateral)	Retrocaecal appendix — psoas muscle irritation
Obturator sign	Flex + internally rotate right hip	Pelvic appendix — obturator internus irritation
Rebound tenderness	Slowly press, then rapidly release	Peritoneal irritation; suggests imminent/actual perforation
Guarding / Rigidity	Involuntary muscular spasm on palpation	Peritonitis — urgent surgical referral

Investigations

Test	Finding	Significance
FBC	WCC >10 × 10⁹/L; neutrophilia	Present in 80%; absence does not exclude
CRP	Elevated (often >50 after 24h)	Rises later than WCC; high CRP = complicated/perforated
Urine dipstick	Mild pyuria (irritation of ureter)	Can be misleading — still consider appendicitis
β-hCG	Must be done in all women of reproductive age	Exclude ectopic pregnancy before any surgical intervention
CT abdomen (contrast)	Dilated appendix >6mm, periappendiceal fat stranding, faecolith	Gold standard sensitivity 94–98%; used if diagnosis uncertain
Ultrasound	Appendix visualised in 50–70% (operator-dependent)	First-line in children and pregnant women (avoid radiation)

Alvarado Score (MANTRELS)

A clinical scoring tool to assist in diagnosis of acute appendicitis. Score 0–10.

Feature	Points
Migration of pain to RIF	1
Anorexia	1
Nausea / Vomiting	1
Tenderness in RIF	2
Rebound tenderness	1
Elevated temperature (>37.3°C)	1
Leucocytosis (WCC >10)	2
Shift to left (neutrophilia)	1
Total	10

1–4
Appendicitis unlikely
Discharge + review

5–6
Possible appendicitis
Active observation / CT

7–8
Probable appendicitis
Surgical consultation

9–10
Almost certainly appendicitis
Urgent surgery

Alvarado ≥7 = surgical consultation recommended. The score is widely used in GCC emergency departments for triage. Note: It is less reliable in women of reproductive age (atypical presentations, gynaecological causes) and the elderly.

Pre-operative Nursing Care

NBM (nil by mouth) — 6 hours for food, 2 hours for clear fluids before surgery
IV access × 2, IV fluids (0.9% NaCl or Hartmann's) for fluid resuscitation
Analgesia — paracetamol and opioids are NOT contraindicated pre-operatively (old myth debunked); adequate analgesia improves patient cooperation with examination
Antiemetics — ondansetron, metoclopramide
Prophylactic antibiotics — given at induction of anaesthesia (cefuroxime + metronidazole for skin and bowel flora)
Consent — appendicectomy (open vs laparoscopic); risk of conversion, stoma (if perforated)
Urinalysis and β-hCG (all females of reproductive age)
Vital signs monitoring — escalate if tachycardia + fever + peritonism develops (perforation)

Post-operative Nursing Care — Appendicectomy

Immediate (0–4 hours)

ABCDE assessment on return from theatre
Vital signs every 15–30 minutes until stable
Pain assessment and analgesia (regular paracetamol + NSAIDs + PRN opioid)
Antiemetics as prescribed
IV fluids until tolerating orally
Monitor wound site for bleeding/dehiscence (laparoscopic: 3 port sites)

Recovery (4–24 hours)

Encourage oral fluids as soon as tolerating
Early mobilisation — within 4–6 hours (reduces VTE, ileus, chest complications)
Progress to light diet when tolerating fluids and bowel sounds present
VTE prophylaxis — LMWH (enoxaparin) and TED stockings
Simple appendicectomy — discharge within 24–48 hours

Perforated / Complicated Appendicitis

Signs of perforation/peritonitis post-op: Pyrexia >38.5°C, tachycardia, abdominal pain/distension, absent bowel sounds, wound dehiscence. Escalate to surgical team immediately.

Prolonged IV antibiotics (co-amoxiclav / piperacillin-tazobactam / metronidazole × 5–7 days)
NG tube if ileus develops
Close monitoring of drain output (if intra-abdominal drain placed)
Stoma care education if stoma formed
Extended hospital stay 5–7 days

Atypical Presentations & Special Populations

Elderly Patients

Pain less severe, atypical — 40–50% present without classic RIF pain
Lower fever (blunted immune response)
Perforation rate up to 40–70% at presentation (delayed diagnosis)
Caecal carcinoma must be excluded in all elderly patients with "appendicitis"

Children

Diagnosis harder — may not localise pain; may only complain of "tummy ache" throughout abdomen
Omentum underdeveloped → perforation leads to more diffuse peritonitis (cannot wall off abscess)
Ultrasound preferred (avoids radiation)
Vomiting, high fever, listlessness + RIF pain = urgent paediatric surgical review

Pregnancy

Most common non-obstetric surgical emergency in pregnancy
Appendix displaced superiorly by growing uterus — pain may be in RUQ in third trimester
MRI preferred to CT (no radiation) when ultrasound inconclusive
Perforation risk increased — conservative management less appropriate
Laparoscopic appendicectomy safe in all trimesters; fetal loss risk ~2% with simple appendicectomy vs 20–35% with perforation

GCC-Specific Context

High dietary fibre intake in some GCC populations is protective; Westernised diet increases risk
Large family size → children presenting to Hajj medical centres with appendicitis during pilgrimage
Access to CT in rural areas of Saudi Arabia and Oman may be limited; clinical scoring tools (Alvarado) are vital
During Ramadan, delayed presentation is common as patients initially attribute pain to hunger/indigestion

MCQ Practice — Appendicitis

Q1. A 22-year-old male presents with 12 hours of periumbilical pain now localised to the right iliac fossa, anorexia, and one episode of vomiting. Temperature 37.8°C, WCC 13.5×10⁹/L. What is his Alvarado score?

A) 5

B) 6

C) 7

D) 9

✅ C — Migration (1) + Anorexia (1) + Nausea/vomiting (1) + RIF tenderness (2) + Elevated temp (1) + Leucocytosis (2) = 8? Wait: no rebound tenderness mentioned, no shift to left mentioned. Migration(1)+Anorexia(1)+N/V(1)+RIF tenderness(2)+Temp(1)+WCC elevated(2) = 8, minus shift to left not mentioned → 7. Score 7 = probable appendicitis → surgical consultation.

Q2. Which clinical sign, when positive, suggests a retrocaecal appendix by demonstrating psoas muscle irritation?

A) Rovsing's sign

B) Obturator sign

C) Psoas sign (iliopsoas sign)

D) Murphy's sign

✅ C — Psoas sign: with the patient in the left lateral position, extension of the right hip causes pain → retrocaecal appendix inflaming the iliopsoas muscle. Obturator sign = pelvic appendix. Rovsing's = LIF palpation causes RIF pain. Murphy's = cholecystitis.

Q3. A woman of reproductive age presents with right iliac fossa pain. Before surgical intervention for suspected appendicitis, the MOST important additional test is:

A) CT abdomen with contrast

B) Urine MC&S

C) Serum β-hCG (pregnancy test)

D) Laparoscopy

✅ C — A serum β-hCG must be performed in ALL women of reproductive age before surgery. Ectopic pregnancy presents identically to appendicitis but requires immediate different management (haemorrhagic shock risk). Operating without ruling out ectopic could be fatal.

Q4. Where is McBurney's point located?

A) Midpoint of the left iliac fossa

B) At the umbilicus

C) One-third of the way along a line from the anterior superior iliac spine (ASIS) to the umbilicus

D) Two-thirds of the way along a line from the pubic symphysis to the right ASIS

✅ C — McBurney's point is located 1/3 along the line from the right ASIS to the umbilicus. It corresponds to the base of the appendix and is the point of maximum tenderness in classic appendicitis.

Appendicitis — Nursing Guide