Special Considerations

During pregnancy, the gravid uterus displaces the appendix superiorly and sometimes laterally as early as the second trimester. The diagnosis can be more difficult, and the ensuing morbidity more serious if the diagnosis is missed. The fetal morbidity rate is as high as 10% for acute appendicitis and 30% when perforated, whereas morbidity to mother and fetus from negative appendectomy are minimal. As a result, there is little role for nonoperative management when the diagnosis of acute appendicits is suspected during pregnancy.

In the past, incidental appendectomy was a common maneuver during other surgical procedures. There is increased morbidity with an incidental appendectomy and currently indications for such are rare and occur mainly when appendiceal pathology is incidentally discovered.

When the 3-day window of the acute presentation of appendicitis has passed before the patient seeks medical attention, there should be a higher index of suspicion for peri-appendicealphlegmon or abscess. Patients may present with fevers and leukocytosis higher than the usual low grade nature of acute appendicitis, or be afebrile with an unimpressive examination despite a perforation and collection walled off from the peritoneum. CT scan plays an important role in the workup of these patients and their subsequent management. Nonoperative management of patients presenting after 7 days of symptoms may be safer with less morbidity than appendectomy.

A peri-appendiceal collection in a patient who is afebrile and nonperitonitic can be initially treated with antibiotics and observation. A collection in a symptomatic patient with an impressive examination warrants at least CT guided percutaneous drainage. Failure to resolve symptoms in a patient in these more conservative manners or clinical deterioration with the development of high fevers and peritonitis are indications for open drainage and appendectomy. A patient treated successfully with antibiotics or percutaneous drainage for ruptured appendicitis should undergo an interval appendectomy 6 weeks later.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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