Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement | to pdf >>

by Kirtland E. Hobler, MD

 

The prevalence of suppurative vs. acute appendicitis has traditionally been used to indicate quality of care, but recently acute and suppurative appendicitis have been suggested to be different disease processes. If so, quality of care might be better determined by measuring speed and accuracy of diagnosis and treatment. We retrospectively reviewed inpatient and outpatient medical charts of 208 health plan members in Raleigh, North Carolina, who had surgery for acute appendicitis during the years 1990 through 1995 to identify and compare duration and clinical features of acute and suppurative appendicitis.

Compared with acute appendicitis, suppurative appendicitis caused more days of pain (2.8 ± 2.2 days vs. 1.7 ± 2.1 days), pathology (3.1 ± 2.3 days vs. 1.1 ± 1.3 days), and delay before seeking treatment (1.7 ± 1.6 days vs. 1.1 ± 1.7 days). Suppurative appendicitis was also associated with a higher incidence of atypical history (65.5% vs. 21.6%). Duration of pain was shown to have a nonlinear relation to duration of pathology (R2 = 0.3, P = .0001) for acute appendicitis and a linear relation (R2 = 0.85, P = .0001) for suppurative appendicitis.

Our data and current medical literature suggest that unlike acute appendicitis, suppurative appendicitis starts with the suppurative process and has an atypical history which makes diagnosis difficult. Improving the speed of diagnosis and treatment of each condition is also discussed.

IntroductionIncidence of suppurative appendicitis has traditionally been used to indicate quality of care for appendicitis: because undiagnosed acute appendicitis was thought to precede suppuration, the latter condition was taken to indicate failure in diagnosis, in treatment, or in both. However, this interpretation of suppurative appendicitis has been challenged by recent studies.

For example, in an elegant epidemiologic study done in Sweden,1 incidence of suppurative appendicitis cases per 100,000 population was not related to incidence of removing normal appendixes, whereas incidence of acute appendicitis was higher in locales where a high proportion of normal appendixes were removed per 100,000 population. Resolving cases of acute appendicitis were thus being discovered at surgery by surgeons who relied on the least stringent indications for appendectomy. Proportion of suppurative appendicitis (number of suppurative appendicitis cases divided by total number of

appendicitis cases) thus only seemed lower in geographic areas where a high proportion of normal appendixes were removed per 100,000 population, because the denominator was inflated. Incidence of suppurative appendicitis therefore did not reliably reflect quality of care for the population studied.

Researchers are also accumulating evidence that acute and suppurative appendicitis are actually different disease processes. Andersson et al1 showed that the incidence of suppurative appendicitis is constant for patients of all ages but that the incidence of acute appendicitis is highest at puberty. Suppurative appendicitis is more often associated with delay in seeking care2 and with obstruction of the appendix by fecalith or hyperplasia,3 whereas acute appendicitis is associated with mucosal ulceration.4 Perhaps a viral cause for these ulcerations might explain epidemic clusters of acute appendicitis. If acute and suppurative appendicitis are different disease processes, then speed of diagnosis and treatment (ie, disease duration) might be a better indicator of quality than incidence of suppuration.

Because the author observed empirically that the suppurative process often seemed to have started near the onset of abdominal pain, this study sought to correlate duration of pathologic process with duration of abdominal pain to determine whether suppurative appendicitis is a complication of acute appendicitis (ie, by noting short duration of suppuration after longer history of pain) or a separate disease process (ie, by noting a strong linear correlation between duration of pathologic process and pain in suppurative appendicitis).

MethodsWe retrospectively reviewed the inpatient medical records of all Kaiser Foundation Health Plan members receiving emergency surgery for acute appendicitis at Rex Hospital in Raleigh, North Carolina, from April 1990 through April 1995. Chart review placed special emphasis on operative and surgical pathology reports. Outpatient records were reviewed for duration of abdominal pain and related evaluations. Normal appendixes were defined as those so indicated in the pathology report, although some patients with normal appendix had other disease processes. Suppurative appendicitis was defined as appendicitis with intraperitoneal pus, perforation, gangrene, or abscess. Because perforation is sometimes difficult to recognize at surgery and acts clinically like suppurative appendicitis, perforation was classified as suppurative. KIRTLAND E. HOBLER, MD is a Board certified general surgeon practicing in the Carolina Permanente Medical Group for the past eight years. He is a Because criteria for measuring duration of the pathologic process in appendicitis have not appeared in the biomedical literature, duration of the pathologic process in acute and suppurative appendicitis was estimated for pathologic conditions seen at surgery: erythema, edema, or fibrin on peritoneal surfaces (0.5 day); pus in peritoneal cavity or leukocytic infiltrates at serosa or outside the appendix (1 day); perforation or gangrene without collagen deposition (2 days); collagen formation outside appendix (4 days); early abscess cavity (5 days); and well-defined abscess (7 days). These estimates reflected the number of days which would ordinarily elapse before surgery would yield that finding. The estimates were based on well-accepted principles of stage of inflammation and wound healing and were adjusted by consensus of 4 Board-certified general surgeons and 6 Board-certified pathologists at Rex Hospital. These estimated durations were then applied to data obtained from operative notes and pathology reports.

Using recently proposed criteria,5 typical appendicitis-related medical history was defined as abdominal pain which progressed from upper abdomen to right lower quadrant and which was followed by either anorexia, nausea, or vomiting. Atypical appendicitis-related medical history was defined as sudden, nonprogressive lower abdominal pain, vague or absent pain localization, or predominant symptoms of diarrhea or vomiting. Typical appendicitis-related physical examination results were defined as guarding or spasm in the right lower quadrant. Typical laboratory findings were defined as white blood cell count >12,000/mm3 (12 x 106/L) as a prominent feature. Delay before seeking treatment was defined as the difference (stated in days) between duration of pain and duration of medical care before appendectomy.

Statistical analysis was done using SPSS software. Statistical significance for differences was determined by using c2 tests for frequencies; and Student's t statistic for means. Duration of pain and duration of pathologic process were evaluated for correlation by plotting days away from the mean for each variable and by using the standardized Scatterplot feature of SPSS. c2 (the coefficient of determination) was used to determine whether the relation between duration of pain and duration of pathologic process was linear and strongly correlated (R2 = 1.0) or weakly correlated and nonlinear (R2 = 0.0).

Acute suppurative appendicitis,   Appendix

A. Brief Descriptions：

1. Cause : It is associated with obstruction (fecalith, gallstone, tumor or ball of worms).

2. Abscess formation within the wall and foci of suppurative necrosis in the mucosa.

B. Gross Findings：

1. Congested & swollen.

2. Dilated lumen contain pus, or a fecalith, or both.

3. Serosa coated with fibrin, fibrinopurulent exudate, or pus.

C. Micro Findings：

1. Mucosal ulceration & infiltration by PMNs, eosinophils, plasma cells, &lymphocytes throughout all layers & frequently into serosa.

2. More advanced stage, the inflammatory process involved the full thickness of wall,with partial necrosis or infarction of wall (perforated areas).

D. Others:

1. Classified into acute, suppurative, & gangrenous stages. 

site acute suppurative gangrenous

mucosa neutrophils suppurative necrosis

hemorrhagic ulceration

wall neutrophils suppurative necrosis

green-black necrosis

serosa congested blood vessels

fibrinous exudates

purulent exudates

green-black necrosis

 

Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasound. Treatment is surgical removal.

In the US, acute appendicitis is the most common cause of acute abdominal pain requiring surgery. Over 5% of the population develops appendicitis at some point. It most commonly occurs in the teens and 20s but may occur at any age.

Other conditions affecting the appendix include carcinoids, cancer, villous adenomas, and diverticula. The appendix may also be affected by Crohn's disease or ulcerative colitis with pancolitis.

Etiology

Appendicitis is thought to result from obstruction of the appendiceal lumen, typically by lymphoid hyperplasia, but occasionally by a fecalith, foreign body, or even worms. The obstruction leads to distention, bacterial overgrowth, ischemia, and inflammation. If untreated, necrosis, gangrene, and perforation occur. If the perforation is contained by the omentum, an appendiceal abscess results.

Symptoms and Signs

The classic symptoms of acute appendicitis are epigastric or periumbilical pain followed by brief nausea, vomiting, and anorexia; after a few hours, the pain shifts to the right lower quadrant. Pain increases with cough and motion. Classic signs are right lower quadrant direct and rebound tenderness located at McBurney's point (junction of the middle and outer thirds of the line joining the umbilicus to the anterior superior spine). Additional signs are pain felt in the right lower quadrant with palpation of the left lower quadrant (Rovsing sign), an increase in pain from passive extension of the right hip joint that stretches the iliopsoas muscle (psoas sign), or pain caused by passive internal rotation of the flexed thigh (obturator sign). Low-grade fever (rectal temperature 37.7 to 38.3° C [100 to 101° F]) is common.

Unfortunately, these classic findings appear in < 50% of patients. Many variations of symptoms and signs occur. Pain may not be localized, particularly in infants and children. Tenderness may be diffuse or, in rare instances, absent. Bowel movements are usually less frequent or absent; if diarrhea is a sign, a retrocecal appendix should be suspected. RBCs or WBCs may be present in the urine. Atypical symptoms are common among elderly patients and pregnant women; in particular, pain is less severe and local tenderness is less marked.

Diagnosis

Clinical evaluation Abdominal CT if necessary Ultrasound an option to CT

When classic symptoms and signs are present, the diagnosis is clinical. In such patients, delaying laparotomy to do imaging tests only increases the likelihood of perforation and subsequent complications. In patients with atypical or equivocal findings, imaging studies should be done without delay. Contrast-enhanced CT has reasonable accuracy in diagnosing appendicitis and can also reveal other causes of an acute abdomen. Graded compression ultrasound can usually be done quickly and uses no radiation (of particular concern in children); however, it is occasionally limited by the presence of bowel gas and is less useful for recognizing nonappendiceal causes of pain. Appendicitis remains primarily a clinical diagnosis. Selective and judicious use of radiographic studies may reduce the rate of negative laparotomy.

Laparoscopy can be used for diagnosis as well as definitive treatment; it may be especially helpful in women with lower abdominal pain of unclear etiology. Laboratory studies typically show leukocytosis (12,000 to 15,000/μL), but this finding is highly variable; a normal WBC count should not be used to exclude appendicitis.

Prognosis

Without surgery or antibiotics, mortality is > 50%.

With early surgery, the mortality rate is < 1%, and convalescence is normally rapid and complete. With complications (rupture and development of an abscess or peritonitis), the prognosis is worse: Repeat operations and a long convalescence may follow.

Treatment

Surgical removal IV fluids and antibiotics

Treatment of acute appendicitis is open or laparoscopic appendectomy; because treatment delay increases mortality, a negative appendectomy rate of 15% is considered acceptable. The surgeon can usually remove the appendix even if perforated. Occasionally, the appendix is difficult to locate: In these cases, it usually lies behind the cecum or the ileum and mesentery of the right colon. A contraindication to appendectomy is inflammatory bowel disease involving the cecum. However, in cases of terminal ileitis and a normal cecum, the appendix should be removed.

Appendectomy should be preceded by IV antibiotics. Third-generation cephalosporins are preferred. For nonperforated appendicitis, no further antibiotics are required. If the appendix is perforated, antibiotics should be continued until the patient's temperature and WBC count have normalized or continued for a fixed course, according to the surgeon's preference. If surgery is impossible, antibiotics—although not curative—markedly improve the survival rate. When a large inflammatory mass is found involving the appendix, terminal ileum, and cecum, resection of the entire mass and ileocolostomy are preferable. In late cases in which a pericolic abscess has already formed, the abscess is drained either by an ultrasound-guided percutaneous catheter or by open operation (with appendectomy to follow at a later date). A Meckel's diverticulum in a patient under the age of 40 should be removed concomitantly with the appendectomy unless extensive inflammation around the appendix prevents the procedure.

Last

Addiss and associates estimated the incidence of acute appendicitis in the United States population to be 11 cases per 10,000 population annually. The disease is slightly more common in males, with a male:female ratio of 1.4:1. In a lifetime, 8.6% of males and 6.7% of females can be expected to develop acute appendicitis. Young age is a risk factor, as nearly 70% of patients with acute appendicitis are less than 30 years of age. The highest incidence of appendicitis in males is in the 10- to 14-year-old age group (27.6 cases per 10,000 population), while the highest female incidence is in the 15- to 19-year-old age group (20.5 cases per 10,000 population). Patients at extremes of age are more likely to develop perforated appendicitis. Overall, perforation was present in 19.2% of cases of acute appendicitis. This number was significantly higher, however, in patients under 5 and over 65 years of age. Although less common in people over 65 years old, acute appendicitis in the elderly progresses to perforation more than 50% of the time.

Etiology and Pathophysiology

Appendicitis, diverticular disease, and colorectal carcinoma have been shown to be diseases of developed civilizations. Burkitt found an increased incidence of appendicitis in Western countries compared to Africa, as well as in wealthy, urban communities compared to rural areas. He attributed this to the Western diet, which is low in dietary fiber and high in refined sugars and fat, and postulated that low-fiber diets lead to less bulky bowel contents, prolonged intestinal transit time, and increased intraluminal pressure. Burkitt theorized that the combination of firm stool leading to appendiceal obstruction and increased intraluminal pressure causing bacterial translocation across the bowel wall resulted in appendicitis. In examining appendixes removed for reasons other than appendicitis, he found fecaliths to be more prevalent in Canadian (32%) than in South African (4%) adults. In a group of patients with appendicitis, fecaliths were more common in Canadians (52%) than in South Africans (23%).He felt this was confirmation that appendiceal obstruction resulted in appendicitis. Of note, however, the majority of patients with appendicitis in his study did not have evidence of a fecalith.

Wangensteen extensively studied the structure and function of the appendix and the role of obstruction in appendicitis.Based on anatomic studies, he postulated that mucosal folds and a sphincterlike orientation of muscle fibers at the appendiceal orifice make the appendix susceptible to obstruction. He proposed the following sequence of events to explain appendicitis:

(1) closed loop obstruction is caused by a fecalith and swelling of the mucosal and submucosal lymphoid tissue at the base of the appendix;

(2) intraluminal pressure rises as the appendiceal mucosa secretes fluid against the fixed obstruction;

(3) increased pressure in the appendiceal wall exceeds capillary pressure and causes mucosal ischemia; and

(4) luminal bacterial overgrowth and translocation of bacteria across the appendiceal wall result in inflammation, edema, and ultimately necrosis. If the appendix is not removed, perforation can ensue.

Although appendiceal obstruction is widely accepted as the primary cause of appendicitis, evidence suggests that this may be only one of many possible etiologies. First, some patients with a fecalith have a histologically normal appendix.Moreover, the majority of patients with appendicitis show no evidence for a fecalith.Arnbjornsson and Bengmark studied at laparotomy the appendixes of patients with suspected appendicitis. They found the intraluminal pressure of the appendix prior to removal to be elevated in only 8 of 27 patients with nonperforated appendicitis. They found no signs of obstruction in the remaining patients with nonperforated appendicitis, as well as all patients with a normal appendix. Taken together, these studies imply that obstruction is but one of the possible etiologies of acute appendicitis.

Complications of AppendicitisSerious appendicitis complications may include:

Abscess Rupture of the appendix Organ failure Peritonitis Death.

Rupture

A rupture is when the appendix bursts or tears. Infants, young children, and older adults are at highest risk of a rupture. If appendicitis is not diagnosed quickly and goes untreated, this particular complication will most likely occur.

Peritonitis or Abscess

Peritonitis is a dangerous infection. This complication can occur when bacteria and other contents of the torn appendix leak into the abdomen (stomach). A ruptured appendix can lead to peritonitis and abscess. An abscess usually takes the form of a swollen mass filled with fluid and bacteria.

AppendicitisAppendicitis is an inflammation of the appendix that occurs most often in people between the ages of 10 and 30. It is considered a medical emergency, and treatment often involves surgery to remove the appendix. If treatment is delayed, the appendix can burst, causing infection and even death. Possible symptoms of an inflamed appendix include abdominal pain, fever, and constipation.

What Is Appendicitis?Appendicitis is an inflammation of the appendix. Once appendicitis begins, there is no effective medical therapy. Therefore, it is considered a medical emergency. When it is treated promptly, most patients recover without difficulty. However, if treatment is delayed, the appendix can burst, causing infection and even death. Although anyone can get appendicitis, it occurs most often in people between the ages of 10 and 30.

Understanding the AppendixThe appendix is a small, tube-like structure that is attached to the first part of the large intestine, also called the colon. It is located in the lower right portion of the abdomen, near where the small intestine attaches to the large intestine, and it has no known function. Removal of the appendix appears to cause no change in digestive function.

What Causes Appendicitis?The inflammation can be caused by a blockage of the inside of the appendix, known as the lumen. Common causes of blockage include:

Feces Infections that lead to swelling Trauma.

(Click Causes of Appendicitis for more information about what causes this condition.)

Common SymptomsNot everyone with appendicitis has related symptoms, especially:

People with certain medical conditions Women who are pregnant Children (see Appendicitis in Children) The elderly.

Pain in the abdomen can be an early symptom. The pain may first appear around the belly button and then move to the lower right area of the abdomen.

(Click Early Appendicitis Symptoms for more information.)

Other common symptoms include:

Pain that intensifies when moving, taking deep breaths, coughing, or sneezing Loss of appetite Nausea Vomiting Constipation or diarrhea Inability to pass gas Low fever that begins after other symptoms

Abdominal swelling Feeling that a bowel movement will relieve discomfort.

These symptoms can be caused by other medical conditions, however. People who have possible symptoms of appendicitis should see a qualified physician immediately.

What Causes Appendicitis?Appendicitis is caused by a blockage of the inside of the appendix (also known as the lumen).

What Causes the Blockage?In most cases, feces will cause a blockage inside of the appendix. However, a bacterial or viral infection in the digestive tract can lead to swelling of the lymph nodes, which squeezes the appendix and causes obstruction. This is known as lymphoid hyperplasia. In rare cases, traumatic injury to the abdomen, or even genetics, may also cause blockage inside of the appendix.

SummaryA blockage of the inside of the appendix leads to increased pressure, impaired blood flow, and inflammation. Gangrene and rupture (breaking or tearing) of the appendix can result if the appendix blockage is not treated in a timely manner.

Appendicitis TreatmentOnce a diagnosis of appendicitis is confirmed, the necessary treatment is usually surgery. In some cases, if the diagnosis is uncertain, the doctor may prescribe antibiotics as treatment if he or she is unsure whether the symptoms are being caused by appendicitis or something else, such as an infection.

An Overview of Appendicitis TreatmentIn most cases, treating appendicitis will involve surgery. Medication may be used as an appendicitis treatment if the doctor is unsure if the patient has appendicitis. However, surgery will be needed if the patient definitely has appendicitis.

Surgery for AppendicitisAcute appendicitis treatment consists of surgery to remove the appendix. This operation may be performed through a standard small incision in the lower-right part of the abdomen, or it may be performed using a laparoscope, which requires three to four smaller incisions. If other conditions are suspected in addition to appendicitis, they may be identified using laparoscopy.

In some patients, laparoscopy is preferable to open surgery as a treatment for appendicitis because the incision is smaller, recovery time is quicker, and less pain medication is required.

Recovery from an appendectomy takes a few weeks. Doctors usually prescribe pain medication and ask patients to limit physical activity. Recovery from laparoscopic appendectomy is generally faster, but limiting strenuous activity may still be necessary for 4 to 6 weeks after surgery. Most people who are treated for appendicitis recover excellently and rarely need to make any changes in their diet, exercise, or lifestyle.

Antibiotics and Other TreatmentsIn some cases, infections may cause the same symptoms as appendicitis. Therefore, if an appendicitis diagnosis is uncertain, people may be watched and sometimes receive antibiotics. If the cause of the pain is an infection, symptoms should resolve with intravenous antibiotics and intravenous fluids. However, if the patient has appendicitis, the condition cannot be treated with antibiotics alone and will require surgery.

Occasionally, the body is able to control an appendiceal perforation (a hole) by forming an abscess. An abscess occurs when an infection is walled off in one part of the body. The doctor may choose to drain the abscess (as part of appendicitis treatment) and leave the drain in the abscess cavity for several weeks. An appendectomy may be scheduled after the abscess is drained.

How to Prevent AppendicitisMany people want to know how to prevent appendicitis. Although there is no way to prevent appendicitis, people who are able to recognize appendicitis symptoms may be able to prevent more serious appendicitis symptoms from occurring.

Appendectomy is the surgical removal of the appendix when an infection has made it inflamed and swollen. This infection, called appendicitis, is considered an emergency because it can be life threatening if untreated — occasionally, an inflamed appendix bursts after a day of symptoms. So it's very important to have it removed as soon as possible.

Fortunately, appendectomy is a common procedure and complications are rare. And if appendicitis is promptly diagnosed and an appendectomy is performed, most kids recover quickly and with little difficulty.

About Appendicitis

Located in the abdomen, the appendix is a small organ that isn't important to a person's health. One end of the appendix is closed and the other opens into the large intestine, the organ that absorbs water from waste (or stool) and moves it out of the body through the anus.

Causes

There's no way to prevent appendicitis. Because the appendix is so close to the large intestine, it can become clogged with stool and bacteria. Other times mucus produced by the appendix can thicken and cause a blockage. In both cases, once the opening to the appendix is congested, it can become inflamed and swollen, causing appendicitis.

Signs and Symptoms

Appendicitis can cause sudden pain in the middle of the abdomen, usually concentrated around the bellybutton. The pain often moves to the lower right part of the abdomen. At first, pain might come and go, then become persistent and sharp.

Appendicitis also can cause:

loss of appetite fever nausea vomiting diarrhea frequent or painful urination

If the appendix bursts, a child can develop a high fever, and pain will move throughout the abdominal area.

Appendectomy

An appendectomy is surgery to remove the appendix.

See also: Appendicitis

Description

The appendix is a small, finger-shaped organ that comes out from the first part of the large intestine. It is removed when it becomes swollen (inflamed) or infected. An appendix that has a hole in it (perforated) can leak and infect the entire abdomen area, which can be life-threatening.

See: Peritonitis

An appendectomy is done using either:

Spinal anesthesia . Medicine is put into your back to make you numb below your waist. You will also get medicine to make you sleepy.

General anesthesia . You will be asleep and not feel any pain during the surgery.

The surgeon makes a small cut in the lower right side of your belly area and removes the appendix.

The appendix can also be removed using small surgical cuts and a camera. This is called a laparoscopic appendectomy.

If the appendix broke open or a pocket of infection (abscess) formed, your abdomen will be washed out during surgery. A small tube may be left in the belly area to help drain out fluids or pus.

Why the Procedure is Performed

An appendectomy is done for appendicitis. The condition can be hard to diagnose, especially in children, older people, and women of childbearing age.

Most often, the first symptom is pain around your belly button.

The pain may be mild at first, but it becomes sharp and severe. The pain often moves into your right lower abdomen and becomes more focused in this area.

Other symptoms include:

Diarrhea or constipation Fever (usually not very high) Nausea and vomiting Reduced appetite

If you have symptoms of appendicitis, seek medical help right away. Do not use heating pads, enemas, laxatives, or other home treatments to try and relieve symptoms.

Your health care provider will examine your abdomen and rectum. Other tests may be done.

Blood tests, including a white blood cell count (WBC), may be done to check for infection. When the diagnosis is not clear, the doctor may order a CT scan or ultrasound to make sure the

appendix is the cause of the problem.

There are no actual tests to confirm that you have appendicitis. Other illnesses can cause the same or similar symptoms.

The goal is to remove an infected appendix before it breaks open (ruptures). After reviewing your symptoms and the results of the physical exam and medical tests, your surgeon will decide whether you need surgery.

Even when the surgeon finds that the appendix is not infected, it will be removed to prevent future problems.

Risks

Risks from any anesthesia include the following:

Reactions to medications Problems breathing

Risks from any surgery include the following:

Bleeding Infection

Other risks with an appendectomy after a ruptured appendix include the following:

Buildup of pus, which may need draining and antibiotics Longer hospital stays Side effects from medications

After the Procedure

Patients tend to recover quickly after a simple appendectomy. Most patients leave the hospital in 1 - 2 days after surgery. You can go back to your normal activities within 2 - 4 weeks after leaving the hospital.

Patients who have the appendix removed through small surgical cuts tend to recover and get back to their daily activities faster.

Recovery is slower and more complicated if the appendix has broken open or an abscess has formed.

Living without an appendix causes no known health problems.

Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). Usually this is due to embolism of a thrombus (blood clot) from the deep veins in the legs, a process termed venous thromboembolism. A small proportion is due to the embolization of air, fat, talc in drugs of intravenous drug abusers or amniotic fluid. The obstruction of the blood flow through the lungs and the resultant pressure on the right ventricle of the heart leads to the symptoms and signs of PE. The risk of PE is increased in various situations, such as cancer or prolonged bed rest.[1]

Symptoms of pulmonary embolism include difficulty breathing, chest pain on inspiration, and palpitations. Clinical signs include low blood oxygen saturation and cyanosis, rapid breathing, and a rapid heart rate. Severe cases of PE can lead to collapse, abnormally low blood pressure, and sudden death.[1]

Diagnosis is based on these clinical findings in combination with laboratory tests (such as the D-dimer test) and imaging studies, usually CT pulmonary angiography. Treatment is typically with anticoagulant medication, including heparin and warfarin. Severe cases may require thrombolysis with drugs such as tissue plasminogen activator (tPA) or may require surgical intervention via pulmonary thrombectomy.[1]

What is a pulmonary embolism?

The lungs are a pair of organs in the chest that are primarily responsible for the exchange of oxygen and carbon dioxide between the air we breathe and blood. The lung is composed of clusters of small air sacs (alveoli) divided by thin, elastic walls (membranes). Capillaries, the tiniest of blood vessels, run within these membranes between the alveoli and allow blood and air

to come near each other. The distance between the air in the lungs and the blood in the capillaries is very small, and allows molecules of oxygen and carbon dioxide to transfer across the membranes.

The exchange of the air between the lungs and blood are through the arterial and venous system. Arteries and veins both carry and move blood throughout the body, but the process for each is very different.

Arteries carry blood from the heart to the body.

Veins return blood from the body to the heart.

The heart is a two-sided pump.

Oxygen-carrying blood travels from the left side of the heart to all the tissues of the body. The oxygen is extracted by the tissue, and carbon dioxide (a waste product) is delivered back into the blood.

The blood, now deoxygenated and with higher levels of carbon dioxide, is returned via the veins to the right side of the heart.

The blood is then pumped out of the right side of the heart to the lungs, where the carbon dioxide is removed and oxygen is returned to the blood from the air we breathe in, which fills the lungs.

Now the blood, high in oxygen and low in carbon dioxide, is returned to the left side of the heart where the process starts all over again.

The blood travels in a circle and is therefore referred to as circulation.

If a blood clot (thrombus) forms in the one of the body's veins (deep vein thrombosis or DVT), it has the potential to break off and enter the circulatory system and travel (or embolize) through the heart and  become lodged in the one of the branches of the pulmonary artery of the lung. A clot that travels through the circulatory system to another location is known as an embolus (plural emboli).

A pulmonary embolus clogs the artery that provides blood supply to part of the lung. The embolus not only prevents the exchange of oxygen and carbon dioxide, but it also decreases blood supply to the lung tissue itself, potentially causing lung tissue to die (infarct).

A pulmonary embolus is one of the life-threatening causes of chest pain and should always be considered when a patient presents to a healthcare provider with complaints of chest pain and shortness of breath.

Non-thrombus causes of pulmonary embolus are rare but include:

fat emboli from a broken femur,

an amniotic fluid embolus in pregnancy, and

in some cases, tumor tissue from cancer.

The presentation is the same as that of a blood clot, caused by blockage of part of the arterial tree of the lung.

Picture of a blood clot is formed

What Is Pulmonary Embolism?

Pulmonary embolism (PULL-mun-ary EM-bo-lizm), or PE, is a sudden blockage in a lung artery. The blockage usually is caused by a blood clot that travels to the lung from a vein in the leg.

A clot that forms in one part of the body and travels in the bloodstream to another part of the body is called an embolus (EM-bo-lus).

PE is a serious condition that can:

Damage part of your lung because of a lack of blood flow to your lung tissue. This damage may lead to pulmonary hypertension (increased pressure in the pulmonary arteries).

Cause low oxygen levels in your blood. Damage other organs in your body because of a lack of oxygen.

If a blood clot is large, or if there are many clots, PE can cause death.

Overview

PE most often is a complication of a condition called deep vein thrombosis (DVT). In DVT, blood clots form in the deep veins of the body—most often in the legs. These clots can break free, travel through the bloodstream to the lungs, and block an artery.

Deep vein clots are not like clots in veins close to the skin's surface. Those clots remain in place and do not cause PE.

Outlook

The exact number of people affected by DVT and PE isn't known. Estimates suggest these conditions affect 300,000 to 600,000 people in the United States each year.

If left untreated, about 30 percent of patients who have PE will die. Most of those who die do so within the first few hours of the event.

The good news is that a prompt diagnosis and proper treatment can save lives and help prevent the complications of PE.

Description

Venous stasis refers to loss of proper function of the veins in the legs that would normally carry blood back toward the heart. This may occur following injury to the veins, which can result in blood clots in the superficial veins known as superficial phlebitis, or following blood clots in the deep veins known as deep venous thrombosis. Swelling in the lower legs and ankle can also occur as a result of heart disease called Chronic Congestive Heart Failure and due to kidney disease. In some instances the cause of the swelling may not be easily identified.

Diagnosis

Individuals with this condition usually exhibit edema, which means swelling, of the legs and ankles. The superficial veins in the legs may be varicosed, causing the veins to be enlarged and appear as a cord or a bunch of grapes. Patients often complain of a feeling of fullness, aching, or tiredness in their legs. These symptoms are worse with standing, and are relieved when the legs are elevated.

As the condition progresses the blood continues to collect in the feet, ankles, and legs. The pigmentation from the red blood cells stains the skin from the inside, and a reddish-brown discoloration develops on the skin. This is called venous stasis dermatitis.

In severe cases of long-standing venous stasis, the skin begins to lose its elasticity, and a sore may develop on the inside of the ankle. This is known as venous stasis ulceration. This ulcer often will drain large amount of fluid and will have a red base. Secondary infection can complicate the ulcer and will require antibiotic treatment.

Further testing may be requested by your doctor to further evaluate the condition of your veins. This may include venous Doppler testing, which uses sound waves to listen to the blood flow through the veins. If there is a suspicion of an acute thrombosis (blood clots), a venogram may be requested. This enables the veins to be visible on x-rays, and the blood clot can be identified with greater certainty. Identification of deep vein thrombosis is important, because failure to properly treat may result in a blood clot breaking loose in the leg and traveling to the lungs called pulmonary embolus, which can be fatal.

Treatment

The most common treatments for venous stasis are rest, elevation, and compression stockings. When elevating your feet the ideal position is to have your feet above the level of your heart. This permits greater return of blood back toward the heart. This usually means you are lying down with your legs raised with pillows.

The compressive stockings come in different lengths. A knee high stocking may be sufficient if the swelling is confined to the lower legs and ankles. However if the swelling extends up to the knee, then a thigh high or panty hose style elastic stocking may be required. The compression stockings are also available in a variety of compression strengths. The greater the compression the more squeeze the stocking will apply to the leg. Generally, over-the-counter elastic stockings are available (without prescription) in most pharmacies or surgical supply stores. These have a compression range of 10 to 20 mm compression. If these do not provide enough compression to control the edema, then a prescription compression stocking may be necessary. These begin at 30 to 40 mm compression, and are often referred to as T.E.D. stockings. In more severe cases a higher level of compression may be necessary. These stockings often need to be custom sized to each individual leg, otherwise they are difficult to put on and may not provide even compression throughout the extremity. Your doctor may also use medications to reduce the swelling called Diuretics. Diuretics increase the output of urine and your doctor should closely monitor the use

of this medication. If the cause of the swelling is due to heart problems or kidney problems your doctor will evaluate the need to adequately treat these conditions.

Thrombophlebitis

Thrombophlebitis is swelling (inflammation) of a vein caused by a blood clot.

Causes

The following increase your chances for thrombophlebitis:

Being hospitalized for a major surgery or with a major illness Disorders that make you more likely to develop blood clots Sitting for a long period of time (such as on a long airplane trip)

There are two main types of thrombophlebitis:

Deep venous thrombosis (affects deeper, larger veins) Superficial thrombophlebitis (affects veins near the skin surface)

Symptoms

The following symptoms are often associated with thrombophlebitis:

Inflammation (swelling) in the part of the body affected Pain in the part of the body affected Skin redness (not always present) Warmth and tenderness over the vein

Exams and Tests

The health care provider can usually diagnose the condition based on how the affected area looks. You may need to have your pulse, blood pressure, temperature, skin condition, and circulation frequently checked to make sure you don't have complications.

If the cause cannot be easily identified, one or more of the following tests may be done:

Blood coagulation studies Doppler ultrasound Venography

Treatment

In general, treatment may include support stockings and wraps to reduce discomfort as well as medications such as:

Analgesics (pain killers) Antibiotics (if infection is present) Anticoagulants (blood thinners) to prevent new clots from forming Nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen to reduce pain and

inflammation Thrombolytics to dissolve an existing clot

You may be told to do the following:

Keep pressure off of the area to reduce pain and decrease the risk of further damage Raise the affected area to reduce swelling

Surgical removal, stripping, or bypass of the vein is rarely needed but may be recommended in some situations.

For more specific recommendations, see the particular condition (superficial thrombophlebitis or deep venous thrombosis).

Outlook (Prognosis)

Thrombophlebitis and other forms of phlebitis usually respond to prompt medical treatment.

Possible Complications

Superficial thrombophlebitis rarely causes complications.

Complications of deep vein thrombosis include blood clots in the lungs (pulmonary embolism) or chronic pain and swelling in the leg.

When to Contact a Medical Professional

Call your health care provider if you have symptoms of thrombophlebitis.

Call your health care provider promptly if thrombophlebitis symptoms do not improve with treatment, if symptoms get worse, or if new symptoms occur (such as an entire limb becoming pale, cold, or swollen).

Prevention

Routine changing of intravenous (IV) lines helps to prevent thrombophlebitis related to IVs.

If you are taking a long car or plane trip, walk or stretch your legs once in a while and drink plenty of liquids. Wearing support hose may help.

If you are hospitalized, your doctor may prescribe medicine to prevent deep venous thrombosis.

Diagnosing Thrombophlebitis

To diagnose superficial thrombophlebitis, doctors will take a medical history (asking about symptoms) and do a physical examination. As well, an ultrasound of the suspected veins may be done.

For DVT, doctors look for signs of swelling and enlargement of the calf (due to swollen leg veins). A diagnosis of DVT is usually confirmed by X-ray using radiopaque dye or with a Doppler test. This is an ultrasound test that detects differences in echoes or sounds made by flowing blood. It can easily detect the presence of blood clots in deep veins. Blood tests may also be performed to check for substances that are increased when a blood clot is present.

Treating and Preventing ThrombophlebitisTo relieve mild inflammation and discomfort in superficial thrombophlebitis, your doctor may suggest elevating the affected area and applying warm moist packs to it for 15 to 20 minutes at a time throughout the day. Pain medications or anti-inflammatory medications may also be prescribed. People with superficial thrombophlebitis should try to stay active (walk around). If the inflammation and symptoms lasts longer than a day or two, or if symptoms become worse, see a doctor as soon as possible.

In cases where the thrombophlebitis is due to an infection, treatment with antibiotics often takes care of the problem. In rare cases, when the antibiotics aren't enough to control the infection, surgical removal of the inflamed portion of the vein may be required.

Once a DVT has been diagnosed, doctors may prescribe blood-thinning (anticoagulant) medications such as heparin*, low-molecular weight heparin, or warfarin. These anticoagulant medications make the blood less likely to clot and help prevent new blood clots from forming.

Often, treatment will start in the hospital so people can be closely looked after but the hospital stay is relatively short, often leaving the same day. Your family doctor can adjust the dose of medications without you going back to the hospital. When there aren't any complications, patients with DVT can usually return to normal activity within 1 or 2 months.

For some people, taking long-term warfarin therapy may be necessary to prevent new blood clots from forming. When medications cannot be used, surgery may be needed to either place a filter into a vein in the abdomen to prevent clots from travelling to the lungs or to remove or bypass the blood clot.

In some women, the use of certain types of oral contraceptives may increase the risk for forming blood clots. The risk is higher for women over 35 years of age who smoke or have a history of previous blood clots. If you take birth control pills and smoke, you should stop smoking to lower your risk for thrombophlebitis or DVT.

To help prevent clots, avoid long periods of immobility during long car trips or airplane flights. Try to walk around and stretch for a few minutes every hour or so. Elevate your legs above your heart level if possible, and if you have a history of blood clots, wear support stockings or socks (also called compression stockings), and drink plenty of fluids. Some people may be prescribed a low-molecular weight heparin to prevent blood clots during a long journey (e.g., airplane trip).