What Is Pseudoappendicitis?
Pseudoappendicitis refers to a condition that resembles appendicitis. Appendicitis is characterized by acute right lower quadrant abdominal pain, anorexia, and point tenderness (McBurney's sign). Pseudoappendicitis is more specifically associated with Yersinia enterocolitica infections. This bacteria is linked to yersiniosis, an infective and inflammatory intestinal condition.
What Causes Pseudoappendicitis?
The American College of Surgeons has listed differentials for the impression of acute abdominal pain, including pelvic inflammatory disease, inflammatory bowel disease, gastroenteritis, right lower lobe pneumonia, intussusception, Meckel's diverticulum, and constipation. The impression of thoracic spine dysfunction was not included in their differential diagnosis. Yersinia is an Enterobacteriaceae gram-negative bacillus. Yersinia has 11 subtypes, only three of which are pathogenic to humans. Yersinia pestis, Yersinia pseudotuberculosis, and Yersinia enterocolitica are all pathogens that can cause human disease. Y. enterocolitica can be found in all animal species, including mammals such as dogs, pigs, cattle, deer, and rodents, as well as many birds and reptiles. It is kept in their intestines until it is passed on to them. This bacteria can be isolated from soil and ponds as well. It is typically transmitted to humans through contaminated milk or water. Undercooked pork consumption is a common source of human infection.
What Is the Epidemiology of Pseudoappendicitis?
Immunocompromised patients are more vulnerable to Y. enterocolitica infections. They are also more likely to develop more severe diseases. Sequelae include sepsis and splenic and hepatic abscesses caused by bacteria spreading from the gut to these organs and the bloodstream. Individuals with hereditary hemochromatosis are more likely to become infected with Y. enterocolitica. This condition is characterized by elevated total iron levels in the blood. Y. enterocolitica is a siderophile and the most common bacteria found in contaminated units of stored packed red blood cells. Healthy patients who contract these bacteria experience self-limiting gastrointestinal symptoms, but the young, elderly, or sick are more likely to contract this infection and develop symptoms. In addition, people who practice poor personal hygiene may be more susceptible to infection. Patients who have recently received a blood transfusion and experience symptoms that are not typical of transfusion reactions, such as abdominal pain, generalized malaise, gastrointestinal (GI) symptoms, fever, and should be evaluated for Y. enterocolitica bacteremia.
What Are the Histopathological Findings of Pseudoappendicitis?
The pathological cause determines the histopathological findings of pseudoappendicitis. As a result, despite the acute clinical presentation mimicking acute appendicitis in some extremely rare cases of pseudoappendicitis, such as Kikuchi-Fujimoto disease (KFD), the histopathological finding is remarkable for histiocytic necrotizing lymphadenitis. Y. enterocolitica, on the other hand, can be isolated from infected tissues, blood, stool, water, and other contaminated things. It causes varying degrees of enteritis as well as mucosal inflammation in the gastrointestinal tract. Histologic findings resembling Salmonella and Shigella infections are common. In addition, inflammation and adenitis will be seen in the lymph nodes of the mesentery.
What Are the Signs and Symptoms of Pseudoappendicitis?
The signs and symptoms of pseudoappendicitis depend upon the underlying cause. The majority of patients who contract Y. enterocolitica do not develop symptoms. Mild diarrhea and abdominal pain are common symptoms of yersiniosis. Watery or bloody diarrhea, fever, chills, and increased abdominal pain are more advanced symptoms of this infection. Patients with mesenteric adenitis will have moderate to severe symptoms. Patients with advanced infections, particularly those left untreated, will exhibit sepsis, dehydration, and shock symptoms.
How Is Pseudoappendicitis Diagnosed?
Various laboratory and radiological tests are performed more frequently to rule out other etiologies such as Meckel's diverticulitis, inflammatory bowel disease, or appendicitis. Stool cultures should be performed to confirm the presence of Y. enterocolitica. If this bacteria is suspected, the microbiology department should be notified because it requires a special Cefsulodin-Irgasan-Novobiocin (CIN) agar to be isolated from stool. Computed tomography (CT) imaging may be required to confirm or rule out intrahepatic or splenic abscesses in severe progressive cases, particularly in immunocompromised patients.
What Is the Differential Diagnosis of Pseudoappendicitis?
The most common misdiagnosis of patients with Y. enterocolitica infections is appendicitis. Hence it is called pseudoappendicitis. The differential diagnosis of pseudoappendicitis includes
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Inflammatory bowel disease.
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Sigmoid diverticulitis.
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Meckel's diverticulitis.
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Mesenteric lymphadenitis.
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Ischemic colitis.
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Giardiasis.
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Shigellosis.
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Clostridium difficile colitis.
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Salmonellosis.
What Is the Prognosis of Pseudoappendicitis?
This disease is usually self-limiting. Fluids, rest, and fever control are usually enough to treat the symptoms, and patients recover completely within 24 to 48 hours. However, patients who are immunocompromised or have more systemic diseases have a poor prognosis.
What Is the Treatment of Pseudoappendicitis?
The majority of Y. enterocolitica infections are self-limiting and do not require treatment. Initially, patients with more severe diarrhea and dehydration should be treated symptomatically. They will need to be resuscitated and stabilized with intervening fluids. To rule out other possible surgical etiologies of their symptoms, appropriate laboratory testing and X-rays should be ordered. Antibiotics are usually not necessary because this is a self-limiting condition. Still, antibiotics should be started in more advanced cases that do not respond to symptomatic therapy or immunocompromised patients. Penicillins and first and second-generation cephalosporins are ineffective against this beta-lactamase-producing bacteria and should not be used. A combination of Doxycycline and an Aminoglycoside is the recommended antibiotic therapy for Y. enterocolitica. Trimethoprim-sulfamethoxazole, fluoroquinolones, chloramphenicol, and third-generation cephalosporins are other effective antibiotics in treating this condition. Immunocompromised patients with splenic or hepatic abscesses may benefit from percutaneous drainage. Long-term intervening antibiotics should also be given.
What Are the Complications of Pseudoappendicitis?
There are no long-term consequences of this disease. Some studies speculated that patients who have had this condition for an extended period of time might develop autoimmune thyroid disease or other autoimmune disorders; however, this has not been proven.
Conclusion
Appropriate history-taking usually leads to the correct diagnosis of pseudoappendicitis. Knowledge of the epidemiology and treatment of this condition may save the ill patient from undergoing unnecessary surgeries. The clinician must be patient, as supportive care and appropriate treatment are the best treatment for this condition. The treating staff and patient must be aware of the disease's self-limiting nature.
