Acute appendicitis

Question 1

A 25 year old man presents with a two week history of right iliac fossa pain and intermittent fevers. His BP is 120/72 mmHg, PR 64/min and T 36.4°C. Examination reveals evidence of a 6cm right iliac fossa mass. There is tenderness over the mass but nowhere else on the abdomen. How would you assess and manage him?

Answer 1

Impression
Given the systemic features of infection, and examination findings of focal tenderness and abdominal mass in the RIF, I am concerned about a complicated appendicitis with abscess/phlegmon formation.

Ddx include other causes of RIF pain and abdo mass

• GIT: complicated hernia, bowel obstruction, appendices tumour, rule out other GIT malignancy, cholecystitis (wrong clinical picture)
• Renal: nephrolithiasis, malignancy
• infective: psoas abscess
• gynaecological (if female)

Goals

• Conduct A to E assessment, ensure HD stability and no acute peritonitis
• Contact gen surg for consult, likely arrange theatres for laparoscopic appendicectomy, or trial of conservative management with bridging ABx (Depends on underlying aetiology).

Question 2

Appendicitis - History

Answer 2

History

• Sx: RIF pain, SOCRATES, systemic features of infection (fevers, night sweats, tachy, palpitations etc), urinary/Bowel movement changes, characterise the mass, nausea/vomiting/anorexia/diarrhoea
• REDS: peritonitis (pain going over bumps into hospital),
• risks: recent illnesses (lymphoid hyperplasia), low fibre diet (faecolith)
• PSHx, PMHx, medications, allergies, last meal

Question 3

Appendicitis - Examination

Answer 3

Examination

• General appearance + vitals: Hd status, endofthebedogram
• abdo exam: focal tenderness vs peritonitis (?acute abdomen), rovings signs, McBurney’s point tenderness, shifting dullness, bowel sound, Psoas vs obturator sign

Question 4

Appendicitis - Investigations

Answer 4

Investigations
Is usually a clinical diagnosis.

Bedside: VBG if concerns for HD instability, UA + MCS
Bloods: FBC, UEC, LFT, CRP/ESR (esp if for conservative management), blood cultures given fevers, rest of septic screen if indicated on History, pre-op bloods if surgery indicated.
- Imaging: abdo ultrasound (evidence of phlegmon, etc), CT abdomen, upright AXR for air under diaphragm as evidence of perforation.

Question 5

Appendicitis - Management

Answer 5

Management
If concern about peritonitis/ acute abdomen, would want urgent surgical review with likely disposition being theatres for laparoscopy +/- laparotomy.
Given stem does not show vitals of HD instability or evidence of generalised peritonitis, am not concerned for this.

Supportive

• Surgical consult
• analgesia, antipyretics, antiemetics
• correct any fluid/electrolyte imbalance (esp if any vomiting)
• keep NBM
• pre-op surgical consent if appropriate
• regular monitoring/observation

Definitive:

• Phlegmon: supportive therapy as appendix is usually destroyed and necrosed. ABx therapy
• If Abscess: >3cm then percutaneous drainage, but less then 3cm then supportive ABx then appendicectomy later down the track once inflammation has subsided.
• ABX: either bridge to surgery or mainstay of treatment (gent, amp, metro - if per then IV, if not the PO)
• laparoscopic appendicectomy; either in acute setting if indicated due to deterioration, or in outpatient setting once infection has subsided.
• Histopathology of resection to rule out carcinoid tumour/other appendices malignancy
• US-guided abscess drainage (by IR)
• Document, inform family