Acute Appendicitis

Question 1

What is acute appendicitis?

Answer 1

Inflammation of the appendix.
Located at the McBurney’s point (⅔ from the umbilicus to the Anterior Superior Iliac Spine (ASIS)).

Question 2

Give the 3 main causes.

Answer 2

1. Faecolith (stone made of faeces)
2. Lymphoid hyperplasia
3. Filarial worms

Question 3

Explain the pathophysiology of acute appendicitis.

Answer 3

1. Occurs when the lumen of the appendix becomes obstructed by lymphoid hyperplasia, filarial worms or a faecolith, resulting in the invasion of gut organisms into the appendix wall.
2. This leads to oedema, ischaemia, necrosis and perforation as well as INFLAMMATION.
3. Inflammation may lead to gangrene and rupture.
4. If the appendix ruptures, then infected and faecal matter will enter the peritoneum, resulting in life-threatening peritonitis.

Question 4

Describe the epidemiology of acute appendicitis - at what ages does it occur? Is it common?

Answer 4

Highest incident between 10-30 YO.
One of the most common surgical emergency.

Question 5

Give 4 symptoms of acute appendicitis.

Answer 5

1. Umbilical (periumbilical) pain → RIF pain (migratory)
   = Pain in the umbilical region (periumbilical pain) that migrates to the right iliac fossa, specifically McBurney’s point after a few hours
   = Really important to know it almost always starts in the periumbilical region - AND THEN migrates to the RIF
2. Nausea & vomiting
3. Anorexia
4. Pyrexia (fever)

Question 6

Give 5 symptoms observed upon physical abdominal examination.

Answer 6

1. Rovsing’s sign (palpation on the LIF causes pain in the RIF)
2. Psoas sign (RIF pain on right hip extension)
3. Obturator sign (RIF on right hip flexion and internal rotation)
4. Guarding on abdominal palpation
   = when abdominal muscles tense up
5. Rebound tenderness in the RIF
   = increased pain when suddenly releasing the pressure of deep palpation

Question 7

Investigations for acute appendiciis diagnosis.

Answer 7

Mostly a clinical diagnosis (meaning it is based on signs and symptoms rather than diagnostic tests)!

1. Blood tests:
   - FBC: leukocytosis + neutrophilia
   * Raised WCC with neutrophil leucocytosis
   * Elevated CRP and ESR
   - U+Es - AKI
2. Abdominal ultrasound:
   * Can detect inflamed appendix and can also indicate an appendix mass or other localised lesion
3. Abdominal CT with contrast:
   * Highly sensitive and specific - GOLD STANDARD for diagnosis
   * Reduces risk of removal of a healthy appendix
4. Pregnancy test - to exclude
5. Urinalysis - to exclude UTI

Question 8

Treatment for acute appendicitis.

Answer 8

1. Removal of appendix - appendicectomy laparoscopically (key hole)

• IV antibiotic pre-op to reduce wound infections
  e.g. IV METRONIDAZOLE and IV CEFUROXIME
• If appendix mass is present, the patient is usually treated with IV fluids and antibiotics until mass disappears over a few weeks.
  Appendicectomy is recommended later to prevent further acute episodes.

Initial:
1. Fluids: patients will require hydration due to fluid losses, as well as due to being nil-by-mouth prior to surgery
2. Analgesia: patients can be in considerable pain
3. Antiemetics: can be given for nausea and vomiting
4. Preoperative IV antibiotics

Question 9

Give 3 complications of acute appendicitis.

Answer 9

1. Appendix mass
2. Perforation
3. Appendix abscess

Question 10

Differential diagnosis of acute appendicitis.

Answer 10

Gynae:
1. Ectopic pregnancy
2. Ovarian torsion
3. Ruptured ovarian cyst

GI:
1. IBD
2. Diverticulitis
3. Meckel’s diverticulum

GU:
1. Kidney stones
2. UTI
3. Testicular torsion