Acute Appendicitis

Question 1

What are possible etiologies for acute appendicitis?

Answer 1

1. Changes in dietary habits - less fibre, increased refined carbohydrates
2. Bacterial Infection 2’ to obstruction of appendiceal lumen
   - Fecolith
   - Lymphoid Hyperplasia (a/w inflammatory [crohn’s] & infective [GE, URTI, IMS,
   - Parasitic Worm
   - TB
   - Tumour of Appendix

Question 2

What is the pathophysiology of acute appendicitis?

Answer 2

Obstruction → distension by mucus → increased luminal and intramural pressure → thrombosis and occlusion of blood supply, stasis of lymphatic flow → ischemia (periumbilical abdominal pain) → necrosis → bacterial overgrowth and invasion (polymicrobial – E coli, Bacteroides fragilis, Peptostreptococcus, Pseudomonas) → fibropurulent reaction on serosa → irritation of parietal peritoneum (localised pain at McBurney’s point)

Question 3

What should be attained on history?

Answer 3

1. Abdominal Pain
   - Visceral discomfort so poorly localised then localised to RIF
2. Nausea Vomiting
   - Occurs after pain
   – if before pain, consider IO
3. Fever

Question 4

What should be done on PE?

Answer 4

1. Vitals
   - Temperature: Low Fever
   - HR: Normal/Slightly elevated
2. Abdomen
   - McBurney Point Tenderness
   - Rebound tenderness, voluntary guarding –> localised peritonism
   - Cutaneous hyperesthesia (spinal nerve of R T10, T11, T12)
   - Rovsing Sign: RIF pain with deep palpation of LIF
   - Psoas Sign: RIF pain with passive right hip flexion
   - Obturator Sign: RIF pain with IR of flexed right hip
   - Cough sign: RIF pain on coughing
3. DRE - pain in suprapubic area, rectal tenderness, hx of diarrhoea
4. For infants/children, examine scrotum due to migration of pus through patent processus vaginalis (ddx: acute testicular torsion)

Question 5

What the differential diagnoses of acute appendicitis?

Answer 5

Question 6

Describe the clinical scoring system for diagnosis of acute appendicitis?

Answer 6

Alvarado Score [MANTRELS]
1. Migratory RIF Pain
2. Anorexia
3. Nausea/Vomiting
4. Tenderness (2pt)
5. Rebound Tenderness
6. Temperature
7. Leukocytosis (2pt)
8. Left Shift of Neutrophils

3 or less: no need imaging, unlikely
4-6: CT
7 or more: surgical consultation

5 or less: no need admission

Question 7

What investigations should be done?

Answer 7

1. FBC*
2. RP*
3. CRP*
4. Blood cultures
5. PT/PTT
6. GXM
7. LFT/Amylase/Lactate/ABG
   8/ ECG
8. CT AP* - i) enlarged appendix >6mm, ii) thickened appendix wall > 2mm with enhancement (target sign), iii) periappendiceal fat stranding, iv) appendicolith, v) complications
9. Erect CXR - r/o perforation
10. Supine AXR - little value
11. Abdominal US: for paeds and pregnant pt (i) non compressible appendix >6mm in AP direction, ii) thickening of appendiceal wall iii) periappendiceal fluid
12. MRI Abdomen - for pregnant patients

*required, rest use clinical judgement

Question 8

What is the management of acute appendicitis?

Answer 8

1. NMB, IV, correct electrolye abnormalities
2. IV Abx
3. Antiemetics, Analgesia
4. Definitive treatment: Lap Appendectomy
   - stop abx postop if uncomplicated
5. if complicated, nonop management follows ochsner sherren regime
   – treat conservatively with antibiotics if patient remains is
   hemodynamically stable and non-peritonitic
   – May benefit from percutaneous drainage of appendiceal abscess
   – Symptomatic patients (during clinic visit) → inflammatory markers, CT scan or diagnostic laparoscopy
   – Asymptomatic patients (during clinic visit) → consider colonoscopy vs. interval appendectomy

Question 9

What are the complications of acute appendicitis?

Answer 9

Hemorrhage
Infection/Sepsis
Conversion to Open
Bowel Resection
Paralytic Ileus
Adhesions
Retained fecolith –> stump appendicitis/leak/fistula