Acute appendicitis

Question 1

What is the pathogenesis?

Answer 1

• Primary obstruction of the appendix lumen (faecolith, lymphoid hyerplasia, filarial worms)
• Fills with mucus and swells
• Pressures result in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow

Question 2

What are the symptoms?

Answer 2

• Periumbilical colicky pain to RIF constant pain
  
  • Gradual onset
• Anorexia
• Vomiting someimes after pain
• Constipation
• Diarrhoea

General symptoms;

• Tachycardia
• Fever
• Furred tongue
• Lying still
• Coughing hurts
• Foetor +/- flushing
• Shallow breaths
• RIF
  
  • Guarding
  • Rebound + percussion tenderness
• PR pain on right

Question 3

What are some signs of appendicitis?

Answer 3

1. Rovsing’s sign
   
   • RIF pain when LIF pressed
2. Psoas sign
   
   • Pain lifting hip against resistance = retrocaecal appendix
3. Cope sign [obturator sign]
   
   • Pain flexing and internal rotating right hip = appendix close

Question 4

What is Rovsing’s sign?

Answer 4

RIF pain when LIF pressed

Question 5

What is Psoas sign?

Answer 5

Pain lifting hip againt resistance = retrocaecal appendix

Question 6

What is Cope/ obturator sign?

Answer 6

Pain flexing and internal rotating right hip = appendix close

Question 7

Why might there be flank/ RUQ pain?

Answer 7

2.5% are retrocecal/ peritoneal

Only sign is right pain in PR

Question 8

What investigations are important?

Answer 8

• Raised WBC
• Pregnancy test (exclude ectopic pregnancy)
• Abdominal X-Ray for ecluding ureteric calculus
• Mid-stream urine (MSU) to exclude UTI
• CRP will be raised but is non-specific
• Pelvic ultrasound for gynaecological pathology
• CT scan is sensitive and specific

Question 9

What are complications of appendicitis?

Answer 9

• Perforation
  
  • Common with faecolith + young children (diagnosed late)
• Appendix mass
  
  • Inflamed appendix covered with omentum
• Appendix abscess

Question 10

What is the treatment of acute appendicitis?

Answer 10

• Prompt appendicectomy
• Antibiotics
• Laparoscopy is good (except in gangrenous)