Acute Appendicitis

Question 1

In which patients is the diagnosis of acute appendicitis difficult

Answer 1

• patients less than three
• pregnant
• older than 60

Question 2

At which age does appendicitis usually occur

Answer 2

Occurs most frequently in the second and third decades of life

Question 3

What is the incidence of appendicitis in the 10 to 20 year age group

Answer 3

233/ 100 000

Question 4

Where is the vermiform appendix located

Answer 4

-Near the ileocaecal valve where the taenia coli converge on the caecum

Question 5

What is the blood supply of the appendix

Answer 5

It is supplied by the appendicular artery, terminal branch of the ileocolic artery, which is a branch of the superior mesenteric artery

Question 6

The attachment of the appendix to the base of the caecum is constant, however where may the tip migrate to?

Answer 6

It may migrate to the retrocaecal, subcecal, preileal, post ileal and pelvic positions

Question 7

What has been proposed as the primary cause of appendicitis?

Answer 7

• Obstruction of the lumen (Frequently implicated but not always required)
• Appendiceal obstruction may be caused by faecoliths, calculi, lymphoid hyperplasia, infectious processes and beneign or malignant tumours

Question 8

What is the natural history of appendicitis following obstruction

Answer 8

• Obstruction leads to increased luminal and intramural pressure resulting in thrombosis and occlusion of the small vessels in the appendiceal wall and stasis of lymphatic flow
• As the appendix becomes engorged, the visceral afferent nerve fibres at T8-10 are stimulated
• Significant inflammation –> necrosis –> perforation –> localized abcess formation or diffuse peritonitis

Question 9

What are the classic symptoms of acute appendicitis

Answer 9

• Right lower quadrant (iliac fossa) abdominal pain
• Anorexia
• Nausea and vomiting
• Abdominal pain is the first symptom; it is peri umbilical in nature with subsequent migration to the right lower quadrant as the inflammation progresses
• Fever and leucocytosis follow later in the cause of the illness
• High grade fever may be a sign of a perforated appendix

Question 10

Differential diagnosis of acute appendicitis

Answer 10

• Urinary tract infection
• Renal calculi
• Gastroenteritis
• Ruptured ovarian cyst
• Pelvic inflammatory disease
• Cholecystitis
• Diverticulitis
• Small bowel obstruction

Question 11

Signs of acute appendicitis

Answer 11

• Localized tenderness
• Rebound tenderness
• Guarding
• Generalized peritonitis (perforation)

Question 12

What is Rovsing’s sign

Answer 12

-Palpation of the left lower quadrant eliciting pain in the right lower quadrant

Question 13

What is obturator sign

Answer 13

Pain with internal rotation of the hip (Pelvic appendix)

Question 14

What is iliopsoas sign

Answer 14

Extension of the right hip eliciting pain in the right hip (retrocaecal appendix)

Question 15

What lab investigations should be done if acute appendicitis is suspected

Answer 15

• Full blood count
• Urinalysis
• Pregnancy test

Question 16

What may abdominal xrays show in a patient with appendicitis

Answer 16

-Non-specific but may demonstrate a faecolith, loss of psoas shadow on the right and a sentinel loop of small bowel in the right lower quadrant

Question 17

Features on ultrasound suggesting appendicitis

Answer 17

• Thickened wall of >2mm
• Increased appendiceal diameter of >6mm
• Free fluid

Question 18

CT scan findings in acute appendicitis

Answer 18

• Thick wall of >2 mm
• Increased diameter of the appendix > 7mm
• Appendocolith
• Phlegmon or abcess
• Free fluid

Question 19

management of patient where there is a doubt in the diagnosis

Answer 19

-Active observation or investigate further

Question 20

Preferred procedure in young female?

Answer 20

Diagnostic laparoscopy should be considered

Question 21

What are the benefits of a laparoscopic appendectomy?

Answer 21

• Less post op pain
• Shorter hospital stay
• Decreased wound infection rate

Question 22

what are the cons of laparoscopic appendectomy

Answer 22

• Longer operative time
• More expensive
• Increased incidence of intra-abdominal collections

Question 23

How should a patient presenting with longer duration of symptoms, finding localized to the right lower quadrant and who have a palpable mass of physical exam?

Answer 23

• Should be treated initially antibiotics, Intravenous fluids and bowel rest
• Most will respond to non-operative management

Question 24

Treatment of appendicular abscess

Answer 24

Ct or ultrasound guided percutaneous drainage is the treatment of choice

Question 25

What should one do if a normal appendix is found intra-operatively

Answer 25

- Important to remove it to avoid confusion about future abdominal pain - Look for other conditions: terminal ileitis, Meckel's deverticulitis, mesenteric adenitis, cholecystitis, Colonic diverticulitis, Pathology of pelvic organs in females

Question 26

Differentials for acute appendicitis in neonates and infants

Answer 26

- Midgut volvulus - Pyloric stenosis - Meckel's diverticulitis - Intussusception

Question 27

How do immunocompromised patients present with acute appendicitis

Answer 27

- Mild tenderness on examination | - Normal WCC

Question 28

Differentials for acute appendicitis in immunocompromised individuals

Answer 28

Broad differentials, including mycobacterial infection, CMV and fungal infections