acute appendicitis

Question 1

etiology and features

Answer 1

• Most common cause of urgent abdominal surgery & provisional diagnosis of all surgical admissions in the UK.

• May affect any age (uncommon < 4 & > 80).
• Peak age of incidence early teens to early twenties

Question 2

3 types

Answer 2

• Mucosal: mildest form, usually diagnosed by pathology reporting.
• Phlegmonous: typical, relatively slow onset & progression.
• Necrotic: often due to acute bacterial infection + ischemic necrosis. Leads to perforation, unless surgically removed!

Question 3

differential diagnosis children

Answer 3

• Non-specific abdominal pain (mesenteric adenitis).
• Meckel’s diverticulitis.
• Ovarian cyst / menstrual symptoms.

Question 4

differential diagnosis adults

Answer 4

• Terminal ileal pathology: Crohn’s, Meckel’s diverticulitis, gastroenteritis.
• Retro Peritoneal pathology: pancreatitis, renal colic.
• Ovarian pathology: ectopic pregnancy, cyst, infection, menstrual pain, endometriosis.

Question 5

differential diagnosis older adults

Answer 5

• Ileocaecal pathology: caecal diverticulitis / tumors.
• Colonic pathology: sigmoid diverticulitis.
• Ovarian pathology: cysts, infection, tumors.

Question 6

clinical presentation

Answer 6

• Malaise, anorexia & fever.
• Diarrhea (common), may be mistaken for acute gastroenteritis.
• Abdominal pain starts centrally & localizes to the right iliac fossa.
• Abdominal pain caused by coughing & moving.
• Fever, tachycardia.
• Abdominal tenderness: peritonism suggests perforation (local / generalized).
• Often maximal over (McBurney’s point) (opposite) but only if appendix is in the conventional anatomical position.
• Palpation of LIF causes pain worse in RIF (Rovsing’s sign).
• Positive rebound test.

Question 7

complications

Answer 7

• Perforation (localized / generalized).
• Right iliac fossa ‘appendix’ mass (usually appendicitis with densely adherent caecum & omentum - forming a mass).
• RIF (right iliac fossa) abscess (usually due to perforated retrocaecal appendicitis).
• Pelvic abscess (usually due to perforated pelvic appendicitis).

Question 8

emergency management

Answer 8

Resuscitation:
• Establish I.V access.
• Catheterize & place on a fluid balance chart only if hypotensive / septic.
• Lab tests: CBC (Hb, WCC), U & E (Na, K), CRP (usually increased WCC, CRP).

Question 9

diagnosis

Answer 9

• Usually according to clinical presentation.
• CT: appropriate in adults, especially > 65 / if the diagnosis is unclear (since the differential diagnosis is much wider & appendicitis relatively less likely in this age group).
• The best investigation in suspected appendix mass / abscess.
• USG (abdominal & pelvic): in young women if ovarian pathology / ectopic pregnancy is suspected.
• Laparoscopy: a useful, minimally invasive, surgical diagnostic method allowing diagnosis of pelvic pathologies (PID) without a major abdominal incision.

Question 10

treatment

Answer 10

Avoid giving I.V ATB’s without a clear diagnosis.

Acute appendicitis:
❖ Open (laparotomy) / laparoscopic appendectomy.
❖ I.V ATB’s (only for perforation).

Appendix mass / abscess:
• I.V ATB’s (cefuroxime (cephalosporin) + metronidazole).
• If symptoms settle: delayed appendectomy after 6 weeks.
• If symptoms do not settle: may need acute appendectomy.
• Appendix abscess may be treated by CT guided drainage