Acute Appendicitis

Question 1

What is the most common surgical emergency

Answer 1

• Acute appendicitis

Question 2

Why does appendicitis rarely occur in under 2s

Answer 2

• because the appendix is cone shaped with a large lumen

Question 3

What is the pathogenesis for acute appendicitis

Answer 3

• gut organisms invade appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith or filarial worms
• leads to oedema, ischaemic necrosis and perforation

Question 4

What is the presentation of acute appendicitis

Answer 4

• periumbilical pain that moves to the RIF

Question 5

why does the pain change location in acute appendicitis

Answer 5

• Early inflammation irritates the structure and walls of the appendix, so a colicky pain is felt periumbilically
• As inflammation progresses and irritates the parietal peritoneum (esp on examination), pain settles at McBurney’s point (2/3 of the way along from the umbilicus to the right ASIS)

Question 6

What are the associated signs with acute appendicitis

Answer 6

• tachycardia
• fever
• peritonism with guarding or rebound tenderness or percussion tenderness in RIF
• anorexia
• vomiting - rare
• Constipation usual - though diarrhoea may occur

Question 7

What named signs are associated with acute appendicitis

Answer 7

Rovsing’s sign = pain > in RIF than LIF when the LIF is pressed

Psoas sign = pain on extending hip if retrocaecal appendix

Cope sign = pain on flexion and internal rotation of the right hip if appendix in close relation to obturator internus

pain on right during DRE - suggests an inflamed, low lying pelvic appendix

Question 8

What are the differential diagnosis to appendicitis

Answer 8

• Ectopic pregnancy (do a pregnancy test!!!)
• UTI
• mesenteric adenines
• cystitis
• cholecystitis
• diverticulitis
• salpingitis/PID
• dysmenorrhoea
• Crohn’s disease
• perforated ulcer
• food poisoning
• Meckel’s diverticulum

Question 9

What investigations do you do in appendicitis

Answer 9

• Bloods - neutrophils and CRP are raised
• US - but not always visualised
• CT - has high diagnostic accuracy and useful if diagnosis is unclear

Question 10

What does pregnancy feel like with appendicitis

Answer 10

• occurs in 1/1000 pregnancies
• mortality higher (especially from 20 weeks gestation)
• perforation is more common and increases foetal mortality
• pain is often less well localised - may be RUQ and signs of peritoneum less obvious

Question 11

What is the treatment of appendicitis

Answer 11

Appendicetomy

- open or laparoscopy

Question 12

What antibiotics are you on appendicitis

Answer 12

• Piperacillin/Tazobactam 4.5g/8h, 1-3 doses IV starting 1h pre-op – reduces wound infections
• Give longer course if perforated

Question 13

when is a laparoscopy not recommended

Answer 13

• in cases of suspected gangrenous perforation as the rate of abscess formation may be higher

Question 14

What are the complications of appendicitis

Answer 14

• perforation
• appendix mass
• appendix abscess

Question 15

describe who appendix perforation usually present in

Answer 15

more common of faecolith is present and in young children as the diagnosis is more often delayed

Question 16

What does an appendix mass result

Answer 16

• When inflamed appendix becomes covered with momentum

Question 17

How do you treat an appendix mass

Answer 17

• Early surgery or initial conservative management - NBM and antibiotics
• if the mass resolves some perform an interval (e.g. delayed) appendectomy
• exclude colonic tumour that can present as early as 40 years

Question 18

When does an appendix abscess happen

Answer 18

• may result if an appendix mass fail to resolve but enlarges and the patient gets more unwell

Question 19

What is the treatment of an appendix abscess

Answer 19

• usually involves drainage (surgical or percutaneous under US/CT guidance) although antibiotics alone may bring resolution

Question 20

What are the different positions that the appendix can be in

Answer 20

• retro-caecal
• post-ileal
• pre-ileal
• pelvic

Question 21

Where is McBurney’s point

Answer 21

2/3 of the way along from the umbilicus to the right ASIS

Question 22

when does RUQ pain present with appendicitis

Answer 22

Inflammation in a retrocaecal/retroperitoneal appendix (2.5%) may cause flank or RUQ pain; its only sign may be ↑tenderness on the right on DRE

Question 23

How does perforated appendicitis present

Answer 23

Peritonitis

• pain is in entire abdomen
• constant and severe
• fever is high
• breathing and heart rate may be fast in response to severe pain
• have other symptoms including chills, weakness and confusion

Question 24

what is the urine results in appendicitis

Answer 24

• pregnancy test - rule out ectopic pregnancy

- done to rule out UTI