Appendicitis

Question 1

Define Appendicitis

Answer 1

Appendicitis refers to inflammation of the appendix

Question 2

What is the key symptom patients present with?

Answer 2

Acute Abdominal pain

Question 3

At what age is there peak incidence of appendicitis

Answer 3

20-40 year olds

Question 4

Why is appendicitis uncommon in the extremes of age?

Answer 4

The young have a relatively wide appendiceal lumen

Whilst in the elderly the appendix is almost entirely obliterated

Question 5

Is there higher prevalence of appendicitis in:

a) Males
b) Females

Answer 5

a) Males

Question 6

Where in the bowel does the appendix open

Answer 6

Opens onto the caecum of the large bowel

Question 7

The majority of appendix are in which position

Answer 7

Retrocaecal

Question 8

What supplies the appendix

Answer 8

Appendix is supplied by the appendiceal mesentery, which hangs from the terminal ileum and contains the appendiceal branch of the ileocolic artery (from the superior mesenteric artery)

Question 9

What are the taeniae coli

Answer 9

Three longitudinal muscles that run the length of the large intestine

Question 10

Name some of the causes of luminal obstruction of the appendix

Answer 10

• Faecolith [most common cause] i.e. hard collections of stool that form and block the lumen
• Lymphoid hyperplasia
• Caecal tumour

Question 11

Describe the pathophysiology of appendicitis

Answer 11

• Typically caused by an obstruction of the lumen of the appendix i.e., the point where the appendix meets the caecum
• Obstruction can result in the trapping of pathogens within the appendix. The stasis can result in bacteria overgrowth leading to infection and inflammation
• Reduced venous drainage and inflammation can result in increased pressure within the appendix.
• As the pressure rises further, the arterial supply to the appendix becomes compromised leading to ischaemia, which in turn can cause perforation of the appendix
• When the appendix ruptures, faecal contents and infective material are released into the peritoneal cavity causing peritonitis i.e. inflammation of the peritoneal lining

Question 12

Name some of the risk factors for appendicitis

Answer 12

• Age
  
  • Peak incidence in 20-40 year olds
    
    • Uncommon in the extremes of age i.e. young children and >50 because the young have a relatively wide appendiceal lumen, whilst in the elderly, it is almost entirely obliterated
• Sex – Higher male prevalence
• Family history
• Ethnicity – more common in Caucasians

Question 13

Describe the abdominal pain associated with appendicitis

Answer 13

Dull central pain that progresses and becomes a sharp pain that moves and becomes localised to the right iliac fossa

Question 14

Name some of the symptoms of appendicitis

Answer 14

• Abdominal pain – key symptom
• Nausea and vomiting
• Loss of appetite
• Low grade fever
• Weight loss
• Constipation

Question 15

Define the term “rebound tenderness”

Answer 15

Pain upon removal of pressure of the palpitation rather than application of pressure to the abdomen

Question 16

Rebound tenderness is a sign of appendicitis over what location of the abdomen?

Answer 16

McBurney’s point - a specific area two thirds of the way between the umbilicus (2) and the anterior superior iliac spine (3)

Question 17

Name some of the signs associated with appendicitis

Answer 17

• Rebound tenderness over McBurney’s point
• Percussion tenderness over McBurney’s point i.e. pain and tenderness when percussing the abdomen
• Rovsing sign: pain in the RIF on palpation of the LIF
• Psoas sign: RIF pain on passive extension of the right hip
  
  • This is suggestive of an inflamed appendix near the psoas major muscle in a retrocaecal position
• Guarding
• Signs of sepsis e.g. tachycardic, hypotensive, pyrexia
• RIF mass – suggestive of an appendiceal abscess

Question 18

Rovsing sign is a sign suggestive of what condition

Answer 18

Appendictis

• Rovsing sign: pain in the RIF on palpation of the LIF

Question 19

Define Rovsing sign

Answer 19

Pain in the RIF on palpation of the LIF

Question 20

Psoas sign is a sign suggestive of which condition

Answer 20

Appendicitis

Question 21

Define Psoas sign

Answer 21

RIF pain on passive extension of the right hip

Question 22

How is appendicitis diagnosed

Answer 22

It is a clinical diangosis i.e. the diagnosis is based on signs and symptoms rather than diagnostic tests.

Can be confirmed with a CT scan

Raised inflammatory markers are suggestive of appendictiis however these may not be elevated early in the disease process

Question 23

What is the first line imaging modality for confirming appendicitis diagnosis

Answer 23

CT scan

Question 24

Why is ultrasound scan the 1st line imaging modality to confirm appendicitis diagnosis in children

Answer 24

To minimise radiation exposure

Question 25

In which patient group is ultrasound scan the 1st line imaging modality in confirming a diagnosis of appendicitis

Answer 25

In women in child bearing age where gynaecological pathology is still a potential In children

Question 26

Serum beta hCG is testing for?

Answer 26

Pregnancy

Question 27

Which blood test is used for pregnancy

Answer 27

Serum beta HCG

Question 28

What is the gold standard treatment for appendicitis

Answer 28

Laparoscopic appendicectomy i.e. appendix removal

Question 29

Why is laparoscopic preferred over open surgery?

Answer 29

Fewer complications and faster recovery time however conversion to open surgery occurs when necessary

Question 30

Antibiotic therapy should be commenced prior to appendicectomy for appendicitis. Which antibiotic is the typical choice?

Answer 30

Co-amoxiclav

Question 31

Describe the time duration of antibiotic therapy in relation to appendicitis

Answer 31

Antibiotic therapy should be commenced prior to surgery and should be continued for 7 days after surgery if pus or perofartion is noted intra-operatively

Question 32

When should antibiotic therapy be continuted for a week after laparoscopic appendicectomy?

Answer 32

If pus or perforation is noted intra-operatively

Question 33

Name the 3 complications of acute appendicitis

Answer 33

* Perforation – causing peritoneal contamination * Appendix mass * Pelvic abscess

Question 34

When would an appendiceal mass occur in the case of an acute appendicitis

Answer 34

Occurs when the omentum and small bowel adhere to inflamed appendix forming a mass in the RIF

Question 35

What is the management of an appendiceal mass secondary to acute appendicitis

Answer 35

Antibiotic therapy and supportive treatment followed by appendicectomy once the acute condition has resolved

Question 36

How would an appendix mass secondary to acute appendicitis present

Answer 36

Fever with a palpable RIF mass

Question 37

How would an appendix mass secondary to acute appendicitis diagnosis be confirmed?

Answer 37

With a CT scan

Question 38

Name some of the complications of appendicectomy

Answer 38

- Bleeding, infection, pain and scars - Damage to bowel, bladder or other organs - Removal of a normal appendix - Anaesthetic risks - Venous thromboembolism (deep vein thrombosis or pulmonary embolism) - Failure