Appendicitis

Question 1

20 year old woman with central abdominal pain which later became localised to lower right quadrant.

Impression/DDx/Goals

Answer 1

Impression:
This presentation most in-keeping with acute appendicitis (migratory peri-umbilical pain), demographic is right. 
RED FLAGS
- perforation
- ovarian torsion
- ectopic pregnancy
- Volvulus/ischaemic bowel
- Malignancy

Consider
- other infective, inflammatory, urinary causes of presentation

Goals:

• identify aetiology of abdominal pain, emergently treat instability/ red flag diagnoses
• appropriately disposition the patient
• initiate appropriate early management

Question 2

Appendicitis - History

Answer 2

Assessment:
- Would initially take A to E approach to ensure haemodynamic stability of patient before proceeding with focussed history.

History:

• Sx: SOCRATES, sx of peritonism, fever
• bowel changes, urinary sx, reproductive sx, sx of malignancy
• sexual history, could be pregnant?
• PMHx, surgical hx
• SNAP

Question 3

Appendicitis - Examination

Answer 3

Exam:

• Vitals: assess for haemodynamic compromise, fever
• Gastro exam: focus on peritonism, locoregional tenderness, Macburney’s point tenderness, psoas/obturator sign, Rosvings sign
• Systemic assessment

Question 4

Appendicitis - Investigations

Answer 4

Investigations:
Alvarado score: clinical criteria for appendicitis, otherwise:
- Bedside: UA (UTI, pregnancy test), VBG
- Bloods: FBC, UEC, bHCG, LFT, CRP/ESR, pre-op bloods
- Imaging: Abdo ultrasound, CT-A

On ultrasound: hyperaemia, thickened wall, peri-appendicular fluid, dilated appendix.

Question 5

Appendicitis - Management

Answer 5

Management:
Supportive/Initial:
- Antibiotics (if complication): Gent + amp + metro
- fluids
- analgesia
- correct electrolytes

Definitive:

• Present to ED - for gen surg consult
• Surgery: laparoscopic appendicectomy
• continue Abx if acutely perforated, otherwise discontinue