Appendicitis

Question 1

Explain the aetiology/risk factors for appendicitis.

Answer 1

• Obstruction of the appendiceal lumen, causing a cycle of progressive inflammation and bacterial overgrowth.
• Poor dietary fibre intake: Increased, bowel transit time, and the formation of faecaliths.

Question 2

Summarise the epidemiology of appendicitis.

Answer 2

Most common cause of acute abdomen in children.

Incidence: 4/1000 children.

Any age, most common >5 years of age, uncommon <3 years.

Question 3

What are the symptoms of appendicitis?

Answer 3

• Classical presentation is when there colicky umbilcal abdominal pain which then localizes to the right iliac fossa.
• Later the pain becomes constant with peritoneal inflammation and worsens with movement.
• Low grade-fever, loss of appetite, lethargy, vomiting, constipation/diarrhea.

Question 4

What are the signs of appendicits?

Answer 4

Tachycardia

Pyrexia

Reluctance to move.

Pain on expansion + recession of the abdomen.

Question 5

What signs are found on abdo exam in appendicitis?

Answer 5

Percussion tenderness (inflammation of peritoneum)
Guarding in RIF (McBurney’s point).
Rovsing’s sign (RIF pain on palpation of LIF).

Question 6

When is a Rectal examination indicated in appendicitis?

Answer 6

: performed by the most senior doctor only when dx is in doubt. Marked tenderness against anterior rectal wall, esp. with a retrocaecal appendix.

Question 7

What are some investigations for appendicitis?

Answer 7

General: Appendicitis is a clinical diagnosis; investigations may aid diagnosis in difficult cases.

Bloods: FBC (normal WCC doesn’t exclude appendicitis), CRP, U&Es (especially if vomiting), clotting. Raised neutrophil count is the most sensitive serological investigation for appendicitis.

Urine: MC&S to exclude UTI, leucocytes may be present with an inflamed appendix against bladder wall (nitrite -ve).

Radiology: Plain AXR not indicated; if performed, may show dilated loops of bowel and a fluid level in the RIF. USS may show the inflamed appendix as a non-compressible tubular structure, presence of free fluid or appendiceal mass.

Question 8

Peritoneal irritation signs may be absent with a

Answer 8

Retrocaecal appendicitis.

Question 9

What bloods may be performed if dx is in doubt in appendicitis?

Answer 9

FBC (normal WCC doesn’t exclude appendicitis)

CRP

U+Es (esp. if vomiting)

Clotting

Raised neutrophil count is the most sensitive serological Ix for appendicitis.

Question 10

What urine Ix may be performed if dx is in doubt in appendicitis?

Answer 10

Urine: MC&S to exclude UTI, leucocytes may be present with an inflamed appendix against bladder wall (nitrite -ve).

Radiology: Plain AXR not indicated; if performed, may show dilated loops of bowel and a fluid level in the RIF. USS may show the inflamed appendix as a non-compressible tubular structure, presence of free fluid or appendiceal mass.

Question 11

What radiological Ix may be performed if dx is in doubt in appendicitis?

Answer 11

Plain AXR not indicated; if performed, may show dilated loops of bowel + a fluid level in the RIF.

USS may show inflamed appendix as a non-compressible tubular structure, presence of free fluid or appendiceal mass.

Question 12

What is the management for appnedicitis?

Answer 12

Refer to paediatric surgery and seniors immediately.

Surgery Planning (“GAME”)

• Group and cross match
  Intravenous antibiotics (cefoxitin or tazocin) – will vary according to trust guidelines.
• MRSA screen
• Nil by mouth (Eating and drinking)- Give intravenous fluids.

Appendectomy (open or laparoscopic): Laparoscopic is preferred in uncomplicated appendicitis. Need an extensive washout – high risk of infection and mortality in children.

If patient is unstable for surgery, they must first be optimized before they undergo surgery.

Question 13

What are complications associated with appendicitis?

Answer 13

• Perforation: <3 years old - 80–100%; >10 years old - 10–20%.
• Complicated appendicitis (perforated/presence of pus)
• Wound infection leading to intra-abdominal abscess formation.
• Decreased fertility in girls after complicated appendicitis (ovarian/fallopian tube involvement)
• Small bowel obstruction
• Adhesions

Question 14

What is the prognosis of appendicitis?

Answer 14

Excellent prognosis with tx