Appendicitis

Question 1

Definition

Answer 1

Acute inflammation and bacteria infection of the appendix due to luminal obstruction

Question 2

What is the appendix

Answer 2

Vestigial organ with disputed functionality
- located at McBurney’s point = 2/3 of the way from the umbilicus and the anterior superior iliac spine

Question 3

Epidemiology

Answer 3

Young age: the highest incidence is between 10-20 years
- Rare before age of two because the appendix is cone shaped with a large lumen
Male

Question 4

Risk Factors

Answer 4

Frequent antibiotic use: imbalance of gut flora + modified response to subsequent infection which may trigger appendicitis
Smoking

Question 5

Aetiology (Think F)

Answer 5

Luminal obstruction with:
FAECOLITH,
Filarial worms,
Foreign body,
Fibrous strictures
Lymphoid hyperplasia (of Peyer’s patches = TEENS),

Question 6

Pathophysiology

Answer 6

Luminal obstruction
- Blockage typically infected with E.COLI = gut organisms invading the appendix wall → oedema, ischaemia +/- perforation
- Can lead to sepsis and death

Question 7

Signs

Answer 7

• Periumbilical pain which migrates to Right iliac fossa (McBurney’s point) rebound tenderness
• Abdominal guarding
• Pyrexic
• Anorexia is very common
• Rosving’s sign: pain in RIF = worsened by pressing on left iliac fossa
• Psoas sign: pain worsened by extending the hip
• Obturator sign: pain is worsened by flexing and internally rotating the hip

Rebound tenderness and percussion tenderness suggests peritonitis = potential ruptured appendix
Tachycardic, hypotension and generalised peritonism: suggests perforation (signs of shock)

Question 8

Where may the pain be for a pregnant woman

Answer 8

In pregnant women after the 1st trimester, the pain may be RUQ or right flank pain due to displacement of appendix by pregnant uterus

Question 9

Symptoms

Answer 9

• Periumbilical pain which migrates from the periumbilicus to the right iliac fossa (McBurney’s point) within 24 hours
• Nausea and vomiting
• Diarrhoea
• Low grade fever

Question 10

CLASSIC TRIAD FOR APPENDICITIS

Answer 10

• Central abdominal pain which migrates to right iliac fossa,
• Low-grade hyperpyrexia
• Anorexia

Question 11

Retrocaecal signs

Answer 11

Pain may be towards the flank
Retrocaecal appendicitis often has few signs on examination

Question 12

Alvarado score

Answer 12

Predict the likelihood of appendicitis. A score of >7 is predictive of acute appendicitis
5-6 warrants an USS or CT

Question 13

Diagnosis

Answer 13

FIRST LINE = Blood tests
- neutrophil-predominant leucocytosis
- Raised ESR + CRP
- U+E = AKI in dehydration 2’ to N+V
GOLD STANDARD = CT abdo + pelvis
- USS = useful and first line in females to exclude gynaecological pathology and children due to good diagnostic accuracy in paediatrics.
Signs but no investigations = diagnostic laparotomy
Pregnancy test = rule out ectopic pregnancy (RIF pain)

Question 14

Treatment

Answer 14

FIRST LINE = Abx + fluids (both before and after
- PIPERCILLIN or TAZOBACTAM
THEN APPENDECTOMY (GOLD STANDARD)
* Must drain abscess’ = resistant to Abx (walled off bacterial collection resistant to systemic Abx = Drainage + INTRA ABSCESS Abx *

Question 15

Complications

Answer 15

Spontaneous Bacterial Peritonitis
Peri appendiceal abscess