Appendicitis

Question 1

What is Appendicitis?

Answer 1

Inflamm of appendix

Question 2

What ages does Appendicitis most commonly happen at?

Answer 2

10-20 yrs

Question 3

What is the pathophysiology of Appendicitis? (5 steps)

Answer 3

1. Lumen obstruction by Lymphoid Hyperplasia / Faecolith / Filarial Worm
2. Pathogens get trapped bc obst @ point where appendix meets bowels
3. Pathogens –> infection + inflamm
4. Inflamm –> gangrene –> Appendix ruptures
5. Faecal contents + infective material released into –> Peritoneal Cavity
6. Peritonitis (inflamm of peritoneal lining)

Question 4

What is a Faecolith?

Answer 4

Stony mass of compacted faeces

Question 5

What are the CF of Appendicitis? (5 + 7 things)

Answer 5

1. Periumbilical pain –> moves to RIF (within first 24 hrs)
2. Fever (low grade)
3. LOA (loss of appetite)
4. N + V
5. Conspitation (sometimes diarrhoea)

@ exam

1. Rovsing’s Sign
2. Psoas Sign
3. Cope Sign
4. Guarding
5. Tenderness @ McBurney’s Point
6. Rebound tenderness (perforation)
7. Percussion tenderness (perforation)

Question 6

What is the explanation for the shift of Periumbilical to RIF pain as Appendicitis progresses? (2 things)

Answer 6

1. Early inflamm = irritiates structures + walls of appendix –> colicky pain referred to Periumbilical region
2. Inflamm progresses = irritates parietal peritoneum (esp @ exam) –> somatic + lateralized pain @ McBurney’s Point in RIF

Question 7

Where is McBurney’s Point?

Answer 7

1/3 of distance between Anterior Superior Iliac Spine (ASIS) and Umbilicus

Question 8

What is Rovsing’s Sign? (2 things)

Answer 8

1. Press the LIF (only)
2. More pain in RIF than LIF

Question 9

What is Psoas Sign?

Answer 9

Pain @ hip extension (if retrocaecal appendix)

Retrocaecal appendix = appendix inflammed so much it’s risen up to be behind level of caecum

Question 10

What is Cope Sign? (2 things)

Answer 10

1. Pain @ flexion + int rot of R hip
2. Indicates inflamm pelvis is close contact w obturator internus muscle

Question 11

What is the diagnosis of Appendicitis usually based on? (2 things)

Answer 11

1. Clinical features
2. Raised inflamm markers

(But imaging used in uncertain cases)

Question 12

What investigations should you do for sus Appendicitis?

Answer 12

1. Bloods
2. CT (highest diagnostic accuracy)
3. US (females / kids)

Question 13

What may the bloods of a Appendicitis show? (2 things)

Answer 13

1. Neutrophil lecuocytosis (high no. of neut)
2. Elevated CRP

Question 14

What is the use of a CT in sus Appendicitis? (2 things)

Answer 14

1. Highest diagnostic accuracy (used to confirm diagnosis)
2. Reduces -ve appendicectomy rate

Question 15

Why would you do US on sus Appendicectomy on females?

Answer 15

To exclude ovarian + gynaecological pathology

Question 16

Why would you do US on sus Appendicectomy on kids?

Answer 16

Less radiation than CT

Question 17

What should you do when CF suggest Appendicitis, but investigations are negative?

Answer 17

Diagnostic Laparoscopy to visualise appendix directly

Can do appendicectomy str8 away if indicated

Question 18

What are some DD of Appendicitis? (4 things)

Answer 18

1. Ectopic pregnancy
2. Ovarian cysts
3. Meckel’s Diverticulum
4. Mesenteric Adenitis

Question 19

Which sus Appendicitis patients should you consider the DD of Ectopic Pregnancy for?

Why is this important?

Answer 19

Females of child-bearing age

Ectopic pregnancy = gynaecological EMERGENCY w high mortality if mismanaged

Question 20

How do you differentiate between Appendicitis and Ectopic Pregnancy?

Answer 20

Serum / urine Human Chorionic Gonadotropin (hCG)

Question 21

How do Ovarian Cysts present similary to Appendicitis?

Answer 21

Pelvic / iliac fossa pain

(Esp when rupture / torsion)

Question 22

What is Mesenteric Adenitis?

Answer 22

Inflamed abdominal lymph nodes

Question 23

How does Mesenteric Adenitis present similarly to Appendicitis?

Answer 23

Abdominal pain, in young children

Question 24

How can you differentiate Mesenteric Adenitis from Appendicitis?

Answer 24

MA = often assoc w tonsillitis / URTI

Question 25

What is the initial management of a patient w sus Appendicitis? (2 things)

Answer 25

1. Emergency admission for appendicectomy surgery 2. Abx

Question 26

What is the definitive treatment for Appendicitis?

Answer 26

Appendicectomy (usually laparoscopic)

Question 27

When is the Appendicectomy preffered to do LAPAROSCOPICALLY? (2 things)

Answer 27

1. Women 2. Obese

Question 28

When is the Appendicectomy preferred to NOT do it laparoscopically? Why?

Answer 28

Sus gangrenous perforation Bc higher rate of abscess formation

Question 29

What are the complications of an Appendicectomy? (6 things)

Answer 29

1. Removal of normal appendix 2. Damage to bowel / other organs 3. Bleeding 4. Infection 5. Pain + Scars 6. DVT / PE

Question 30

What are the complications of Appendicitis? (3 things)

Answer 30

1. Perforation (13-20% of cases) 2. Appendix Mass 3. Appendix Abscess

Question 31

When is Perforation more commonly seen as a complication of Appendicitis? Why?

Answer 31

1. When Faecolith present 2. Young children Bc diagnosis often delayed

Question 32

How can Appendix Masses occur as a complication of Appendicitis?

Answer 32

When Appendix becomes covered with omentum

Question 33

How is an Appendix Mass (complication of Appendicitis) diagnosed?

Answer 33

US / CT

Question 34

How should you manage an Appendix Mass (complication of appendicitis)? (3 points)

Answer 34

1. Early surgery OR 1. Conservatively: NBM / Abx 2. If resolved, can do delayed Appendicectomy

Question 35

What should you exclude when you sus Appendix Mass (complication of Appendicitis)? How will you exclude it?

Answer 35

Colonic tumour (presents early as 40 yrs old) Laparotomy or Colonoscopy

Question 36

How can an Appendix Abscess occur as a complication of Appendicitis? (2 points)

Answer 36

1. Appendix Mass fails to resolve --\> enlarges 2. Patient becomes more unwell

Question 37

What is the treatment for an Appendix Abscess (complication of Appendicitis)? (2 things)

Answer 37

1. Drainage (surgical / percutaenous under CT/US guidance) 2. Abx (could resolve it alone)