Appendicitis

Question 1

Examining an abdomen - what to do before you even touch patient?

Answer 1

• Get them to fully blow tummy out
• Then fully suck in
• Then cough
• Will see patients with peritonism doing very little movements and even localise their pain by putting a hand do it
• Then you can examine away from these areas first

Question 2

Pathophys of appendicitis

Answer 2

• Luminal obstruction
• Faecolith or lymphoid hyperplasia (rarer malignancy can cause)
• Inflammation then occurs as bacteria multiply
• Increased pressure, reduced venous drainage –> ischaemia
• –> necrosis and can perforate

Question 3

RF appendicitis

Answer 3

• FH
• Ethnicity - caucasions
• Environmental - summer

Question 4

Presentation of appecidicitis

Answer 4

• Abdominal pain
• Poorly localised, dull peri-umbilical pain
• Later migrates to RIF
• Can have vomitting, anorexia, nausea or diarrhoea too

Question 5

Examination appendicitis

Answer 5

• Rebound tenderness
• Percussion tenderness over McBurneys point
• Guarding esp if perforated
• In severe cases, signs of sepsis

Question 6

Specific examination signs for appendicitis

Answer 6

• Rovsings sign - palpation of LIF causes pain in RIF
• Psoas sign - RIF pain on extension of R hip - retrocaecal appendix abutting psoas muscle

Question 7

What is McBurneys point?

Answer 7

2/3 the way from umbilicus to ASIS

Question 8

Appendicitis in children vs adults

Answer 8

• Childen can present atypical
• Can just be diarrhoea, urinary symptoms and left sided pain sometimes
• Always examine all systems and check genitals to exclude torsion

Question 9

Differentials for appendicitis

Answer 9

• Ovarian cyst rupture, ovarian torsion, ectopic pregnancy, PID
• IBD, Meckels diveriticulum, diverticular disease
• Testicular torsion, epididymo-orchitis
• Ureteric stone, UTI, pyelonephritis

Based on anatomy in that area

Question 10

Investigations for suspected appendicitis

Answer 10

• Urinalysis - assess for renal/urological cause
• Pregnancy test for women of reporductive age
• Routine bloods - FBC, CRP, Clotting screen, group&save, serum b-hCG if not excluded ectopic

Can get +ve leukocytes on urine dip due to local inflammation

Question 11

Imaging for appendicitis

Answer 11

Clinical assessment with biochemical picture can diagnose
But due to wide differentials may need:
* USS - gynae and children
* CT - appendicitis, assess GI and urological
* MRI - 2nd line in children and women

Question 12

Risk stratification scores appendicitis

Answer 12

• Men - appendicitis inflammatory response score
• Women - adult appendicitis score
• Children - Shera score

These are best for each group

Question 13

Management appendicitis

Answer 13

• Laparascopic appendicectomy
• Certain cases can be trialled with abx alone if high risk surgery with uncomplicated

Question 14

How management differs with appendiceal mass

Answer 14

• If mass, abx therapy
• Interval appendicetomy performed 6-8 weeks later

Question 15

What is an appendiceal mass?

Answer 15

• Inflammatory phelgmon (acute inflam of soft tissues)
• Formed by body in response to acute appendicitis
• Oedematous and adherant omentum and small bowel loops form around appendix (almost becomes a sticky ball of inflammation)
• Can be diagnosed pre-op via exam and imaging

Question 16

What happens to appendix once removed?

Answer 16

Sent to histopathology to assess for underlying malignancy

Question 17

Complications of acute appendicitis

Answer 17

• Perforation
• Surgical site infection
• Appendiceal mass
• Abscess formation - delayed presentation, need IV abx and radiologically guided drainage prior to surgery