Appendicitis

Question 1

Appendicitis is the most common what?

Answer 1

Surgical emergency.

Question 2

Define appendicitis.

Answer 2

Acute inflammation of the vermiform appendix.

Question 3

How does appendicitis typically present?

Answer 3

As acute abdominal pain starting in the mid-abdomen and later localising to the RIF.

Question 4

Who is affected?

Answer 4

· Slightly more common in males.
· Incidence is lower in populations with a high-fibre diet.
· More commonly seen in patients aged between early teens and late 40s.

Question 5

What is the pathophysiology for appendicitis?

Answer 5

· The lumen distal to the obstruction starts to fill with mucous and acts as a closed-loop obstruction.
· This leads to distension and an increase in intraluminal and intramural pressure.
· The resident bacteria in the appendix rapidly multiply.
· Distension of the lumen causes anorexia, N&V and visceral pain.
· As the pressure of the lumen exceeds the venous pressure, the venules and capillaries become thrombosed but arterioles remain open, which leads to engorgement and congestion of the appendix.
· The inflammatory process soon involves the serosa of the appendix, hence the parietal peritoneum in the region, causing RIF pain.
· Once the small arterioles are thrombosed, the area at the anti-mesenteric border becomes ischaemic, and infarction and perforation occur.

Question 6

Prognosis?

Answer 6

Good if treated in a timely manner.

Question 7

What is the aetiology of appendicitis?

Answer 7

· Appendix lumen obstruction is the main cause.
· Faecolith (hard mass of faecal matter), normal stool or lymphoid hyperplasia are the main causes of obstruction.
· Faecolith alone causes simple appendicitis in 40%, gangrenous non-perforated appendicitis in 65% and perforated appendicitis in 90% of cases.

Question 8

Suggest risk factors which may cause appendicitis?

Answer 8

· <6 months of breastfeeding.
· Low dietary fibre - constipation.
· Improved personal hygiene - GI microbial flora.
· Smoking - increased passive and actual smoking increases risk.

Question 9

What are the main 2 symptoms patients with appendicitis present with?

Answer 9

1. Abdominal pain.

2. Anorexia.

Question 10

What 4 signs may be present on examination?

Answer 10

1. McBurney’s sign - RIF pain - maximal site of tenderness, pain.
2. Rovsing’s sign - RIF pain when compression LIF - palpation of the left lower quadrant increases the pain in the right lower quadrant.
3. Psoas sign - Pain occurs at RIF by extension of the right thigh on left lateral position.
4. Obturator sign - Pain occurs at RIF by internal rotation of the flexed right thigh.

Question 11

What investigations would you request if you suspected a patient had appendicitis?

Answer 11

No single investigation to rule out appendicitis, however there are some tests to rule out differentials:

· FBC - Mild leukocytosis with increased neutrophils.
· Urinalysis and pregnancy test.
· USS or CT scan.

Question 12

What scoring system is used for appendicitis?

Answer 12

Alvardo Scoring System – scoring system for acute appendicitis, not very good:

• Migration of Pain, Nausea/Vomiting, Anorexia, Rebound Pain, Temp >37.3, Neutrophil Count >75%»_space;> 1 Point each.
• RIF Tenderness, WCC >Q0X109/L»_space;> 2 Points each.
• 5-6 = Possible, 7-8 = Probable, >9 = Very Probable

Question 13

Suggest some GI differential diagnoses.

Answer 13

· Acute mesenteric adenitis - usually in children with recent URTI, diffuse pain not localised, generalised lymphadenopathy.
· Viral gastroenteritis - profuse diarrhoea, nausea and vomiting, no localising signs.
· Meckel’s diverticulum - usually asymptomatic.
· Intussusception - occurs in young children, sudden onset of colicky pain, sausage-shaped mass in the RIF.
· Crohn’s disease.
· Peptic ulcer disease.

Question 14

Suggest some urological differential diagnoses.

Answer 14

· Right sided ureteric stone - colicky pain and severe.
· Cholecystitis - RUQ.
· UTI.
· Primary peritonitis.

Question 15

Suggest some gynaecological differential diagnoses.

Answer 15

· ID - bilateral pain, vaginal discharge.
· Ectopic pregnancy - vaginal bleeding or spotting, high HCG.
· Ovarian torsion.

Question 16

What are the 4 treatment options?

Answer 16

1. Uncomplicated presentation:
   - 1st line - appendectomy + supportive care.
   - Adjunct - IV abx.
2. Unwell with perforation or abscess:
   - 1st line - IV abx + supportive care.
   - Perforation - appendectomy.
   - Abscess - drainage +/- interval appendectomy.
3. Supportive care:
   - NBM.
   - IV fluids.
   - Analgesics.
   - Anti-emetics.
4. Appendicectomy surgery by:
   - Open or laparoscopic.
   - IV Ax pre-op reduces wound infections (cefuroxime plus metronidazole).

Question 17

What complications can arise?

Answer 17

· Perforation. 
· Generalised peritonitis.
· Appendicular mass.
· Appendicular abscess.
· Surgical wound infection.