Appendictis

Question 1

Definition

Answer 1

Inflammation of vermiform appendix

Question 2

Pathophysiology

Answer 2

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. As the condition progresses, the resident bacteria in the appendix rapidly multiply.

Pressure +->-ve venous outflow->congestion->thrombosed->ischemic->necrotic->perforation, abscess

Question 3

Clinical features

Answer 3

Periumbilical pain moves to RIF
ANorexia
Vomiting rarely prominent
Constipation
Check for recent infections->mesenteric adenitis

Question 4

Physical examination

Answer 4

TachyC
Low grade fever
Lying still
Coughing hurts
Flushing
Guarding in RIF, rebound/percussion tenderness
Rovsings, Psoas sign, McBurney's point

Question 5

Investigations

Answer 5

FBC->Leukocytosis
Abdominal/pelvic CT or USS if equivocal
Pregnancy
Urine dipstick

Question 6

Management

Answer 6

1. Surgical consult
2. 2 large bore IV cannulae
3. Investigations
4. Analgesia and antiemetic
5. Keep NBM
6. IVF
7. Amoxycillin + gentamicin + metronidazole
8. Consent and book for appendisectomy

Question 7

Antibiotic therapy

Answer 7

For successful surgery->change IV to orals after for total of 7 days (IV + orals)
If non-perforated->can discontinue after appendisectomy

Question 8

MANTRELS score

Answer 8

Higher the score out of 10= higher chance

Migration to RLQ
Anorexia
Nausea and vomiting
Tenderness in RLQ
Rebound tenderness
Elevated temperature
Leukocytosis (2 points)
Shift of WBC count to left

Question 9

Consenting for lap appendix

Answer 9

1. Explain diagnosis->appendicitis, inflammation of appendix, very common
2. Treatment->only recommended treatment is surgery. Key-hole->three incisions, while under a GA, will image organs, remove appendix even if doesn’t appear inflamed. Once removed, sutured, dissolvable.
3. Risks
   a. GA->NV, difficulty passing urine. Muscle ches, temporary nerve, blood clot leg, chest infection, allergy/shock, hyperthermia, stroke, MI, death->rare
   b. Procedure->Lung collapse (pain relief and antibiotics), DVT/PE, wound infections/dishiscience, hemorrhage
   c. Appendectomy->removal of normal appendix, injury to bladder/bowel/ureter, iA abscess, paralytic ileus, bowel perforation
4. No other treatment options, can lead to infection and death if not treated.
5. After surgery->encouraged to move ASAP. Most of normal activities in 2 weeks, normal in one month.
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