Appendix

Question 1

What is the appendix?

Answer 1

• It is a blind ending hollow tube that originates from the caecum 2,5 cm away
• It is 8 cm on average
• arterial supply is the ileocolic artery
• nerve supply is the autonomic nervous system

Question 2

What age does it peak?

Answer 2

Between 10 and 30 years

Question 3

What is the most accepted postulation about appendicitis?

Answer 3

Lymphoid hyperplasia(swelling of lymphoid tissue), faecoliths that get stuck and causes increased secretions, dehydration and parasites

Question 4

How does the luminal obstruction come about?

Answer 4

-It arises as a result of the increased mucus which becomes stagnant which leads to bacterial overgrowth which produces pus and increases the luminal pressure . Ischaemia and infarction occurs which leads to perforation and abscess formation locally or becomes generalised peritonitis

Question 5

What is the clinical presentation of a patient with appendicitis?

Answer 5

1. Vague central abdominal pain and nausea and vomiting in 75% of patients
2. Anorexia in 90%
3. low grade fever 37,8
4. The pain then travels to the right iliac fossa(tenderness over Mcburneys point) and becomes constant and worse
5. Nausea and vomiting that occurs after the pain

Question 6

Where is Mcburneys point located?

Answer 6

The intersection of the middle and lateral thirds of an oblique line from the umbilicus to the anterior superior iliac spine

Question 7

What are the late signs of appendiciis?

Answer 7

Peritonitis with percussion tenderness, muscle guarding, rebound tenderness
Local: abscess or appendix mass
Free perforation: generalised peritonitis and septic shock

Question 8

In which patients does it occur atypically and why?

Answer 8

1. Pregnant- occurs in the RUQ because pregnancy pushes the appendix upwards
2. Infants/children- can occur hemiscrotally because the pus can travel down the patent processus vaginalis and can be confused for acute testicular torsion
3. Retrocaecal- Presents in the right upper quadrant
4. When it is in the pelvis: affecting the bladder and rectum-dysuria and feeling of defecation

Question 9

Who are the patients that are usually immuno-surpressed and prone to appendicitis?

Answer 9

1. old and young
2. Diabetes, HIV/AIDS
3. Immunosuppressant drugs

Question 10

What are the signs that we can ellicit on physical exam?

Answer 10

1. Rovsings sign: pain in the right inferior flank when we press on the left inferior flank
2. Obturators sign: pain with passive internal rotation of the flexed hip (pelvic appendix)
3. Dunphy’s sign: increase in the abdominal pain when coughing
4. Iliopsoas sign: pain with extension of the right hip(retrocaceal appendix)

Question 11

What do you find when you do bloods on this patient:

Answer 11

1. Leucocytosis(raised white cell count) average of 15 000 and only 10% are normal
2. Differential to the left: 75% of neutrophils in 75% of cases
3. Raised CRP

Question 12

What imaging would you do in this particular patient?

Answer 12

1. AXR- may only show the faecolith and the right psoas margin may be ill-defined
2. Abdominal ultrasound: we can diagnose if we see >2mm in the thickness and >6mm in appendiceal diameter and free fluid
3. CT scan: >2mm, >7mm increased diamter of the appendix, presence of a phlegmon/absess/free fluid

Question 13

What is the differential diagnosis of pain in RIF?

Answer 13

1. Gynaecological: ectopic pregnancy, endometriosis, salpingitis, ovarian pathology
2. mesenteric adenitis
3. Crohns disease, TB , lymphoma,
4. Meckels diverticulitis
5. Urinary tract infections/stones
6. caecal carcinoma

Question 14

What are the complications with appendicitis?

Answer 14

1. perforation: localised(absess)
   free perforation(generalised peritonitis)
   increased incidence of infertility
2. Liver abscess
3. Septic shock: multi-organ failure
4. Pylephlebitis: suppurative thromobophlebitis of the portal venous system

Question 15

What is the Mx of a patient with appendicitis?

Answer 15

1. open or laparoscopic appendicectomy
2. Give IV antibiotics that you start preoperatively
3. Give IV fluid and analgesia
4. If patient is in septic shock then ICU is NB

Question 16

What is a phlegmon?

Answer 16

It is a mass with no collection

Question 17

How do you treat phlegmon?

Answer 17

1. With IV antibiotics and fluids and interval appendidectomy in 6 weeks
   2.

Question 18

How does an abscess present?

Answer 18

1. Febrile, higher white cell count, tender on palpation, and differentiated on CT or ultrasound

Question 19

How would you manage a patient with an abscess?

Answer 19

1. Either percutaneously under radiological guidance do a appendicectomy
2. Or you have open surgical drainage(extraperitoneally) and then do the appendicectomy

Question 20

If a normal appendix is encountered what is the best management?

Answer 20

You need to remove the appendix ASAP and ensure that you exclude other gynaecological possibilities, Meckel’s , mesenteric adentitis etc.

Question 21

What are some of the post-operative complications associated with in appendicitis?

Answer 21

Early- wound infection, leakage of appendiceal stump, intra-abdominal abscess
Late- infertility, adhesions(small bowel obstruction)

Question 22

What is chronic appendicitis?

Answer 22

• pain which occurs for more 3 weeks
• appendicitis which was treated conservatively previously
• chronic intermittent pain in the right iliac fossa

Question 23

What are some of the tumours of the appendix?

Answer 23

1. adenocarcinoma
2. carcinoid: benign/malignant
3. mucocele: cyst, dilated appendix filled with mucin