11. Acute appendicitis (diagnosis and treatment)

Question 1

Types of acute appendicitis

Answer 1

• Mucosal: mild, usually doesn’t present with symptoms
• Phlegmonous: slow onset and progression
• Necrotic: often due to acute bacterial infection with ischaemic necrosis

Question 2

Differential diagnosis: kids

Answer 2

• Non-specific abdominal pain
• Meckel’s diverticulitis
• Ovarian cysts/menstrual symptoms

Question 3

Differential diagnosis: adults

Answer 3

• Crohn’s disease
• Meckel’s diverticulitis
• Retroperitoneal pathology: pancreatitis, renal colic
• Ovarian pathology: ectopic pregnancy, cyst, infection, menstrual cramps

Question 4

Differential diagnosis: elderly

Answer 4

• Caecal diverticulitis, caecal tumours
• Sigmoid diverticulitis
• Ovarian pathology

Question 5

Clinical signs and symptoms

Answer 5

• Malaise, anorexia, fever
• Diarrhoea
• Abdominal pain starting centrally and then localising to McBurney’s point and the right
iliac fossa
• Abdominal pain worsening with coughing and movement
• Fever, tachycardia
• Abdominal tenderness: particularly on releasing pressure
• Rovsing’s sign- palpation of the left iliac fossa worsens pain in the right iliac fossa

Question 6

Rovsing’s sign explanation

Answer 6

Pain nerves deep in intestines are not good at localizing, and pain will not become localized before the peritoneum also becomes inflamed.

When applying pressure to left ilocecal fossa, the contents in the abdomen are shifted and further irritate the inflamed peritoneum.

Question 7

Complications of appendicitis

Answer 7

• Perforation

* Abscess

Question 8

Definitive management of appendicitis

Answer 8

• Appendectomy - laprascopy is preferred

* IV-antibiotics, continued after surgery if there are signs of perforation

Question 9

Open appendectomy steps 1 - 4

Answer 9

1) A transverse or oblique incision is made over McBurney’s point.
2) The layers of the abdominal wall are split
3) The caecum is localised and mobilised into the surgical incision
4) The mesoappendix is divided and the vessels are ligated

Question 10

Open appendectomy steps 5 - 8 (main procedure)

Answer 10

5) A purse string suture is placed in the caecum near the base of the appendix
6) The base of the appendix is tied off and cut out
7) The mucosa of the stump is cauterised to prevent bacterial spilling and mucocele formation. The stump is inverted and the purse-string suture tied securely

8) The caecum is returned to its normal position and the wound is irrigated and closed in
layers. If perforation has occurs, a drain may be placed