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ANKI GI > [18] Acute Appendicitis > Flashcards

[18] Acute Appendicitis Flashcards

1
Q

What is appendicitis?

A

Inflammation of the appendix

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2
Q

What causes appendicitis?

A

Direct luminal obstruction

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3
Q

What is appendicitis secondary too?

A

Usually faecolith, but may also be due to lymphoid hyperplasia, impacted stool, or an appendiceal or caecal tumour

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4
Q

Who does acute appendicitis usually affect?

A

Those in their second or third decade

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5
Q

What is the lifetime risk of acute appendicitis?

A

7-8%

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6
Q

What are the risk factors for acute appendicitis?

A

Family history
Ethnicity
Environmental - more common during Summer

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7
Q

What % of risk of appendicitis does genetics account for?

A

Around 30%

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8
Q

How does ethnicity affect the risk of acute appendicitis?

A

It is more common in Caucasians, yet ethnic minorities are at greater risk of perforation if they do get it

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9
Q

What are the symptoms of acute appendicitis?

A

Abdominal pain
Nausea and vomiting
Anorexia
Diarrhoea or constipation

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10
Q

Describe the pain in acute appendicitis

A

It is initially peri-umbilical, dull, and poorly localised, but later migrates to the right iliac fossa, where it is well-localised and sharp

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11
Q

Describe the timing of the vomiting in appendicitis

A

It is typically after the pain, not preceding it

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12
Q

What may be found on examination in acute appendicitis?

A

Patients may be tachycardic, tachypnoeic, and pyrexical
When examining the abdomen, the most specific findings are rebound tenderness and percussion pain at McBurney’s point, as well as potential signs of guarding if perforated

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13
Q

Where is McBurneys point?

A

2/3 of the way between the umbilicus and the ASIS

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14
Q

How might an appendiceal abscess present on examination?

A

RIF mass

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15
Q

What ‘textbook signs’ may be found on examination in acute appendicitis?

A

Rovsing’s sign

Psoas sign

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16
Q

What is Rovsing’s sign?

A

RIF pain on palpation of the LIF

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17
Q

What is the psoas sign?

A

RIF pain with extension of the right hip

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18
Q

What does psoas sign suggest?

A

An inflamed appendix abutting psoas major muscle in a retrocaecal position

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19
Q

How useful in clinical signs of appendicitis in diagnosis?

A

They have a poor predictive value alone, but are stronger in concert

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20
Q

What is required in females of reproductive age with suspected appendicitis?

A

Pelvic examination, to assess for any potential gynaecological pathology

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21
Q

What is the most important differential diagnoses to consider in acute appendicitis in the younger female patient?

A

Gynaecological pathology, especially ectopic pregnancy or ovarian cyst rupture

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22
Q

What are the other gynaecological differential diagnoses of acute appendicitis?

A

Pelvic inflammatory disease

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23
Q

What are the renal differential diagnoses of acute appendicitis?

A

Ureteric stones
Urinary tract infection
Pyelonephritis

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24
Q

What are the gastrointestinal differential diagnoses of acute appendicitis?

A

Diverticulitis
IBD
Mesenteric adenitis
Meckel’s diverticulum

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25
Q

What are the urological differential diagnoses of acute appendicitis?

A

Testicular torsion

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26
Q

What investigations may be done in suspected acute appendicitis?

A

Urinalysis
Blood tests
Imaging

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27
Q

Why should urinalysis be done for all patients with suspected appendicitis?

A

To exclude UTI or any other renal/urological causes

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28
Q

What finding on urine dipstick can be present in appendicitis?

A

Leucocytes

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29
Q

What urine test is vital for any woman of reproductive age?

A

Pregnancy test

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30
Q

What blood tests will be done in suspected acute appendicitis?

A

FBC and CRP
Baseline blood tests required for pre-operative assessment
Serum ß-hCG

31
Q

Why are FBC and CRP done in suspected acute appendicitis?

A

To assess for raised inflammatory markers (raised WCC and CRP)

32
Q

When will a serum ß-hCG be done in suspected acute appendicitis?

A

If ectopic pregnancy still has not been excluded

33
Q

Is imaging required to diagnose or treat appendicitis?

A

No, as most cases should be a clinical diagnosis

34
Q

When might imaging be used in suspected acute appendicitis?

A

If the clinical features are inconclusive, and an alternative diagnosis is sought

35
Q

What imaging can be used in acute appendicitis?

A

Trans-abdominal ultrasound

CT scan

36
Q

Why is a CT scan useful in elderly patients with suspected appendicitis?

A

Due to the potential of malignancy causing appendicitis, as treatment would be different

37
Q

What is the advantage of trans-abdominal ultrasound in acute appendicitis?

A

Good sensitivity and specificity

38
Q

Who is trans-abdominal USS most useful in with acute appendicitis?

A

Children

39
Q

Why is trans-abdominal ultrasound most useful in children with acute appendicitis?

A

Less abdominal fat

Will be exposed to lower levels of radiation

40
Q

What is the purpose of risk stratification scores in appendicitis?

A

They attempt to assist in the diagnosis of appendicitis

41
Q

Give two examples of risk stratification scores in appendicitis?

A

Alvarado score

Appendicitis Inflammatory Response Score

42
Q

What is it important to consider when using risk stratification scores for appendicitis?

A

The score should only be used to assist the surgeon in their decision making, and should not replace their clinical judgement

43
Q

What does the Appendicitis Inflammatory Response Score aim to triage patients into?

A

Low risk
Intermediate risk
High risk

44
Q

What are the parameters in the Appendicitis Inflammatory Response Score?

A

Vomiting - 1 point
RIF pain - 1 point
Pyrexical (>38.5) - 1 point
WBC - 10-14.9 = 1 point, >15 = 2 points
Polymorphonuclear leukocytes - 70-84% = 1 point, >85% = 2 points
CRP - 10-49 = 1 point, >50g = 2 points
Rebound tenderness or guarding - light = 1 point, medium = 2 points, strong = 3 points

45
Q

How many points is considered to be low risk in the AIR score?

A

0-4

46
Q

What management is required for low risk appendicitis according to the AIR score?

A

No intervention required

47
Q

How many points is considered to be medium risk in the AIR score?

A

5-8

48
Q

What management is required for medium risk appendicitis according to the AIR score?

A

Inpatient observation or further imaging

49
Q

How many points is considered to be high risk in the AIR score?

A

9-12

50
Q

What management is required for high risk appendicitis according to the AIR score?

A

Surgical exploration recommended

51
Q

What is the current definitive treatment for acute appendicitis?

A

Laparoscopic appendicetomy

52
Q

Should conservative antibiotic therapy be used in uncomplicated appendicitis?

A

There is some debate about this - a Cochrange analysis found that whilst appendectomy should remain the standard treatment, further research is still warranted. Primary antibiotic treatment for simple inflamed appendix can be successful, but has a failure rate of 25-30% in one year

53
Q

Why is appendicitis sometimes treatable with antibiotics, and sometimes not?

A

The current theory suggests that appendicitis appears in two seperate forms - one type is a simple reversible inflammation, whilst a second type will rapidly progress to gangrene and perforation. The former can be treated successfully with antibiotics, the latter requires surgical intervention

54
Q

What findings appear to predict antibiotic success?

A

CRP <60
WBC <12 x 10^9
Age <60

55
Q

Why is laparoscopic appendectomy the gold standard for treating appendicitis?

A

Due to a very low morbidity from the procedure, and the risk of possible readmission if treated with antibiotic therapy alone

56
Q

What is the additional advantage of a laparoscopic appendectomy in females?

A

It allows for better visualisation of the uterus and ovaries

57
Q

What should be done when any removed appendix following appendicitis?

A

It should be sent to histopathology to look for malignancy

58
Q

What malignancies typically arise in the appendix?

A

Carcinoid
Adenocarcinoma
Mucinous cystadenoma

59
Q

What should be done during a laparoscopic appendectomy, as per any laparoscopic procedure?

A

The entirety of the abdomen should be inspected for any other evident pathology, including checking for any Meckel’s diverticulum present

60
Q

What approach to appendectomy may be used in pregnancy?

A

An open approach

61
Q

What is the advantage of a laparoscopic appendectomy over an open approach?

A

A laparoscopic approach has been shown to reduce hospital stay and has an earlier return to baseline activity

62
Q

What is the mortality associated with appendicitis in developed health systems?

A

Low - 0.09 - 0.24%

63
Q

What are the complications of acute appendicitis?

A

Perforation
Wound infection
Appendix mass
Pelvic abscess

64
Q

What causes an appendix mass after appendicitis?

A

The omentum and small bowel adhere to the appendix

65
Q

What is involved in the traditional management of an appendix mass after appendicitis?

A

Conservative approach with antibiotics

66
Q

What % of cases of appendicitis are complicated by a pelvic abscess?

A

9.4%

67
Q

Where are pelvic abscesses following appendicitis more common?

A

In perforation

68
Q

How does a pelvic abscess present?

A

Fever with palpable RIF mass

69
Q

What does a pelvic abscess typically require for confirmation?

A

US scan or CT scan

70
Q

How are pelvic abscesses managed?

A

Usually with antibiotics and percutaneous drainage of abscess

71
Q

What is immediate surgery for pelvic abscesses associated with?

A

Increased morbidity and ileo-caecal resection

72
Q

What follow up is recommended after conservative treatment for pelvic abscesses?

A

Follow-up with CT scan for patients over >40years

73
Q

Why is follow up with CT scan recommended for patients >40 years with pelvic abscesses?

A

Due to around 2% prevalence of concurrent malignancy

ANKI GI (43 decks)

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