Abdominal pain

Question 1

What are your differential diagnoses?

Answer 1

• Appendicitis
• Gynae related differentials – ectopic pregnancy, ovarian cyst torsion, endometriosis
• Renal colic
• Acute pancreatitis
• Perforated peptic ulcer
• Gastroenteritis
• Crohn’s ileitis
• Bowel perforation
• Meckel’s diverticulitis
• Ruptured AAA

Question 2

What are the classical examination findings for a patient with acute appendicitis?

Answer 2

• Tender right iliac fossa
• Worse at McBurney’s point
• Guarding/local peritonism
• Rovsing’s sign positive
• Obturator sign positive

Question 3

Where is McBurney’s point located?

Answer 3

McBurney’s point is the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus

Question 4

How do you illicit Rovsing’s sign?

Answer 4

By palpation in the left iliac fossa. In acute appendicitis, this produces pain/ localised tenderness in the right iliac fossa.

Question 5

What are the variations in the anatomical position of the appendix?

Answer 5

• Retrocaecal – 74%
• Pelvic- 21%
• Paracaecal- 2%
• Subcaecal- 1.5%
• Pre-ileal- 1%
• Post-ileal- 0.5%

Question 6

What investigations would you order in this case?

Answer 6

Bedside tests: Urine dipstick, b-HCG + MC+S, 12 lead ECG. Urine pregnancy test

Haematological tests: FBC, U+Es, LFTs, Clotting, Group and save, blood cultures, amylase/lipase and venous blood gas.

Radiological tests:
- Erect CXR to rule out perforation in the context of acute abdominal pain with peritonitis.
- Ultrasound abdomen, Ultrasound pelvis – considered if clinical doubt for example if difficulty in differentiating between GI and gynae causes.
- CT – may be used if cause uncertain or to evaluate for complications of cause e.g. perforation.
- MRI – mainly reserved for pregnant women when ultrasound is non-diagnostic

Question 7

Do you know of any scoring systems to assess the likelihood of the diagnosis of appendicitis?

Answer 7

The Alvarado scoring system
A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates a probable appendicitis, and a score of 9 or 10 indicates a very probable acute appendicitis.

Question 8

Subsequent investigation results revealed a negative urine pregnancy test, and an abdominal ultrasound noted an inflamed appendix. How would you proceed?

Answer 8

Informing:
- General surgery registrar +/- consultant
- Emergency anaesthetists
- Theatre co-ordinator

Preoperative preparation
- Reassessing the patient using an ABCDE approach to ensure clinically stable
- Book the case in the emergency theatre
- Discussing the situation with the patient and make nil by mouth
- Preparing consent for appendicectomy and mark surgical site
- Check bloods and ensure blood is crossmatched
- Analgesia to make them as comfortable as possible.