Acute appendicitis Flashcards
Pathogenesis
• Obstruction of the appendix - Faecolith most commonly - Lymphoid hyperplasia post-infection - Tumour (e.g. caecal Ca, carcinoid) -Worms e.g. Schistosomiasis • Gut organisms proliferate causing infection behind obstruction • oedema causes ischaemia and necrosis which can lead to perforation - Peritonitis - Abscess - Appendix mass
Presentation
Early inflammation causes appendiceal irritation:
• Visceral pain - general umbilical pain
Late inflammation → parietal peritoneum irritation
• Pain localised in RIF
Symptoms: • Colicky abdo pain - Central → localised in RIF - Worse with movement • Anorexia • Nausea and vomiting • Constipation / diarrhoea
Signs • Low-grade pyrexia • ↑HR, shallow breathing • Guarding and tenderness: @ McBurney’s point • Appendix mass may be palpable in RIF
Special signs
Rebound tenderness
Rovsing’s Sign
Psoas Sign
Cope Sign
Rovsing’s Sign
Pressure in LIF → more pain in RIF
Psoas Sign
Pain on extending the hip: retrocaecal appendix
Cope Sign
Flexion + internal rotation of R hip → pain
- Appendix lying close to obturator internus
Investigations
Dx is principally clinical
- Bloods: FBC, CRP, G+S, clotting
- Urine
- Sterile pyuria: may indicate bladder irritation
- Ketones: anorexia
- Exclude UTI
- β-HCG - pregnancy test
• Imaging
- first line - USS: exclude gynae path and visualise inflamed
appendix
• Diagnostic lap
Management of
- Fluids
- Abx: cef + met - 6 - 8 weeks
- Analgesia: paracetamol, NSAIDs, codeine phosphate
- If certain diagnosis: appendicectomy (open or lap)
- Uncertain Dx → active observation
Complications of acute appendicitis
Appendix Mass -inflamed appendix with adherent covering of omentum and small bowel
Appendix Abscess
Perforation
- Commoner if faecolith present and in young children as dx delayed
• Deteriorating pt. with peritonitis
Treatment of appendix mass
Dx: US or CT Mx - Initially: Abx + NBM - Resolution of mass → interval appendicectomy - Exclude a colonic tumour: colonoscopy
Treatment of Appendix Abscess
Abx + NBM
CT-guided percutaneous drainage
If no resolution, surgery may involve right hemicolectomy.
Risk factors for appendicitis
Genetic
Caucasian
Environmental - summer
