Acute Appendicitis Flashcards
What is the pathophysiology of acute appendicitis?
Direct luminal obstruction, usually secondary to faecolith or lymphoid hyperplasia, impacted stool or rarely appendiceal or caecal tumour.
When obstructed commensal bacteria in the appendix can multiply, resulting in acute inflammation. Reduced venous drainage and localised inflammation can result in increased pressure within the appendix in turn resulting in ischaemia. Can lead to necroisis and perforation.
What are the risk factors of acute appendicitis?
Family history
Ethnicity - more common in Caucasians
Environmental - seasonal presentation during the summer
Most common in 2nd and 3rd decade of life
What is the classical presentation of acute appendicitis?
Abdominal pain poorly localised to peri-umbilical but later migrates to RIF where it is well-localised and sharp.
What some associated symptoms of acute appendicitis?
Vomiting (after pain), Anorexia Nausea Diarrhoea Constipation
What are some examination finding of acute appendicitis?
Rebound tenderness and percussion pain over McBurney’s point as well as guarding (esp if perforated).
RIF mass if appendiceal abscess present
Sepsis signs - hypotensive and tachycardia in severe cases
What are some specific signs for acute appendicitis?
Rovsings sign: RIF pain on palpation of LIF
Psoas sign: RIF pain with extension of the right hip - inflamed appendix in retrocaecal position
Where is McBurney’s point?
2/3rds of the way from umbilicus to ASIS
How may acute appendicitis present in children?
High percentage don’t present in classical way.
Atypical presentation include - diarrhoea, urinary symptoms or even left side pain
What is important to examine in child with suspected acute appendicitis but with atypical symptoms?
GI system
Cardio respiratory system
Urinary system
Genital examination in boys - testicular torsion, epididymitis
Children under 6 with symptoms over 48hrs more likely to have perforated appendix.
What are the differential diagnosis of acute appendicitis?
Gynaecological - ovarian cyst rupture, ectopic pregnancy, pelvic inflammatory disease
Renal - ureteric stones, UTI, pyelonephritis
GI - IBD, meckels diverticulum, diverticular disease
Urological - testicular torsion, epididymio-orchitis
In children - acute Mesenteric adenitis, gastroenteritis, constipation, intussusception, UTI
What investigations should be requested in suspected acute appendicitis?
Urinalysis - exclude renal or urological cause
Any women of reproductive age - pregnancy test/ serum beta-HCG
Routine bloods as well as pre-op baseline bloods
Imaging:
-not usually required as clinical diagnosis but in uncertainty of diagnoses esp in children -
Ultrasound
CT imaging
What risk stratification scores are there for acute appendicitis?
Men - Appendicitis inflammatory response score
Women - Adult appendicitis score
Children - Shera score
What is the current definitive treatment for acute appendicitis?
Laparoscopic appendicectomy
What is the management in cases of appendiceal mass?
Antibiotic therapy with interval appendectomy in approx 6-8 weeks
What are the advantages of laparoscopic appendectomy over open appendectomy?
Low morbidity
Allows better visualisation of gynaecological pathology
Reduces hospital stay and permits earlier return to baseline activity
