Acute Appendicitis Flashcards
What does the tip of the appendix explain
It explains the variations in the presentation to the appendix
Where are the various locations of the tip of the appendix
Retrocaecal (70%)
Pelvic (26%)
Subcecal (2%)
Preileal (1%)
Postileal (0.5%)
Paracecal (0.3%)
Subhepatic (0.2%)
What is one notable condition that causes right iliac fossa pain
Acute appendicitis
What is the most common abdominal emergency
Acute appendicitis
Worldwide, what is the leading cause of death in general surgery
Perforated appendicitis
What are the stages of appendicitis
Oedematous stage
Purulent (phlegmonous) stage
Gangrenous stage
Obstruction of the lumen of the appendix may be caused by
Lymphoid hyperplasia (60% observed in children)
Inspissated stools (faecolith, appendicolith, 35% seen in adults)
Vegetable matter or seeds (4%)
Parasites
Neoplasms
Fibrous adhesions
Strictures
Kinking of the appendix
What is the pathophysiology of appendicitis
Luminal blockade predisposes to closed loop obstruction
Obstruction contributes to bacterial overgrowth
Continued secretion of mucus leads to intraluminal distension and wall pressure
Impairment of lymphatic and venous drainage results in mucosal ischaemia, infarction and necrosis
Gangrene supervenes when there is added putrefaction
Perforation
Inflammation of the adjacent peritoneum gives rise to localized pain in the RLQ of the abdomen
Abscess cavity walled off by small intestine and omentum
Suppuration may spread into the entire peritoneal cavity to cause generalized peritonitis
What happens in the oedematous stage of appendicitis
Appendicitis may have spontaneous regression or may evolve to purulent stage
The mesoappendix is commonly involved with inflammation
What are the characteristics of the purulent stage of appendicitis
Spontaneous regression rarely occurs and appendicitis usually evolves to perforation and rupture. Also, generalized peritonitis may occur
What are some characteristics of the gangrenous stage of appendicitis
Spontaneous regression never occurs
Peritonitis is present
List the constituents of Murphy’s clinical triad
Abdominal pain
Vomiting
Fever (appendix located anteriorly)
What is a typical presentation (in 55% of patients) of appendicitis
Murphy’s classical triad
Typically, a vague periumbilical or central abdominal visceral pain mediated by T9, T10 parasympathetic nerves. This pain migrates or moves or shifts and localizes in the right iliac fossa. The pain here is colicky in nature and is mediated by the somatic nerves. The pain is worsened by movement and is relieved by lying still
What are some atypical presentations of a patient with a retrocaecal appendix
A dull ache is often described. Right loin pain is often present, with tenderness on examination
Muscular rigidity and tenderness to deep palpation are often absent because of protection from the overlying caecum
The psoas muscle may be irritated in this position, leading to right hip flexion and exacerbation of the pain on hip extension (psoas stretch sign)
What is the atypical presentation of a patient with subcecal and pelvic appendicitis
Atypical pain (suprapubic area) is commonly encountered in pelvic appendicitis
Patient may report dysuria and urinary frequency due to the inflamed appendix irritating the bladder
Patient may also have diarrhoea or tenesmus due to irritation of the pelvic colon
Abdominal tenderness may be lacking, but rectal or vaginal tenderness may be present on the right
Urinalysis reveals microscopic haematuria and leucocytes
What is the atypical presentation of a patient with a post or preileal appendix
Signs and symptoms may be lacking. Vomiting may be more prominent, and diarrhoea may result from irritation of the distal ileum
What are some physical examination findings in appendicitis
Patients still lie usually with the flexed hip
Fever, tachycardia, furred tongue and appendiceal fetor
Tenderness in the RIF with maximal tenderness at the McBurney’s point
Percussion or rebound tenderness in RIF. Percussion more accurate to eliciting rebound tenderness than palpation with quick release (Blumberg’s sign)
Guarding or rigidity in RIF
Reduced bowel sounds from paralytic ileus
Pain in right inferior fossa/right left quadrant during palpation of the left inferior fossa/left lower quadrant
Which sign is this
Rovsing’s sign
Pain on extension of the right hip (retrocaecal appendix)
What sign is this
Iliopsoas sign
Pain on internal rotation of the hip (suggesting pelvic appendicitis). The appendix lies adjacent to the obturator internus muscle
Obturator sign
Pain in RLQ upon coughing, deep breathing or sneezing
What sign is this
Dunphy’s sign
Pain caused by gentle traction of right testicle
What sign is this
Ten horn sign
Pain or pressure in epigastrium or anterior chest with persistent firm pressure applied to the McBurney’s point
What sign is this
Aaron’s sign
Sharp pain created by compressing appendix between abdominal wall and iliacus (indicative of chronic appendicitis)
What sign is this
Bassler’s sign
What are some physical examination tests to perform on a person with appendicitis
Rectal examination (Tenderness in pelvic appendicitis)
Pelvic examination (Tenderness elicited in pelvic appendicitis)
Generalized tenderness, rebound tenderness and guarding (rupture or perforation with generalized peritonitis)
Varying degrees of dehydration to shock
What are some special considerations to take note of of a child with appendicitis
It is uncommon in young children
It poses special difficulties in this age group
Young children are unable to relate a history
Often have abdominal pain from other causes
May have more nonspecific signs and symptoms
These factors contribute to a perforation rate as high as 50% in this group
What are some special considerations to take note of of a pregnant women with appendicitis
The location of the appendix begins to shift significantly by fourth to fifth months of gestation
1st trimester : RLQ
2nd trimester: Level of the umbilicus
3rd trimester : RUQ, closer to the gallbladder
Nausea and vomiting are often present, with associated tenderness located anywhere on the right hand side of the abdomen
Maternal mortality is negligible in cases of simple appendicitis but rises to 4% with advanced gestation and perforation
Fetal mortality ranges from 0 - 1.5% in cases of simple appendicitis to 20 – 35% in cases of perforation
Common symptoms of pregnancy may mimic appendicitis
The leukocytosis of pregnancy renders the WBC count less useful
As in nonpregnant patients, appendectomy is the standard for treatment
What are some special considerations to take note of of an elderly with appendicitis
They have the highest mortality rates
5-8% incidence of appendicitis occurs in this age group
The usual signs and symptoms of appendicitis may be diminished, atypical or absent in the elderly, which leads to a higher rate of perforation
More frequent perforation combined with a higher incidence of other medical problems (co morbidities) and less reserve to fight infection contribute to a mortality rate of up to 5% or more
What are some laboratory studies for appendicitis
FBC: Shows leukocytosis with neutrophil predominance (left shift) in
most cases
In 10% of cases, WBC count and differential are normal. WBC >20,000/ml suggest complicated appendicitis with gangrene or perforation
C-reactive protein levels are high. A clear clinical diagnosis at this stage obviates the need for further investigations and should prompt immediate surgical intervention laboratory studies
Hyperbilirubinemia is useful as an indicator for perforated appendicitis
Urinalysis to rule out UTI and pyuria because the inflammatory process may lie adjacent to the right ureter or urinary bladder in patients with pelvic appendicitis
What are some additional biomarkers in the laboratory study of appendicitis
Calprotectin (CP)
Serum Amyloid A (SAA)
Procalcitonin
Plasma pentraxin - 3
Equivocal or ambiguous cases of appendicitis will require what kind of imaging
Ultrasound sonography (USG)
What are the characteristics of an inflamed appendix
Thickened appendicular wall. 7mm or more in anteroposterior diameter
There is a non-compressible luminal structure
There is appendicolith
There is periappendicular fluid or mass in advanced cases
It is aperistaltic
What are some advantages of USG imaging in appendicitis
It is non-invasive
Requires no elaborate patient preparation
Safe (no exposure to ionizing radiation)
Can be used in children and pregnant women (can assess state of foetus in addition)
Excludes other diagnosis. In women, pelvic pathologies such as ectopic pregnancy, PID, twisted ovarian cyst or tumour
However, it is operator dependent and not ready at night or weekends
What other investigations apart from USG could be employed in equivocal cases
CT scan
Plain abdominal x-ray
MRI
What are some advantages of CT scan imaging for appendicitis
It has a higher resolution than USD
Accuracy is approximately 95%
It has contributed immensely to the decline of negative appendicectomy (NA)
Not safe in children and pregnant women due to ionizing radiation. However, radiation exposure from a single diagnostic procedure does not result in harmful effects on the foetus
What is some facts of using a plain abdominal x-ray imaging for appendicitis
Normal in 85% of patients
10% have non-specific findings such as ileus and small-bowel obstruction
Specific findings such as faecolith is seen in 4% -5% of cases
Others;
Loss of psoas shadow
Deformity of the caecal outline
Rarely free air under the diaphragm, indicating perforated appendicitis
Which imaging is used to investigate for appendicitis when USG is inconclusive or where available, is preferable to USG in the diagnosis of appendicitis because of its lower non-visualization rates
MRI
What are some strategies that have been put in place to improve diagnostic accuracy for appendicitis
The use of diagnostic scoring systems
Using laboratory markers such as CRP, diagnostic laparoscopy and advanced imaging modalities such as CT, MRI and USG
How the diagnostic tools are combined into practice depends heavily on what
Setting, resource availability and clinical goals (Eg. In rural Africa where poverty is rife, accurate clinical assessment remains the corner stone of diagnosis for most patients)
List some popular scoring systems used to diagnose appendicitis
Alvarado’s score
Modified Alvaraldo’s score
Anderson’s score
What is the most well known scoring system for appendicitis
Alvarado’s score
Introduced in 1986
Describe the Alvarado’s scoring system
The score is based on 3 symptoms, 3 signs and 2 laboratory findings
Each of these factors equal 1 point, except the tenderness and leukocytosis each of which earn 2 points
What is the total score in the Alvarado’s test
10 points
What are the three symptoms in the Alvarado’s test
Migratory pain in RIF
Anorexia
Nausea & vomiting
What are the three signs in the Alvarado’s test
Tenderness in right left quadrant Rebound tenderness
Elevated temperature
What are the two laboratory findings in the Alvarado’s score
Leukocytosis
Shift to the left of neutrophils
What does a score of 1-4 mean in the Alvarado’s scoring system
Acute appendicitis very unlikely, keep for observation
What does a score of 5-6 mean in Alvarado’s scoring system
Acute appendicitis maybe, regular observation
What does a score of 7-8 mean in the Alvarado’s scoring system
Acute appendicitis probable, operate
What is the mnemonic of the Alvarado’s scoring system
MANTRELS
(Migratory pain in right iliac fossa, anorexia, nausea and vomiting, tenderness in right lower quadrant, rebound tenderness, elevated temperature, leukocytosis, shift to the left of neutrophils)
What are the names of the two people who modified Alvarado’s scoring system into a more practical, reliable and easy score for safe and accurate decision making in patients with appendicitis
O Bengezi and M. Al-Fallouji have modified the Alvarado score
What is the mnemonic for the modified Alvarado’s scoring system
MANTREEL
(Migratory pain in right iliac fossa, anorexia, nausea and vomiting, tenderness in right lower quadrant, rigidity and/or rebound, tenderness in right iliac fossa, elevated temperature, extra sign(s) eg cough test and/or Rovsing’s sign and/or rectal tend, leukocytosis)
Pain upon removal of pressure rather than application of pressure to the abdomen
What sign is this
Blumberg’s sign (rebound tenderness)
