Acute Appendicitis Flashcards
What are possible etiologies for acute appendicitis?
- Changes in dietary habits - less fibre, increased refined carbohydrates
- Bacterial Infection 2’ to obstruction of appendiceal lumen
- Fecolith
- Lymphoid Hyperplasia (a/w inflammatory [crohn’s] & infective [GE, URTI, IMS,
- Parasitic Worm
- TB
- Tumour of Appendix
What is the pathophysiology of acute appendicitis?
Obstruction → distension by mucus → increased luminal and intramural pressure → thrombosis and occlusion of blood supply, stasis of lymphatic flow → ischemia (periumbilical abdominal pain) → necrosis → bacterial overgrowth and invasion (polymicrobial – E coli, Bacteroides fragilis, Peptostreptococcus, Pseudomonas) → fibropurulent reaction on serosa → irritation of parietal peritoneum (localised pain at McBurney’s point)
What should be attained on history?
- Abdominal Pain
- Visceral discomfort so poorly localised then localised to RIF - Nausea Vomiting
- Occurs after pain
– if before pain, consider IO - Fever
What should be done on PE?
- Vitals
- Temperature: Low Fever
- HR: Normal/Slightly elevated - Abdomen
- McBurney Point Tenderness
- Rebound tenderness, voluntary guarding –> localised peritonism
- Cutaneous hyperesthesia (spinal nerve of R T10, T11, T12)
- Rovsing Sign: RIF pain with deep palpation of LIF
- Psoas Sign: RIF pain with passive right hip flexion
- Obturator Sign: RIF pain with IR of flexed right hip
- Cough sign: RIF pain on coughing - DRE - pain in suprapubic area, rectal tenderness, hx of diarrhoea
- For infants/children, examine scrotum due to migration of pus through patent processus vaginalis (ddx: acute testicular torsion)
What the differential diagnoses of acute appendicitis?
Describe the clinical scoring system for diagnosis of acute appendicitis?
Alvarado Score [MANTRELS]
1. Migratory RIF Pain
2. Anorexia
3. Nausea/Vomiting
4. Tenderness (2pt)
5. Rebound Tenderness
6. Temperature
7. Leukocytosis (2pt)
8. Left Shift of Neutrophils
3 or less: no need imaging, unlikely
4-6: CT
7 or more: surgical consultation
5 or less: no need admission
What investigations should be done?
- FBC*
- RP*
- CRP*
- Blood cultures
- PT/PTT
- GXM
- LFT/Amylase/Lactate/ABG
8/ ECG - CT AP* - i) enlarged appendix >6mm, ii) thickened appendix wall > 2mm with enhancement (target sign), iii) periappendiceal fat stranding, iv) appendicolith, v) complications
- Erect CXR - r/o perforation
- Supine AXR - little value
- Abdominal US: for paeds and pregnant pt (i) non compressible appendix >6mm in AP direction, ii) thickening of appendiceal wall iii) periappendiceal fluid
- MRI Abdomen - for pregnant patients
*required, rest use clinical judgement
What is the management of acute appendicitis?
- NMB, IV, correct electrolye abnormalities
- IV Abx
- Antiemetics, Analgesia
- Definitive treatment: Lap Appendectomy
- stop abx postop if uncomplicated - if complicated, nonop management follows ochsner sherren regime
– treat conservatively with antibiotics if patient remains is
hemodynamically stable and non-peritonitic
– May benefit from percutaneous drainage of appendiceal abscess
– Symptomatic patients (during clinic visit) → inflammatory markers, CT scan or diagnostic laparoscopy
– Asymptomatic patients (during clinic visit) → consider colonoscopy vs. interval appendectomy
What are the complications of acute appendicitis?
Hemorrhage
Infection/Sepsis
Conversion to Open
Bowel Resection
Paralytic Ileus
Adhesions
Retained fecolith –> stump appendicitis/leak/fistula