Acute Appendicitis Flashcards

1
Q

What are possible etiologies for acute appendicitis?

A
  1. Changes in dietary habits - less fibre, increased refined carbohydrates
  2. 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
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2
Q

What is the pathophysiology of acute appendicitis?

A

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)

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3
Q

What should be attained on history?

A
  1. Abdominal Pain
    - Visceral discomfort so poorly localised then localised to RIF
  2. Nausea Vomiting
    - Occurs after pain
    – if before pain, consider IO
  3. Fever
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4
Q

What should be done on PE?

A
  1. Vitals
    - Temperature: Low Fever
    - HR: Normal/Slightly elevated
  2. 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
  3. DRE - pain in suprapubic area, rectal tenderness, hx of diarrhoea
  4. For infants/children, examine scrotum due to migration of pus through patent processus vaginalis (ddx: acute testicular torsion)
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5
Q

What the differential diagnoses of acute appendicitis?

A
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6
Q

Describe the clinical scoring system for diagnosis of acute appendicitis?

A

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

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7
Q

What investigations should be done?

A
  1. FBC*
  2. RP*
  3. CRP*
  4. Blood cultures
  5. PT/PTT
  6. GXM
  7. LFT/Amylase/Lactate/ABG
    8/ ECG
  8. CT AP* - i) enlarged appendix >6mm, ii) thickened appendix wall > 2mm with enhancement (target sign), iii) periappendiceal fat stranding, iv) appendicolith, v) complications
  9. Erect CXR - r/o perforation
  10. Supine AXR - little value
  11. Abdominal US: for paeds and pregnant pt (i) non compressible appendix >6mm in AP direction, ii) thickening of appendiceal wall iii) periappendiceal fluid
  12. MRI Abdomen - for pregnant patients

*required, rest use clinical judgement

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8
Q

What is the management of acute appendicitis?

A
  1. NMB, IV, correct electrolye abnormalities
  2. IV Abx
  3. Antiemetics, Analgesia
  4. Definitive treatment: Lap Appendectomy
    - stop abx postop if uncomplicated
  5. 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
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9
Q

What are the complications of acute appendicitis?

A

Hemorrhage
Infection/Sepsis
Conversion to Open
Bowel Resection
Paralytic Ileus
Adhesions
Retained fecolith –> stump appendicitis/leak/fistula

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