Acute Appendicitis

Question 1

Give the definition of Appendicitis

Answer 1

Inflammation of the inner lining of the appendix that may perforate and spread to surrounding tissue

Question 2

What is the most common cause of Acute abdomen?
What is the most common surgical emergency?

Answer 2

Acute Appendicitis (for both)

Question 3

Describe the general location of the appendix (In the GI tract)
What are the two most common appendix tip positions?
Where is the specific location of the opening of the appendix mesentery?

Answer 3

Base of caecum where the 3 Tenia Coli converge
Retrocecal/retroperitoneal (62%) > Pelvic (34%)
Opens (to the posterior wall of the caecum) 2cm below the ileocecal valve

Question 4

What is the blood supply to the appendix?

Answer 4

Ileocolic artery or post. cecal artery

Question 5

What is the peak incidence of acute appendicitis?

Answer 5

Early teens to early 20s OR 2nd and 3rd decade of life OR 10-19. whichever you want

Question 6

What is the main cause of appendicitis?
What can lead to this cause occuring?

Answer 6

Obstruction typically due to faecolith, lymphoid hyperplasia, tumour, adhesions, foreign body

Question 7

What is an “Appendix Mass”?

Answer 7

It is a complication of acute appendicitis where there is adherence of the omentum to cecum creating a cecal mass following perforation and peritonitis (by definition)

Question 8

One of the complications of acute appendicitis is a contained abscess. Where are these abscesses typically found?

Answer 8

Based on position of tip of appendix:
Retrocecal => RIF abscess
Pelvic => Pelvic abscess

Question 9

Explain the pathogenesis of Acute Appendicitis leading to its complications.
Confused? Then just Explain the pathogenesis and then state the complications

Answer 9

Obstruction (by fecolith, lymphadenopathy, tumour etc…)
=> Inflammation of appendiceal wall, filling lumen with pus => Contained abscess (RIF/pelvic)
=> Ischemia and infarction => devitalized wall => invaded by microorganisms
=> Perforation => Generalized peritonitis => Adhesions of omentum and cecum forming RIF “Appendix Mass” and localizing pain

Complications of Appendicitis:
Contained abscess typically in RIF and Pelvis
Perforation (and sepsis by definition)
Peritonitis
“Appendix Mass”

Question 10

What is a Faecolith

Answer 10

A Faecolith (lith=stone) => dry compact feces, stone-like
Causes obstruction especially near the ileocecal valve (where most things are held up anyways) leading to inflammation and acute appendicitis

Question 11

What are the causes of lymphoid hyperplasia/lymphadenopathy

Answer 11

Infection (viral e.g. EBV, and Bacterial)
Autoimmune diseases (SLE, RA, Kawasaki)
Cancer/lymphoproliferative: Lymphoma, Leukemia, metastasis

Question 12

Adhesions are one of the main causes of obstruction leading to acute appendicitis for example. What is the main non-pathological cause of adhesions?
What is the main pathological cause?

Answer 12

Nonpathological: Post-op
Pathological: Infection/peritonitis

Question 13

What are the general signs and symptoms of acute abdomen?

Answer 13

Abrupt severe abdominal pain
Nausea and vomiting => weight loss
Bloating/swelling
Fever and chills
Change in bowel habits
Inability to pass stool

Tenderness and rigidity on palpation
Rebound Tenderness (peritonitis)
Tachycardia
Tachypnea

Question 14

In an early presentation of acute appendicitis, where would the pain be?
In the “late” presentation?
Why is there a difference?
How long does it usually take from first presentation until “late” presentation

Answer 14

Pain initially starts in the suprapubic/central/visceral. This is because pain is initially referred from the autonomic system which can only tell the difference between the foregut (epigastric), midgut (umbilical), and hindgut (suprapubic). Eventually, inflammation spreads to the peritineum which has somatic innervation (T10-T12) => tenderness and guarding and localization of pain to the RIF

It typically takes 24-48 hours for the pain to localize

Question 15

How would you locate the appendix via surface anatomy?

Answer 15

1/3 distance from ASIS to Umbilicus - McBurney’s point

Question 16

The typical presentation of acute appendicitis refers to that of the retrocecal variant. What additional signs and symptoms would be present on the presentation of the pelvic variant?

Answer 16

Pelvic variant indicates overlap with gynaecological and urological symptoms =>
Urinary frequency/dysuria (from difficulty emptying)
Pain on urination
Pelvic pain
+
Obturator sign positive (pain on RIGHT hip flexion + internal rotation)

Question 17

What are the signs and symptoms of Acute Appendicitis?

Answer 17

Signs and symptoms of acute abdomen (Abrupt severe abdo pain, nausea + vomiting + weight loss, bloating/swelling, fever and chills, change in bowel habits, inability to pass stool or gas, tenderness and rigidity on palpation, tachypnea, tachycardia)
+
1) Pain starts in suprapubic/central area before localizing to a CONSTANT RIF pain at McBurney’s point
2) !!!Pain is exacerbated by movement => patient is still!!!
3) IF PELVIC: urinary frequency/dysurea, pain on urination/intercourse, pelvic pain
4) Rovsing sign, obturator sign, psoas sign positive as appropriate

Question 18

You are asked to complete an examination on a patient with acute appendicitis. What are you looking for that is consistent with this?

Answer 18

Patient sitting still, not moving (extra points)
Tachycardia and tachypnea
Mild pyrexia (extra points)
Tenderness and guarding on palpation
Rovsing sign, obturator sign, psoas sign positive as appropriate

Question 19

what are the special tests you would conduct on a patient with acute appendicitis? Explain how you would perform each and what you are looking for?

Answer 19

Rosving sign: Palpation of the LIF leads to increased pain on RIF
Obturator sign: RIGHT hip flexion leads to increased pain on RIF
Psoas sign: Right hip hyperextension leads to discomfort

Question 20

What special test(s) would you conduct for patients suffering from retrocecal acute appendicitis?

Answer 20

Rosving sign: Palpation of the LIF leads to increased pain on RIF
Psoas sign: Right hip hyperextension leads to discomfort

Question 21

What special test(s) would you conduct for patients suffering from pelvic acute appendicitis?

Answer 21

Rosving sign: Palpation of the LIF leads to increased pain on RIF
Obturator sign: RIGHT hip flexion leads to increased pain on RIF

Question 22

QUICK: Give your differential diagnoses for Acute Suprapubic/RIF pain.
For 5/5, I need 10

Answer 22

Here, were thinking of acute appendicitis which presents with this pain. Think of the 2 main variants. Note for this you need to remember than retrocecal = retroperitoneal

Acute appendicitis
Retrocecal => terminal ileal pathology => Crohn’s (IBD), Meckel’s diverticulum, Gastroenteritis
Retroperitoneal => Renal colic (nephrolithiasis), acute pancreatitis
Pelvic => Gynaecology and urology => !!Ectopic Pregnancy!!, Ovarian cyst, ovarian torsion, testicular torsion, UTI, PID (pelvic inflammatory disease)
!!!Special Population: Mesenteric Lymphadenitis (children) and Cecal tumour (Elderly)

Question 23

What is the gold standard for diagnosing Meckel’s diverticulitis?

Answer 23

Meckel Scan which is IV Technetium scan (similar to nuclear technetium used to localize blood source)

Question 24

How would you rule out an ectopic pregnancy in acute AAA?

Answer 24

Rule out pregnancy => B-HCG test conducted via urine or serum (more accurate)

Question 25

How would you rule out ovarian torsion or an ovarian cyst? and hence also used to diagnose it ahahaha

Answer 25

Pelvic US

Question 26

How is Acute appendicitis diagnosed?
What investigations would you carry out to confirm your diagnosis of Acute Appendicitis and rule out ddx?

Answer 26

Acute Appendicitis is a clinical diagnosis
Bedside: MSU (midstream urine) !!for dispstick, culture, and sensitivity!! and urine B-HCG (ectopic pregnancy)
Bloods: FBC, U&E, Coag, CRP, +/- serum B-HCG (more accurate)
Imaging: Pelvic US (rules out majority) +/- CT abdomen/Pelvis if dx is unclear (not necessary)

Question 27

A patient presents to the ED with acute abdomen (not acute appendicitis specifically). What is your Pre-op management in any case?

Answer 27

ABCDE management employing (I am assuming youre giving fluid resus at 10-20ml/kg with an aim of 1-2L within 1 hour)
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)

Question 28

What is the Definitive Treatment of Acute Appendicitis? (Gold standard)
What does this procedure entail?
What is the escalation from this?
What are the complications of these procedures?

Answer 28

Laparoscopic Appendicectomy: Gold standard with 3 ports (Suprapubic, umbilical, and RIF)
Involves locating the appendix, dividing and ligating its mesentery, clamping the base, and excising the appendix.

in 10% of cases, they are converted to Open appendicectomy.
Complications: Incisional hernia, Ileus (constipation) => Inguinal hernia, Adhesions, and common surgical complications (Hemorrhage, pain, infection, DVT…)

Question 29

A 20 year old patient presents with Acute Appendicitis. What is your Full management plan?

Answer 29

ABCDE management employing (I am assuming youre giving fluid resus at 10-20ml/kg with an aim of 1-2L within 1 hour)
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)

Definitive Treatment of Acute Appendicitis:
Laparoscopic Appendicectomy: Gold standard with 3 ports (Suprapubic, umbilical, and LIF)
Involves locating the appendix, dividing and ligating its mesentery, clamping the base, and excising the appendix.
If not, escalate to Open

Question 30

In the realm of acute appendicitis, when would you opt for a non-operative approach?

Answer 30

1) Patient is very old/frail => poor patient condition
2) Appendix mass or abscess without peritonitis (may become operative later)

Question 31

In what case would you perform open appendicectomy as first-line

Answer 31

In children <30kg with acute appendicitis

Question 32

What incisions are associated with open appendectomy? Where are they located?
Bonus: What incisions are associated with laparoscopic appendicectomy?

Answer 32

Gridiron or Lanz (horizontal) centered on McBurney’s point

Laparoscopic: Ports at RIF OR LIF (for some reason), Umbilicus, and suprapubic

Question 33

A patient presents to the ED with symptoms of acute abdomen with central/suprapubic pain. The patient is deteriorating. On US a mass was found in the RIF. Give 2 likely diagnoses.
How would you manage this patient?

Answer 33

The patient is experiencing symptoms of acute appendicitis however there is no peritonitis as pain has not localized. US has shown a mass in the RIF which could be an adhesion or an abscess (can be a tumour but unlikely)
=> adhesion of the omentum and cecum => “Appendix Mass”
OR Contained abscess

Management: Start IV antibiotics.
If symptoms settle, continue antibiotics and repeat scan in 6 weeks
If symptoms do not settle, urgent appendicectomy
OR
For abscess, CT-guided drainage is an option

Question 34

What is shown in this image?

Answer 34

Facial flushing. Redness + warmth
a/w polycythemia and carcinoid syndrome (not asked in question)

Question 35

How would you identify bronchospasms?

Answer 35

Wheezing on auscultation

Question 36

Give the symptoms of Carcinoid syndrome
What is the main cause of carcinoid syndrome?

Answer 36

Recurrent episodes of diarrhoea
Facial flushing
Bronchospasm (wheezing)

Neuroendocrine tumours, more specifically carcinoid tumours

Question 37

Carcinoid tumours are typically discovered intraoperatively during an appendectomy. Where are the most common organs for Carcinoid tumours?

Answer 37

GI tract (appendix)
Lungs

Question 38

What is the most common tumour of the appendix?
What symptoms would you be looking out for?
How would you treat it?

Answer 38

Carcinoid tumour
Carcinoid syndrome => Recurrent bouts of diarrhoea, facial flushing and bronchospasm (wheezing)
Treated according to size where:
<2 cm = appendectomy
>2 cm = Right hemicolectomy

Question 39

What scoring system is used for acute appendicitis?
What is it used for?
What are its components and relevant cutoffs?

Answer 39

Alvarado appendicitis score
It is used best to exclude appendicitis
It is based on 3 components: Symptoms, signs, and lab results as seen in the pic
0-3 = low risk
4-6 = observe, may need intervention
7-10 Male = Appendectomy, Female = Diagnostic Laparoscopy

Question 40

What is rebound tenderness?

Answer 40

More pain when pressure on tender area released

Question 41

A patient with acute abdomen presents to you. The consultant asks you to exclude pancreatitis. How would you? Give 2

Answer 41

Serum amylase
Epigastric pain radiating to the back
if vs. Hemorrhagic, think of Grey-turner retroperitoneal ecchymosis or Cullen’s Periumbilical ecchymosis