Acute Appendicitis

Question 1

What is the key anatomy of the appendix?

Answer 1

Small pouch attached to caecum
Supplied by the appendicular vein and artery in the mesoappendix (branch from SMA/SMV)
Most common position is retrocecal (70%)
Most dangerous positions is the pre-ileal

Question 2

What are the different anatomical positions of the appendix?

Answer 2

Question 3

What are some risk factors for acute appendicitis?

Answer 3

2nd and 3rd decade of life
Genetics - positive family history
Caucasian populations
Summer
Recently improved hygiene - changes gut flora
Smoking - passive in children and active in adults.

Question 4

What are the common causes of an obstructed appendix?

Answer 4

Faecolith (poo)
Lymphoid hyperplasia
Impacted stool
Appendiceal or caecal tumour

Question 5

What is the basic pathology causing appendicitis?

Answer 5

Obstruction of lumen
Bacterial overgrowth
Increased pressure
Ischemia and necrosis
Perforation

Question 6

Give the more detailed pathophysiology of appendicitis

Answer 6

Luminal obstruction commensal bacteria in the appendix multiply causing suppurative inflammation
Pressure builds up
Causes decreased venous and lymph drainage from appendix, may also have blood vessel thrombosis.
Leads to ischaemia
Cells die - becomes necrotis
Walls break down - may perforate releasing foecal and infective content into the peritoneal cavity.
May form an abscess or phlegmon.

Question 7

What is the key pain history in appendicitis?

Answer 7

Generalised central abdominal pain (visceral peritonitis) migrates to RIF (parietal peritonitis) within 24-48hrs.
Often worse with movement, such as coughing or hoping.

Question 8

What are the key symptoms of acute appendicitis?

Answer 8

Murphys triad - migratory pain, fever, vomiting
Vomiting (due to pylorospasm so usually stomach contents - post dates pain)
Nausea
Anorexia (almost all cases)
Change in bowel habit

Question 9

What are the features/signs of acute appendicitis on examination?

Answer 9

1. Unwell (more in adults) well (children)
2. Tenderness, rebound tenderness, percussion tenderness over McBurney point.
   Guarding
3. Mass in RIF - abscess in appendix
4. Should watch for change in baseline features - fever, tachypnoea, tachycardia, hypotension (sepsis).
5. Rovsings sign - palpate LLQ pain in RLQ
6. Psoas sign - passive extension of right thigh with person in left lateral position pain in RLQ
7. Obturator sign - passive internal rotation of the flexed right thigh elicits pain in the right lower quadrant.

Question 10

What signs and symptoms indicate a perforated acute appendicitis is more likely?

Answer 10

Rebound tenderness
Percussion tenderness
Abdominal distention
Guarding.

Question 11

Where is Mcburneys point?

Answer 11

1/3 way between ASIS and umbilicus

Question 12

What lab investigations should always be done for a patients with suspected appendicitis?

Answer 12

FBC - elevated WBC and shift to left (neutrophilic)
CRP - elevated
LFTs - may be elevated (infection can spread via venous drainage)
RFTs - rule out UTIs
Amylase - elevated in pancreatitis
Group and save - prep for surgery
Urine dipstick - rule out UTI
Pregnancy test - rule out ectopic pregnancy
U&Es - potassium concerns over vomitting

Question 13

What is the Alvarado scoring system used for?

Answer 13

To improve diangostic accuracy of acute appendicitis particualrly in children, reduce negative appendectomies.

Question 14

How do you calculate the Alvarado score?

Answer 14

Score of one for: Migration of pain, anorexia, nausea, tenderness, rebound pain, pyrexia, shift of wbcs to the left
Score of two for - tenderness in right lower quadrant, leuococytosis

Also known as the MANTRELS score

Question 15

What do the different values of a Alvarado score indicate in relations to acure appendicitis?

Answer 15

Less than 5 - unlikely to be appendicitis
5-6 is compatible with appendicitis - require further investigations
7-9 highlight likely to be appendicitis
10 appendicitis is confirmed

Question 16

What imaging techniques may be used for suspected appendicitisis?

Answer 16

Contrast enhanced CT abdo - investigation of choice - 90% specificity and sensitivity
Abdo ultrasound - confirm in 50%, used in paeds
Erect CXR rule out other diagnosis aka perforated gut
Explorative laparoscopy to confirm diagnosis in cases of low certainity

Question 17

What type of diagnosis is acute appendicitis?

Answer 17

Clinical diagnosis - signs, symptoms, examination, and investigations (bloods)

Question 18

What is Valentino’s syndrome?

Answer 18

When a perforated peptic or duodenal ulcer, presents similarly to acute appendicitis as chemical fluids travels via the right paracolic gutter to the RIF, causing peritoneal irritation, mimic appendicitis

Question 19

What treatment tends to be used for acute appendicitis?

Answer 19

Definitive treatment - laparoscopic appendicectomy.
Conservative management includes: NBM, IV fluids, Analgesia, antiemetics, IV antibiotics

Question 20

What are some complications of acute appendicitis?

Answer 20

Rupture - 10 to 20% mortaility rate - cause peritonitis - emergency laparotomy, appendicetomy and peritoneal wash.
Appendicular mass formation - omentum and small bowel adhere to appendix - ochsner sherren regimen (delayed surgery)
Pelvic abscess (peria[[endiceal or subphrenic)
Small bowel obstruction

Question 21

What are some post operative complications of a appendicectomy?

Answer 21

Superficial wound infection
Stump leakage
Stump appendicitis
Intra-abdominal abscess
Small bowel perforation

Question 22

What differential diagnosis need to be consider alongside acute appendicitis?

Answer 22

GI - IBD, Meckels diverticulum (2yrs age), Diverticular disease (more LLQ pain)

Renal - UTI, renal caliculi

Urological - testicular torsion, epididymo orchitis (external gen exam)

Gynaecological - ectopic pregnancy, ovarian torsion, ovarian cyst

Question 23

What scoring system is used for Paediatric appendicitis?

Answer 23

Paediatric Appendicitis Score
Nausea/emesis, anorexia, migration of pain to RLQ, low grade fever (>=38), leukocytosis (>10,000/mm3) and left shift - (>75% neutrophilia) scores 1 point
RLQ tenderness on light palpitations and cough/percussion/heel tapping tenderness at RLQ scores 2 points each

PAS 1-3 is a low risk
PAS 4-7 is a medium risk
PAS 8-10 is a high risk.

Question 24

How do the symptoms of acute appendicitis vary based on the position of the appendix?

Answer 24

Subcaecal/pelvic - suprapubic pain, urinary frequency, diarrhoea and tenesmus due to rectal irritation,a lacking abdominal tenderness, microscopic haematuria and leucocytes may be present on urine dipstick testing
Pre-ileal, post-ileal - vomiting and diarrhoea
Retrocaecal/retrocolic - right loin pain, tenderness to deep palpitation may be absent.

Question 25

Define acute appendicitis.

Answer 25

Acute inflammation of the vermiform appendix, most likely due to obstruction of the lumen of the appendix.

Question 26

What is the epidemiology of appendicitis?

Answer 26

1 in 13 people with develop appendicitis over their lifetime
Most common between age 10-30years, highest incidence in children and adolescence
Large majority present as medical emergencies
50,000 cases in England Hospitals in 2020
Slight male to female predominance 1.4:1