Acute Appendicitis Flashcards
What is acute appendicitis?
An inflammation of the appendix
What surgical procedure is the commonest abdominal emergency worldwide?
Appendectomy
What protects the orifice of the appendix?
Valve of Gerlach (a semilunar mucosal fold)
What artery provides blood supply to the appendix?
Appendicular artery (a branch of the lower division of the ileocolic artery)
What is the pathophysiological consequence of thrombosis of the appendicular artery?
Gangrenous appendicitis
What are the sympathetic nerve supplies to the appendix?
T9 & T10 (celiac plexus)
What is the parasympathetic nerve supply to the appendix?
Vagus nerve
What is the primary cause of appendicitis?
Obstruction of the appendiceal lumen
What are the three most common causes of luminal obstruction in appendicitis?
Lymphoid hyperplasia, fecal stasis/fecaliths, and foreign bodies/neoplasms
What is the most common position of the appendix?
Retrocecal (74%)
What is the sequence of pathophysiological events in appendicitis?
Lumen obstruction โ Increased intraluminal pressure & mucus accumulation โ Venous congestion & lymphatic obstruction โ Bacterial overgrowth & acute inflammation โ Ischemia & necrosis โ Perforation โ Complications (abscess, peritonitis)
What is the classic clinical presentation of peri-umbilical pain in appendicitis?
Pain localizes to the right iliac fossa
Name three clinical signs used to diagnose appendicitis.
Pointing sign, Rovsingโs sign, and Psoas sign
What is the Rovsingโs sign in appendicitis?
Deep palpation of the left iliac fossa causes pain in the right iliac fossa
What is the Psoas sign in appendicitis?
Pain in the right iliac fossa when the right knee is extended with the patient in a flexed hip position
What is the Obturator sign in appendicitis?
Right iliac fossa pain when the hip is flexed and internally rotated
What predisposing factor related to diet is associated with appendicitis?
Decreased dietary fiber and increased consumption of refined carbohydrates
What complications can result from appendiceal perforation?
Abscess and peritonitis
What is the peritoneum?
The peritoneum is the largest serous membrane of the body, consisting of parietal and visceral layers.
What are the two layers of the peritoneum?
Parietal layer (lines the cavity wall) and visceral layer (covers abdominal organs).
What type of epithelium covers the peritoneum?
Simple squamous epithelium (mesothelium).
What is the function of serous fluid secreted by the peritoneum?
It lubricates organs, allowing them to glide smoothly over each other or against the cavity wall.
What is peritonitis?
Inflammation of the peritoneum, usually caused by bacterial or fungal infection.
What are common causes of peritonitis?
Ruptured appendix, perforated colon, penetrating abdominal injury, gastrointestinal infections.
What are symptoms of peritonitis?
Generalized abdominal pain, distention, fever, nausea, vomiting, diarrhea/constipation.
What is a key sign of peritonitis on abdominal examination?
The abdomen does not move with respiration.
What investigations are done for peritonitis?
Full blood count, blood culture, abdominal fluid m/c/s, CT scan, X-ray.
How is peritonitis managed?
Treat underlying cause, antibiotics, analgesics, surgery if needed.
What are complications of peritonitis?
Hepatic encephalopathy, hepatorenal syndrome, sepsis, septic shock.
What is the Alvarado score used for?
Assessing the likelihood of acute appendicitis in patients with right lower quadrant pain.
What Alvarado score indicates appendicitis is most likely?
7-10.
What are key symptoms in the Alvarado score?
RLQ pain, anorexia, nausea/vomiting, tenderness, rebound tenderness, fever, leukocytosis.
What are common investigations for appendicitis?
FBC, urinalysis, pregnancy test, abdominal ultrasound, chest X-ray.
What are some differential diagnoses of appendicitis?
Perforated PUD, intestinal obstruction, acute pyelonephritis, acute pancreatitis, ectopic pregnancy.
What is the definitive treatment for appendicitis?
Appendectomy (surgical removal of the appendix).
What are types of appendectomy?
Emergency, elective, incidental, interval, laparoscopic.
What is an interval appendectomy?
Appendectomy performed 6-8 weeks after resolution of complications like abscess or mass.
What are complications of appendicitis?
Appendiceal gangrene, abscess, perforation, peritonitis, chronic appendicitis.
What are post-op complications of appendectomy?
Paralytic ileus, wound infection, intra-abdominal abscess, fecal fistula, Richterโs hernia.
What is an appendix mass?
An inflammatory mass of the appendix, terminal ileum, and cecum wrapped in omentum.
How is an appendix mass managed?
Conservative management with Ochsner-Sherren regimen, followed by interval appendectomy in 6-8 weeks
What are criteria for stopping conservative management of an appendix mass?
Rising pulse
Rising temperature >39ยฐC
Increasing mass size
Worsening patient condition
Features of intestinal obstruction
Features of Perforation
Features of Peritonitis
What is the management of a ruptured appendix?
Explorative laparotomy with peritoneal lavage using saline.
What is the Alvarado score used for?
Assessing the likelihood of acute appendicitis in patients with right lower quadrant pain.
What are the components of the Alvarado score?
Migration of pain, RLQ tenderness, rebound tenderness, anorexia, nausea/vomiting, elevated temperature, leukocytosis, and shift to the left.
What Alvarado score range suggests appendicitis is most likely?
7-10.
What investigations help diagnose acute appendicitis?
FBC, urinalysis, pregnancy test, abdominal ultrasound, chest X-ray.
What gastrointestinal conditions are differential diagnoses for appendicitis?
Perforated PUD, intestinal obstruction, perforated typhoid enteritis, Crohnโs disease.
Which gynecological conditions mimic appendicitis?
Right ectopic pregnancy, acute PID, endometriosis.
What pediatric conditions can mimic appendicitis?
Gastroenteritis, right basal pneumonia, intussusception, lobar pneumonia, herpes zoster, malaria, sickle cell crisis.
What is the primary surgical treatment for appendicitis?
Appendectomy.
What are the common incisions for appendectomy?
Lanz and gridiron incisions.
What are the types of appendectomy?
Emergency, elective, incidental, interval, laparoscopic.
What is an interval appendectomy?
Appendectomy done 6-8 weeks after resolution of complicated appendicitis (e.g., appendiceal mass or abscess).
What are complications of appendicitis?
Appendiceal gangrene, appendiceal mass, appendiceal abscess, perforation, spreading peritonitis, intra-abdominal abscess.
What are post-op complications of appendectomy?
Paralytic ileus, wound infection, intra-abdominal abscess, fecal fistula, portal pyemia, adhesive intestinal obstruction, Richterโs hernia.
What is an appendiceal mass?
An inflammatory mass consisting of an inflamed appendix, terminal ileum, and cecum wrapped in omentum.
What is the recommended management for an appendiceal mass?
Conservative (Ochsner-Sherrenโs regimen) to reduce the risk of bowel injury and fistula formation.
What is the Ochsner-Sherrenโs regimen?
This is a form of conservative therapy for Appendiceal mass.
A - Aspiration with NG tube if patient is vomiting
B - Bowel rest (NPO) & general assessment
C - Charts (PR, Temp, BP, RR) - 4 hrly
D - Drugs (antibiotics & analgesia)
E - Electrolytes correction
F - Fluid rehydration
When should conservative management of an appendiceal mass be stopped?
Rising pulse, temperature >39ยฐC, increasing mass size, persistent vomiting, worsening condition, intestinal obstruction, intestinal perforation, peritonitis.
How is an appendix abscess managed?
Incision and drainage; if appendix is identified, excision is performed, otherwise interval appendectomy is done after 6-8 weeks.
What is the surgical approach for a ruptured appendix?
Explorative laparotomy with a lower midline incision and peritoneal lavage with saline.
Which imaging modality is preferred for diagnosing appendicitis in children?
Abdominal ultrasound.
What is the most common complication of untreated appendicitis?
Perforation leading to peritonitis.
What is the key clinical feature of appendicitis on examination?
Tenderness at McBurneyโs point.
What is Rovsingโs sign?
Pain in the RLQ when the LLQ is palpated, suggesting appendicitis.
What is the first-line antibiotic choice for suspected appendicitis?
A broad-spectrum antibiotic covering gram-negative and anaerobic bacteria.
What laboratory finding strongly suggests appendicitis?
Leukocytosis with a left shift (increased immature neutrophils).
