Acute Appendicitis Flashcards

1
Q

In which patients is the diagnosis of acute appendicitis difficult

A
  • patients less than three
  • pregnant
  • older than 60
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2
Q

At which age does appendicitis usually occur

A

Occurs most frequently in the second and third decades of life

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3
Q

What is the incidence of appendicitis in the 10 to 20 year age group

A

233/ 100 000

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4
Q

Where is the vermiform appendix located

A

-Near the ileocaecal valve where the taenia coli converge on the caecum

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5
Q

What is the blood supply of the appendix

A

It is supplied by the appendicular artery, terminal branch of the ileocolic artery, which is a branch of the superior mesenteric artery

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6
Q

The attachment of the appendix to the base of the caecum is constant, however where may the tip migrate to?

A

It may migrate to the retrocaecal, subcecal, preileal, post ileal and pelvic positions

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7
Q

What has been proposed as the primary cause of appendicitis?

A
  • Obstruction of the lumen (Frequently implicated but not always required)
  • Appendiceal obstruction may be caused by faecoliths, calculi, lymphoid hyperplasia, infectious processes and beneign or malignant tumours
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8
Q

What is the natural history of appendicitis following obstruction

A
  • Obstruction leads to increased luminal and intramural pressure resulting in thrombosis and occlusion of the small vessels in the appendiceal wall and stasis of lymphatic flow
  • As the appendix becomes engorged, the visceral afferent nerve fibres at T8-10 are stimulated
  • Significant inflammation –> necrosis –> perforation –> localized abcess formation or diffuse peritonitis
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9
Q

What are the classic symptoms of acute appendicitis

A
  • Right lower quadrant (iliac fossa) abdominal pain
  • Anorexia
  • Nausea and vomiting
  • Abdominal pain is the first symptom; it is peri umbilical in nature with subsequent migration to the right lower quadrant as the inflammation progresses
  • Fever and leucocytosis follow later in the cause of the illness
  • High grade fever may be a sign of a perforated appendix
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10
Q

Differential diagnosis of acute appendicitis

A
  • Urinary tract infection
  • Renal calculi
  • Gastroenteritis
  • Ruptured ovarian cyst
  • Pelvic inflammatory disease
  • Cholecystitis
  • Diverticulitis
  • Small bowel obstruction
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11
Q

Signs of acute appendicitis

A
  • Localized tenderness
  • Rebound tenderness
  • Guarding
  • Generalized peritonitis (perforation)
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12
Q

What is Rovsing’s sign

A

-Palpation of the left lower quadrant eliciting pain in the right lower quadrant

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13
Q

What is obturator sign

A

Pain with internal rotation of the hip (Pelvic appendix)

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14
Q

What is iliopsoas sign

A

Extension of the right hip eliciting pain in the right hip (retrocaecal appendix)

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15
Q

What lab investigations should be done if acute appendicitis is suspected

A
  • Full blood count
  • Urinalysis
  • Pregnancy test
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16
Q

What may abdominal xrays show in a patient with appendicitis

A

-Non-specific but may demonstrate a faecolith, loss of psoas shadow on the right and a sentinel loop of small bowel in the right lower quadrant

17
Q

Features on ultrasound suggesting appendicitis

A
  • Thickened wall of >2mm
  • Increased appendiceal diameter of >6mm
  • Free fluid
18
Q

CT scan findings in acute appendicitis

A
  • Thick wall of >2 mm
  • Increased diameter of the appendix > 7mm
  • Appendocolith
  • Phlegmon or abcess
  • Free fluid
19
Q

management of patient where there is a doubt in the diagnosis

A

-Active observation or investigate further

20
Q

Preferred procedure in young female?

A

Diagnostic laparoscopy should be considered

21
Q

What are the benefits of a laparoscopic appendectomy?

A
  • Less post op pain
  • Shorter hospital stay
  • Decreased wound infection rate
22
Q

what are the cons of laparoscopic appendectomy

A
  • Longer operative time
  • More expensive
  • Increased incidence of intra-abdominal collections
23
Q

How should a patient presenting with longer duration of symptoms, finding localized to the right lower quadrant and who have a palpable mass of physical exam?

A
  • Should be treated initially antibiotics, Intravenous fluids and bowel rest
  • Most will respond to non-operative management
24
Q

Treatment of appendicular abscess

A

Ct or ultrasound guided percutaneous drainage is the treatment of choice

25
Q

What should one do if a normal appendix is found intra-operatively

A
  • Important to remove it to avoid confusion about future abdominal pain
  • Look for other conditions: terminal ileitis, Meckel’s deverticulitis, mesenteric adenitis, cholecystitis, Colonic diverticulitis, Pathology of pelvic organs in females
26
Q

Differentials for acute appendicitis in neonates and infants

A
  • Midgut volvulus
  • Pyloric stenosis
  • Meckel’s diverticulitis
  • Intussusception
27
Q

How do immunocompromised patients present with acute appendicitis

A
  • Mild tenderness on examination

- Normal WCC

28
Q

Differentials for acute appendicitis in immunocompromised individuals

A

Broad differentials, including mycobacterial infection, CMV and fungal infections