Acute Appendicitis

Question 1

List the signs and symptoms of acute appendicitis?

Answer 1

Symptoms:
General umbilical pain which radiates and localises in the RIF. Pain will be much worse on movement.
Nausea and vomiting.
Anorexia
Constipation

Signs:
Peritonitic pain
Afebrile or low grade pyrexia
Rising pulse rate may be a sign of it becoming generalised peritonitis.
Rovsings signs: Pushing on the LIF increases pain due to the pressure irritating the appendix.
Guarding
Rebound

Question 2

What are the other possible differential diagnoses?

Answer 2

Any cause of generalised peritonitis.
Caecal volvulus.
Ovarian cyst rupture.

Question 3

What investigations would you do in suspected appendicitis?

Answer 3

• Routine bloods: You would expect raised WBC and CRP.
• Urinalysis to exclude urinary tract infection.
• Pregnancy test to exclude ectopic pregnancy.
• CT for diagnostics (enlarged appendix), CT is much more accurate, however it can be a clinical diagnosis. dont usually do.
• PR and pelvic examination

Question 4

List the complications of a appendicitis?

Answer 4

Perforation:
Generalised peritonitis
Sepsis leading to death
Abcess Formation: will need draining + antibiotics
Other abscesses: pelvic and subphrenic
Appendix mass: the omentum and small bowel adhere to the appendix causing a mass.
Adhesions

Question 5

What are the complications following appendectomies and how can they be avoided?

Answer 5

Wound infection: check wound healing, dress it correctly and clean it.

Port site hernia: same risk as normal hernias (increasing intra-abdominal pressure)

Adhesions.

Haematoma

Question 6

What are the causes of RIF masses?

Answer 6

Crohn's disease
Carcinoma of colon/ carcinoid tumour
Mucocele of the gallbladder
Psoas abscess
Pelvic kidney
Gynae: Ovarian cyst, Fibroid, tumour
Lymphoma
Appendix mass
Iliac aneurysm
TB mass

Question 7

Discuss the pathology of the causes of a RIF mass

Answer 7

Crohn’s disease: chronic inflammation leading to fibrosis causing a mass. (as per normal IBD)

Carcinoma of colon. (staging and resection)

Psoas abscess, will be filled with puss and therefore hard and palpable. (drainage and abx)

Pelvic kidney, Kidney replacements are often put in the RIF.

Tb granulomatous inflammation. (quadruple therapy)

Question 8

What are the signs of:

a) a pelvic appendix
b) retroperitoneal retrocaecal appendix

Answer 8

a) PR painful on the RHS, Obturator sign/ Copes (pain on flexion and internal rotation of R hip), pain may be more suprapubic and may have some urinary symptoms due to local irritation
b) Psoas sign (pain on right hip extension), may not be as tender as expected and there may only be pain on deep palpation.

Question 9

What is a carcinoid tumour?

Answer 9

Most common type of neuroendocrine tumour. If arrises from the midgut - associated with carcinoid syndrome (flushing, wheeze, diarrhoea, nausea). Can originate from the tip of the appendix.

Question 10

How would you treat an appendix mass?

What is the main risk of an appendix mass?

Answer 10

• USS/CT to confirm diagnosis
• IV Antibiotics (cefuroxime and metronidazole), mark out the size of the mass
• If it does not resolve (get smaller) in 2 days then percutaneous drainage is neccessary
• Appendectomy 3 months later when resolved

Risk that it will develop into an abscess