Acute appendicitis Flashcards
What are the different potential positions of the appendix?
- pre-ileal
- post-ileal
- sub-ileal
- sub-caecal
- paracaecal
- retrocaecal
- pelvic
- long
What are the differential diagnoses of appendicitis?
- GI:
- Acute cholecystitis
- Acute pancreatitis
- Perforated ulcer
- Meckel’s diverticulum
- Diverticulitis
- Strangulated hernias - Urinary:
- Testicular torsion
- UTI
- Renal calculi - Genitallllls:
- Ectopic pregnancy
- Testicular torsion
- Rupture of ovarian cyst
- PID - Other:
- DKA
- Pneumonia
- Porphyria
What is the classic presentation of acute appendicitis?
- pain starting in the umbilicus and moving to the RIF
- rebound tenderness and involuntary guarding
- anorexia, nausea and vomiting
- tachypnoea, tachycardia and pyrexia
- Rovsing’s sign
- Psoas sign
- Cope/obturator sign
What is Rovsing’s sign?
Pain the the RIF when LIF is pressed due to stretching of the peritoneum on the inflamed appendix
What is the psoas sign?
Pain in hip extension with patient on side
If retrocaecal appendix or psoas abscess this may cause the patient to have involuntary flexion of the hip
What is the cope/obturator sign?
Pain in flexion and internal rotation of the thigh with the patient on their back
If patient has a pelvic appendix
What is the alternative/atypical presentation of acute appendicitis?
- Retrocaecal appendices can also result in pain in the R lumbar or R hypochondrium
- PR examination would result in pain on the right hand side with a retrocaecal appendix
- Other positions can cause:
1. rectal pain (local irritation and diarrhoea)
2. Lower back pain
3. Suprapubic pain (increased frequency of urination, dysuria and pyuria)
4. Pain mimicking PID if close to the Fallopian tubes
What is the gold standard diagnostic investigation for acute appendicitis?
US
May help in some patients where the diagnosis is doubtful and in the assessment of an appendix mass or abscess
What other investigations are used to diagnose appendicitis?
- Bloods: neutrophil leukocytosis and raised CRP
- Urinalysis: exclude UTI and ectopic pregnancy:
- CT: more sensitive and specific than US, but the delay in diagnosis may be fatal
- Diagnostic laparoscopy when diagnosis is unclear
- not indicated if there is gangrenous or perforated appendicitis
What might a CT show in acute appendicitis?
- enlarged appendix
- appendices wall thickening
- peri-appendiceal fat stringing
- appendiceal wall enhancement
What are the early complications of appendectomy?
- Appendix stump blowout - spillage of colonic contents into peritoneal cavity
- Generalised peritonitis
- Abscesses
- Retained faecolith causing chronic local infection
- Haematoma
- Superficial/deep wound infection
- Dehiscence (wound gapes or bursts open)
What are the intermediate complications of appendectomy?
- intestinal obstruction due to adhesions
What are the late complications of appendectomy?
- infertility due to tubal occlusion following pelvic infection
- incisional hernia
How do appendiceal masses occur?
Most likely due to an inflamed appendix that has become walled off by adhesions to the momentum and adjacent viscera, with or without the presence of local abscesses
What is the initial management of appendix masses?
- outlines of the mass are marked on the skin
- patient is put on a fluid diet and monitored looking at general condition, temperature and pulse
- 80% of cases the mass resolves
- appendectomy occurs 3 months later
- in other cases the abscess is drained
