Acute Appendicitis

Question 1

Define “Acute Appendicitis”

Answer 1

Sudden onset inflammation of the appendix. The most common cause of acute abd

Question 2

1) What is the appendix?
2) Where is it located?
3) What are its contents?

Answer 2

1) blind muscular tube w/ mucosal, submucosal, muscular + serosa layers
2) retrocaecal (75%), pelvic (21%), subcaecal (1.5%), paracaecal (2%). Constant base of appendix @ confluence of 3 taeniae coli, fuse to form outer longitudinal mm coat of appendix
3) appendicular a, lymphatic channels, adults = fats & children = transparent

Question 3

Discuss the aetiology of acute appendicitis

Answer 3

decreased fibre intake + increased refined (processed) carbs

obstruction of appendiceal lumen via faecaliths/lymphoid hyperplasia + less commonly parasites, TB, tumour, FB

Question 4

What is the pathology of acute appendicitis

Answer 4

lymphoid hyperplasia -> blocked lumen -> continous mucous secretion + inflammatory exudate -> increased intraluminal pressure bc more blockage -> obstruct lymph drainage -> oedema + bacterial translocation to submucosal layer -> mucosal ulceration -> progression -> further distention -> venous obstruction + ischaemia of appendix wall -> bacteria invades thru muscularis propria + submucosa -> acute appendicitis

Question 5

What are the 4 classical features of acute appendicitis to note on hx?

Answer 5

1) Migratory Pain
2) Nausea + Vomiting
3) Fever
4) Anorexia
5) Others - diarrhoea/constipation

Question 6

What are the cardinal features of acute appendicitis seen on PE?

Answer 6

unwell pt w/ lowgrade pyrexia
localised abd tenderness
mm guarding and rebound tenderness

Question 7

What can be inspected on inspection + palpation in a pt w/ acute appendicitis?

Answer 7

Inspection - limitation of resp mvts in lower abd
Palpation - mm guarding & max tenderness @ McBurney’s pt, RIF tenderness, tenderness on percussion, rebound tenderness, rigidity & guarding

Question 8

What signs should be elicited on examination in a pt w/ suspected acute appendicitis?

Answer 8

Cough sign
Rovsing Sign
Obturator Sign
Psoas Sign

Question 9

What are the DDx of acute appendicitis in children?

Answer 9

Gastroenteritis
Mesenteric adenitis 
Meckel's Diverticulum
Lobar Pneumonia
Intussusception

Question 10

What are the DDx of acute appendicitis in adults?

Answer 10

terminal ileitis
perforated PUD

Male specific
testicular torsion
epidydymitis orchitis

Female specific
ovarion torsion
ectopic pregnancy
pelvic inflammatory ds
ruptured ovarian cyst

Question 11

What are the DDx of acute appendicitis in the elderly?

Answer 11

diverticulitis
intestinal obstruction
colonic Ca

Question 12

Name the factors of the Alvarado Score used to dx acute appendicitis

Answer 12

MANTRELS
M - migratory pain
A - anorexia
N - N&V
T - tenderness (RIF)
R - rebound tenderness
E - increased tEmp >37.3
L - Leucocytes > 10 000
S - Lt Shift of Neutrophils

(Leucocytes + RIF tenderness = 2 pts each, everything else is 1 pt)

Question 13

So, what investigations are done to confirm acute appendicitis?

Answer 13

FBC + CRP. blood culture
Abd U/S
Abd CT

Question 14

What investigations are done to r/o DDx and assess the cx of acute appendicitis?

Answer 14

Pregnancy test
Erect CXR
Urine dipstick
U&E/Cr
PT/PTT

Question 15

How does one manage a pt w/ acute appendicitis?

Answer 15

Rehydrate pt + ABCs
Definitive tx = appendectomy
If appendix = perforated -> broad spectrum antibiotics for 5-7 days
If appendix is not perforated -> 1 dose antibiotics before surgery and none needed after
Conservative tx: Ochsner Sherren regime - only if really can’t operate!

Question 16

What are the complications of acute appendicitis?

Answer 16

1) Local - retained faecalith, stump appendicitis, leak, fistula
2) Haemorrhage - intra-abd, abd wall haematoma, scrotal haematoma
3) Infxn/sepsis - wound infxn, abscess (intra-abd, appendiceal stump, pelvic, scrotal)
4) Paralytic ileus