Acute Appendicitis Flashcards
What is the most common surgical emergency
- Acute appendicitis
Why does appendicitis rarely occur in under 2s
- because the appendix is cone shaped with a large lumen
What is the pathogenesis for acute appendicitis
- gut organisms invade appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith or filarial worms
- leads to oedema, ischaemic necrosis and perforation
What is the presentation of acute appendicitis
- periumbilical pain that moves to the RIF
why does the pain change location in acute appendicitis
- Early inflammation irritates the structure and walls of the appendix, so a colicky pain is felt periumbilically
- As inflammation progresses and irritates the parietal peritoneum (esp on examination), pain settles at McBurney’s point (2/3 of the way along from the umbilicus to the right ASIS)
What are the associated signs with acute appendicitis
- tachycardia
- fever
- peritonism with guarding or rebound tenderness or percussion tenderness in RIF
- anorexia
- vomiting - rare
- Constipation usual - though diarrhoea may occur
What named signs are associated with acute appendicitis
Rovsing’s sign = pain > in RIF than LIF when the LIF is pressed
Psoas sign = pain on extending hip if retrocaecal appendix
Cope sign = pain on flexion and internal rotation of the right hip if appendix in close relation to obturator internus
pain on right during DRE - suggests an inflamed, low lying pelvic appendix
What are the differential diagnosis to appendicitis
- Ectopic pregnancy (do a pregnancy test!!!)
- UTI
- mesenteric adenines
- cystitis
- cholecystitis
- diverticulitis
- salpingitis/PID
- dysmenorrhoea
- Crohn’s disease
- perforated ulcer
- food poisoning
- Meckel’s diverticulum
What investigations do you do in appendicitis
- Bloods - neutrophils and CRP are raised
- US - but not always visualised
- CT - has high diagnostic accuracy and useful if diagnosis is unclear
What does pregnancy feel like with appendicitis
- occurs in 1/1000 pregnancies
- mortality higher (especially from 20 weeks gestation)
- perforation is more common and increases foetal mortality
- pain is often less well localised - may be RUQ and signs of peritoneum less obvious
What is the treatment of appendicitis
Appendicetomy
- open or laparoscopy
What antibiotics are you on appendicitis
- Piperacillin/Tazobactam 4.5g/8h, 1-3 doses IV starting 1h pre-op – reduces wound infections
- Give longer course if perforated
when is a laparoscopy not recommended
- in cases of suspected gangrenous perforation as the rate of abscess formation may be higher
What are the complications of appendicitis
- perforation
- appendix mass
- appendix abscess
describe who appendix perforation usually present in
more common of faecolith is present and in young children as the diagnosis is more often delayed
What does an appendix mass result
- When inflamed appendix becomes covered with momentum
How do you treat an appendix mass
- Early surgery or initial conservative management - NBM and antibiotics
- if the mass resolves some perform an interval (e.g. delayed) appendectomy
- exclude colonic tumour that can present as early as 40 years
When does an appendix abscess happen
- may result if an appendix mass fail to resolve but enlarges and the patient gets more unwell
What is the treatment of an appendix abscess
- usually involves drainage (surgical or percutaneous under US/CT guidance) although antibiotics alone may bring resolution
What are the different positions that the appendix can be in
- retro-caecal
- post-ileal
- pre-ileal
- pelvic
Where is McBurney’s point
2/3 of the way along from the umbilicus to the right ASIS
when does RUQ pain present with appendicitis
Inflammation in a retrocaecal/retroperitoneal appendix (2.5%) may cause flank or RUQ pain; its only sign may be ↑tenderness on the right on DRE
How does perforated appendicitis present
Peritonitis
- pain is in entire abdomen
- constant and severe
- fever is high
- breathing and heart rate may be fast in response to severe pain
- have other symptoms including chills, weakness and confusion
what is the urine results in appendicitis
- pregnancy test - rule out ectopic pregnancy
- done to rule out UTI
