Acute Appendicitis

Question 1

What is appendicitis?

Answer 1

Inflammation of the appendix and is a common acute surgical presentation

Question 2

Epidemiology

Answer 2

20-30s

Overall lifetime ris of 7-8%

One of the most common causes of abdo pain in young people and children

Question 3

Aetiology

Answer 3

Usually caused by direct luminal obstruction or

Secondary due to faecolith, lymphoid hyperplasia, impacted stool or…

Rarely appendiceal or caecal tumour

Question 4

Pathophysiology

Answer 4

When obstructed the commensal bacteria that usually reside in the appendix can start to multiply.

This leads to acute inflammation

Reduced venous drainage and localised inflammation leads to increased pressure within the appendix which can lead to ischaemia.

If this is left untreated necrosis and perforation can occur.

Question 5

Risk factors

Answer 5

Family history

Ethnicity (caucasians)

Environmental (more common during summer)

Question 6

Clinical features

Answer 6

Abdo pain that starts peri-umbilical with dull and poorly localised pain.

It then moves to right iliac fossa where it becomes sharp and localised.

Vomiting, anorexia, diarrhoea, constipation

Question 7

Examination findings

Answer 7

Rebound tenderness and percussion pain over McBurney’s point

Guarding

Can have sepsis, tachycardia and be hypotensive.

Appendiceal abscess -> RIF mass

Question 8

Specific signs of appendicitis

Answer 8

Rovsing’s sign = RIF fossa pain on palpation of LIF

Psoas sign = RIF pain with extension of right hip (retrocaecal position of appendix)

Question 9

Clinical features of acute appendicitis in children

Answer 9

Atypical manner

Diarrhoea, urinary symptoms or even left sided pain.

Make sure you exclude testicular torsion or epididymitis

Children under 6 with symptoms over 48h are significantly more likely to have a perforated appendix

Question 10

Dx

Answer 10

Gynae = ovarian cyst rupture, ectopic pregnancy, PID

Renal = ureteric stones, UTI, pyelonephritis

GI = IBD, Meckel’s diverticulum, diverticular disease

Uro = testicular torsion, epididymo-orchitis

Acute mesenteric adenitis, gastroenteritis, constipation, intussusception.

Question 11

Laboratory tests

Answer 11

Urinalysis to exclude renal or urological cause

Pregnancy test

Routine bloods like FBC and CRP.

Serum beta-hCG if ectopic pregnancy has not been excluded.

Question 12

Imaging

Answer 12

Clinical diagnosis mainly

USS or CT are often requested if clinical features are inconclusive.

USS first line especially wiht transvaginal approach

CT has good sensitivity and specificity and can exlclude GI and urological causes

Question 13

What risk stratification score is used in acute appendicitis?

Answer 13

Men - Appendicitis inflammatory response score

Women - Adult appendicitis score

Children - Shera score

Question 14

Definitive treatment of appendicitis

Answer 14

Laparoscopic appendicectomy

Question 15

Conservative abx therapy is sometimes used but has a fairly high failure rate.

When is abx therapy favoured?

Answer 15

Appendiceal mass and then an interval appendectomy is done 6-8 weeks later.

Question 16

Surgical intervention

Answer 16

Pre-operative abx should always be given

Laparascopic appendectomy is gold standard.

The appendix should then be sent for histopathology to look for malignancy.

The entirety of the abdomen should also be inspected for any other pathology like Meckel’s diverticulum.

Question 17

What surgical intervention might be done in pregnancy?

Answer 17

Open approach via a Lanz incision.

However even in pregnancy laparoscopic is becoming more common.

Question 18

Complications

Answer 18

Perforation (particularly in children)

Surgical site infection

Appendix mass where omentum and small bowel adhere to the appendix

Pelvic abscess