apendicitis

Question 1

what is apendicitis and what is it caused by?

Answer 1

• acute inflamation and bacterial infection of the apendix

- occuring due to luminal obstruction by hard stool, lymphoid hyperplasia of pyers patch or fibrous stricture

Question 2

what are risk facotrs for apendicitis

Answer 2

• Young age: the highest incidence is between 10-20 years of age [2]
  Male
• Frequent antibiotic use: causes an imbalance in gut flora and a modified response to subsequent infection which may trigger appendicitis
• Smoking

Question 3

what is the clinical triad for apendicitis?

Answer 3

1. central abdominal pain migrating to the right illiac fossa
2. low grade pyrexia
3. annorexia

Question 4

what signs would suggest perforation of the appendix?

Answer 4

Tachycardia, hypotension and generalised peritonism

Question 5

what is rovsigns sign?

Answer 5

pain in the right iliac fossa is worsened by pressing on left iliac fossa; now thought to be of limited diagnostic value

Question 6

what is psoas sign?

Answer 6

pain is worsened by extending the hip

Question 7

what is obturators sign?

Answer 7

pain is worsened by flexing and internally rotating the hip

Question 8

what are the primary investigations for apendicitis?

Answer 8

FBC: leukocytosis and neutrophilia is seen in up to 90% of patients

CRP: raised due to inflammation

U&Es: acute kidney injury in dehydration secondary to vomiting, or in instances of perforation and sepsis

Group & save: important to conduct prior to surgical intervention

Urinalysis: perform in all patients to exclude renal colic, a urinary tract infection or pregnancy in women; in appendicitis, there may be a mild leukocytosis without nitrites

Question 9

what imatging investigations for apendicitis?

Answer 9

Abdominal ultrasound: preferred in children, pregnant, and breastfeeding women and may show a non-compressible inflamed appendix however the appendix often cannot be visualised; sensitivity is 86% and specificity is 81%

CT abdomen/pelvis with contrast: CT has a 95% sensitivity and specificity for appendicitis; becoming increasingly used as the first diagnostic test for appendicitis

MRI abdomen/pelvis: mainly reserved for pregnant women when ultrasound is non-diagnostic

Question 10

what is initial management of apendicitis?

Answer 10

Fluids: patients will require hydration due to fluid losses, as well as due to being nil-by-mouth prior to surgery

Analgesia: patients can be in considerable pain

Antiemetics: can be given for nausea and vomiting e.g. ondansetron

Preoperative IV antibiotics: prophylactic antibiotics are associated with reduced wound infection rates, e.g. ceftriaxone and metronidazole

Question 11

what is definitive management of apendicitis?

Answer 11

prompt appendicectomy: laparoscopic appendicectomy. Significant abdominal lavage is required for perforated appendicitis

Postoperative antibiotics: usually given for only 24 hours, but occasionally patients are discharged on a brief course of oral antibiotics if the appendix was perforated or necrotic

Question 12

what are the complications of appendicitis?

Answer 12

Perforation (15-20%): if left untreated, there is a significant risk of appendiceal rupture, which will lead to sepsis and death if untreated

Appendiceal mass: a walled-off perforated appendix may form a mass in the right iliac fossa; for patients with an appendix mass without peritonitis, broad-spectrum antibiotics are usually offered with consideration of an interval

appendicectomy
Abscess: inflammation may cause the formation of a localised collection of pus in proximity to the appendix, which will require drainage