Appendicitis

Question 1

Define Appendicitis

Answer 1

Inflammation of the appendix

Question 2

Summarise the epidemiology of appendicitis

Answer 2

The MOST COMMON surgical emergency
Can occur at any age
Most commonly occurs between 10-20 yrs

Question 3

Explain the aetiology / risk factors of appendicitis

Answer 3

Gut organisms invade the appendix wall after lumen obstruction (e.g. by lymphoid hyperplasia, faecolith or filarial worms)

This leads to oedema, ischaemic necrosis and perforation

Question 4

Presenting symptoms of appendicitis?

Answer 4

Periumbilical pain that moves to the right iliac fossa

Anorexia

Vomiting

Constipation

Diarrhoea

Question 5

Why does the pain radiate?

Answer 5

initial pain is due to inflammation of the visceral peritoneum and appendix itself and visceral pain tends to be poorly localised and the pain is referred to the midline

As the inflammation spreads to the parietal peritoneum, which is somatosensory, it is localised at the right lower quadrant – the point of pain is known as MCBURNEY’S POINT

Question 6

Where is McBurney’s point?

Answer 6

1/3 of the distance from the ASIS to the umbilicus – roughly corresponds to location of base of appendix)

Question 7

Signs of appendicits on PE?

Answer 7

o	Tachycardia
o	Fever 
o	Furred tongue 
o	Lying still 
o	Coughing hurts 
o	Foetor with/without flushing 
o	Shallow breaths 

● RIF Signs
o Guarding
o Rebound and percussion tenderness
o PR pain on the right side (sign of low-lying pelvic appendix)

Question 8

What are some special signs for appendicits?

Answer 8

Rovsing’s sign
Psoas sign
Cope sign

Question 9

What is Rovsing’s sign?

Answer 9

palpation of the left iliac fossa causes more pain in the right iliac fossa than the left

Question 10

What is Psoas sign?

Answer 10

pain on extending the hip

Question 11

What is Cope sign?

Answer 11

pain on flexion and internal rotation of the hip (occurs if the appendix is in close proximity to the obturator internus)

Question 12

What are some possible variations in the clinical picture?

Answer 12

Inflammation of retrocaecal/retroperitoneal appendix may cause flank pain or RUQ pain

The only sign may be tenderness on the right on DRE

o A child may have vague abdominal pain and will not eat their favourite food

o A shocked confused 80+ year old who is not in any pain

Question 13

Investigations for appendicitis?

Answer 13

● Bloods
o High WCC (mainly neutrophils)
o High CRP
o Pregnancy test

● Ultrasound may help

● CT - high diagnostic accuracy but may cause fatal delay

Question 14

Management for appendicits?

Answer 14

Prompt appendiectomy
ABs (Cef/Met)
Laparoscopy - diagnostic and therapeutic

Question 15

Possible complications of appendicitis?

Answer 15

Perforation
Appendix mass
Appendix abscess