Appendicitis

Question 1

Appendicitis has a slight … preponderance and is uncommon at the extremes of age. The majority of cases occur in those aged 15-59 years old.

Answer 1

Appendicitis has a slight male preponderance and is uncommon at the extremes of age. The majority of cases occur in those aged 15-59 years old.

Question 2

The appendix is a short appendage, normally 5-10 cm long, that opens onto the ….

Answer 2

The appendix is a short appendage, normally 5-10 cm long, that opens onto the caecum.

Question 3

Appendicitis is normally caused by obstruction of the … of the appendix.

Answer 3

Appendicitis is normally caused by obstruction of the lumen of the appendix.

Question 4

Appendiceal obstruction may result from a variety of causes. One of the most common causes are …. These are hard collections of stool that form and block the appendiceal lumen. Other causes include lymphoid hyperplasia, fibrous stricture or carcinoid tumours.

Answer 4

Appendiceal obstruction may result from a variety of causes. One of the most common causes are faecoliths. These are hard collections of stool that form and block the appendiceal lumen. Other causes include lymphoid hyperplasia, fibrous stricture or carcinoid tumours.

Question 5

Appendicitis is uncommon at the extremes of age. The young have a relatively wide appendiceal …, whilst in the elderly, it is almost entirely obliterated.

Answer 5

Appendicitis is uncommon at the extremes of age. The young have a relatively wide appendiceal lumen, whilst in the elderly, it is almost entirely obliterated.

Question 6

Obstruction of the appendiceal lumen causes stasis and resultant bacterial overgrowth. The proliferation of bacteria leads to an increase in … pressure. As the pressure rises in the appendix it causes venous and lymphatic congestion. As the pressure rises further, the arterial supply to the appendix becomes compromised leading to …, perforation and generalised ….

Answer 6

Obstruction of the appendiceal lumen causes stasis and resultant bacterial overgrowth. The proliferation of bacteria leads to an increase in intraluminal pressure. As the pressure rises in the appendix it causes venous and lymphatic congestion. As the pressure rises further, the arterial supply to the appendix becomes compromised leading to gangrene, perforation and generalised peritonitis.

Question 7

Appendicitis - risk of perforation

Answer 7

Appendicitis - The risk of perforation increases with time though varies between individuals. One study showed the risk of perforation to be 20% at 24 hours whilst another estimated it to be 15-35% at 72 hours.

Question 8

Patients classically complain of a colicky, peri-umbilical pain which migrates to the right iliac fossa (RIF) and becomes constant - what is this describing?

Answer 8

Patients classically complain of a colicky, peri-umbilical pain which migrates to the right iliac fossa (RIF) and becomes constant - appendicits

Question 9

Common clinical features associated with acute appendicitis include …, anorexia and constipation. … may be seen but is typically mild when present.

Answer 9

Common clinical features associated with acute appendicitis include nausea, anorexia and constipation. Diarrhoea may be seen but is typically mild when present.

Question 10

Acute appendicitis is uncommon at the extremes of age where it also tends to have an atypical presentation. Pregnant women may have a displaced appendix resulting in … pain. A high degree of clinical suspicion is required as delayed treatment results in high morbidity and mortality in both the mother and foetus.

Answer 10

Acute appendicitis is uncommon at the extremes of age where it also tends to have an atypical presentation. Pregnant women may have a displaced appendix resulting in flank pain. A high degree of clinical suspicion is required as delayed treatment results in high morbidity and mortality in both the mother and foetus.

Question 11

Symptoms of appendicitis

Answer 11

Classical migratory abdominal pain
RIF pain
Nausea
Anorexia
Constipation

Question 12

Signs of appendicitis

Answer 12

RIF tenderness
Percussion tenderness
Localised guarding
Tachycardia
Pyrexia

Question 13

… sign: pain in the RIF on palpation of the LIF.

Answer 13

Rovsing sign: pain in the RIF on palpation of the LIF.

Question 14

… sign: the patient lies on their left side with knees flexed, positive when there is pain in the RIF on passive extension of the right hip.

Answer 14

Psoas sign: the patient lies on their left side with knees flexed, positive when there is pain in the RIF on passive extension of the right hip.

Question 15

… sign: pain in the RIF on passive internal rotation of a flexed right hip.

Answer 15

Obturator sign: pain in the RIF on passive internal rotation of a flexed right hip.

Question 16

Additional signs in appendicitis - name 3

Answer 16

Rovsing sign: pain in the RIF on palpation of the LIF.

Psoas sign: the patient lies on their left side with knees flexed, positive when there is pain in the RIF on passive extension of the right hip.

Obturator sign: pain in the RIF on passive internal rotation of a flexed right hip.

Question 17

This is showing what condition?

Answer 17

Appendicitis presentation

Question 18

Bedside investigations in appendicitis (suspected)

Answer 18

Bedside

Observations
Urine dip
Pregnancy test

Question 19

Blood tests in appendicitis (suspected)

Answer 19

FBC
U&Es
CRP
LFTs
Amylase
Group & save
Clotting screen

Question 20

Imaging for appendicitis - options?

Answer 20

Ultrasound: may identify appendicitis, though sensitivity is operator-dependent. Pelvic ultrasound is often used in female patients where the differential includes gynaecological pathology.

Computed tomography: the use of CT to confirm the diagnosis of appendicitis is becoming increasingly commonplace particularly in older patients or if there is diagnostic uncertainty.

Question 21

The Alvarado score gives an estimate of the likelihood of … based upon two major and six minor criteria

Answer 21

Question 22

The Alvarado score gives an estimate of the likelihood of appendicitis based upon two major and six minor criteria.

What score is unlikely?
Possible?
Likely?

Answer 22

What score is unlikely? 1-4
Possible? 5-6
Likely? >7

Question 23

Management of appendicitis

Answer 23

Question 24

Conservative management in appendicitis

Answer 24

A number of studies (BMJ, JAMA) have shown that uncomplicated acute appendicitis may be treated initially with antibiotics (co-amoxiclav is commonly used in the absence of a penicillin allergy). A proportion of these patients, 27% in one study, required surgery within one year. Beyond this, there would likely continue to be a risk of re-developing appendicitis.

Question 25

In the UK, the majority of patients with suspected appendicitis receive surgical management in the form of a …

Answer 25

In the UK, the majority of patients with suspected appendicitis receive surgical management in the form of a laparoscopic appendicectomy (with conversion to open surgery when necessary). This is a ‘keyhole’ procedure with high success and low complication rates.

Question 26

Pre-operatively for appendicitis, antibiotic therapy should be commenced - what is used (no penicillin allergy?)

Answer 26

Pre-operatively, antibiotic therapy should be commenced (co-amoxiclav is commonly used in the absence of a penicillin allergy) and normally continued for 7 days only if pus or perforation is noted intra-operatively. Depending on the operative findings a temporary drain may be inserted.

Question 27

Appendicitis - Pre-operatively, antibiotic therapy should be commenced (co-amoxiclav is commonly used in the absence of a penicillin allergy) and normally continued for … only if pus or perforation is noted intra-operatively.

Depending on the operative findings a temporary drain may be inserted.

Answer 27

Appendicitis - Pre-operatively, antibiotic therapy should be commenced (co-amoxiclav is commonly used in the absence of a penicillin allergy) and normally continued for 7 days only if pus or perforation is noted intra-operatively. Depending on the operative findings a temporary drain may be inserted.

Question 28

Surgical management in those with an appendiceal mass (a collection of pus and stuck bowel) would likely be complicated by … and …. As such simple localised cases may be treated with antibiotics alone. Larger abscesses may benefit from a … drain and complicated loculated disease may necessitate surgical intervention.

Answer 28

Surgical management in those with an appendiceal mass (a collection of pus and stuck bowel) would likely be complicated by inflammation and adhesions. As such simple localised cases may be treated with antibiotics alone. Larger abscesses may benefit from a percutaneous drain and complicated loculated disease may necessitate surgical intervention.

Question 29

Rovsing’s sign

Answer 29

This is when palpation of the left lower quadrant of a patient’s abdomen increases the pain felt in the right lower quadrant.
It is a sign of appendicitis.
This occurs as the peritoneal lining has become inflamed around the appendix thus irritating the muscles here; upon palpation of the left side the perineal lining is stretched and will produce pain where the peritoneum is irritating the muscle.
The patient may also display McBurney’s sign (deep tenderness on palpation of McBurney’s point), or Aaron’s sign (referred pain in the epigastrium upon deep palpation of the right lower quadrant).