Appendicitis Flashcards
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.
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.
The appendix is a short appendage, normally 5-10 cm long, that opens onto the ….
The appendix is a short appendage, normally 5-10 cm long, that opens onto the caecum.
Appendicitis is normally caused by obstruction of the … of the appendix.
Appendicitis is normally caused by obstruction of the lumen of the appendix.
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.
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.
Appendicitis is uncommon at the extremes of age. The young have a relatively wide appendiceal …, whilst in the elderly, it is almost entirely obliterated.
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.
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 ….
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.
Appendicitis - risk of perforation
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.
Patients classically complain of a colicky, peri-umbilical pain which migrates to the right iliac fossa (RIF) and becomes constant - what is this describing?
Patients classically complain of a colicky, peri-umbilical pain which migrates to the right iliac fossa (RIF) and becomes constant - appendicits
Common clinical features associated with acute appendicitis include …, anorexia and constipation. … may be seen but is typically mild when present.
Common clinical features associated with acute appendicitis include nausea, anorexia and constipation. Diarrhoea may be seen but is typically mild when present.
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.
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.
Symptoms of appendicitis
Classical migratory abdominal pain RIF pain Nausea Anorexia Constipation
Signs of appendicitis
RIF tenderness Percussion tenderness Localised guarding Tachycardia Pyrexia
… sign: pain in the RIF on palpation of the LIF.
Rovsing sign: pain in the RIF on palpation of the LIF.
… 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.
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.
… sign: pain in the RIF on passive internal rotation of a flexed right hip.
Obturator sign: pain in the RIF on passive internal rotation of a flexed right hip.
Additional signs in appendicitis - name 3
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.
This is showing what condition?
Appendicitis presentation
Bedside investigations in appendicitis (suspected)
Bedside
Observations
Urine dip
Pregnancy test
Blood tests in appendicitis (suspected)
FBC U&Es CRP LFTs Amylase Group & save Clotting screen
Imaging for appendicitis - options?
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.
The Alvarado score gives an estimate of the likelihood of … based upon two major and six minor criteria
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?
What score is unlikely? 1-4
Possible? 5-6
Likely? >7
Management of appendicitis
Conservative management in appendicitis
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.
In the UK, the majority of patients with suspected appendicitis receive surgical management in the form of a …
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.
Pre-operatively for appendicitis, antibiotic therapy should be commenced - what is used (no penicillin allergy?)
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.
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.
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.
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.
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.
Rovsing’s sign
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).
