Appendicitis

Question 1

Pathophysiology appendicitis? (2)

Answer 1

• Obstruction to appendix lumen (66%) by fecolith mostly, or foreign body eg seeds, parasites, lymphoid tissue
• inflammation in mucous membrane or lymph tissue

Question 2

Name 6 positions of appendix from most to least common

Answer 2

•Retrocaecal 74%
• pelvic 21%
• postileal 5%
• paracaecal
• subcaecal
• preileal

Question 3

Name 4 types of appendicitis

Answer 3

• Acute “uncomplicated” appendicitis: micro perforations with peri-appendiceal fluid
• perforation with peritonitis (generalised,uncontrolled or free perforation )
•Perforation with abscess (localised,walled off or contained )
• appendix phlegmon (sterilized, controlled inflammatory mass)

Question 3

Name 4 types of appendicitis

Answer 3

• Acute “uncomplicated” appendicitis: micro perforations with peri-appendiceal fluid
• perforation with peritonitis (generalised,uncontrolled or free perforation )
•Perforation with abscess (localised,walled off or contained )
• appendix phlegmon (sterilized, controlled inflammatory mass)

Question 4

Appendicitis diagnosis?

Answer 4

Clinical using Alvarado score mantrles

Signs
• right lower quadrant tenderness (2) T
• fever > 37,3 (1) E
• rebound tender ( 1) R

Symptoms
• migration of pain to right lower quadrant ( 1 ) M
• anorexia ( 1) A
• nausea or vomiting ( 1) N

Lab values
• Leukocytosis >10000 (2) L
• leukocyte left shift >75% neutrophils (1) S

Score < 5 unlikely , discharge (30%)
5-6 possible, observe or admit (66%)
7-8 likely, surgery
9-10 definite, surgery (93% )

Question 5

Differential diagnosis appendicitis? (7)

Answer 5

• Pelvic inflammatory disease , UTI (urinary symptoms)
• complicated peptic ulcer disease
• ovarian mass
• Tb
• colon cancer, retroperitoneal tumour
• Chron’s disease
• amebiasis, actinomycosis
• mesenteric adenitis (usually preceded by sore throat)
• Meckel’s diverticulitis ( symptoms include rectal bleeding)
• gastroenteritis (pain not migratory but generalised)

Question 6

Ultrasound features appendicitis?

Answer 6

Fat stranding, inflammation

Question 7

Treatment appendix phlegmon?

Answer 7

• Antibiotics 7-10 days
• interval appendicectomy after 6 weeks

Question 8

Clinical findings appendicitis? (7)

Answer 8

• Rif tender
• RLQ peritonism
• rovsing sign: palpation LIF causes rif pain
• psoas sign: extension r thigh in L lat position cause rif pain
• obturator sign : internal rotation of flexed R thigh cause pain
• hop test: hopping or jumping cause abdominal pain
• Murphy’s triad: nausea and vomit, low grade fever, rif pain

Question 9

Ultrasound findings appendicitis? (4)

Answer 9

• Non-compressible appendix (>6 mm diameter)
. Appendicolith
• wall thickening ≥3 mm with hyperaemia

Secondary signs = free fluid rif, echogenicity (whiter) mesenteric fat to rule out other causes eg mesenteric adenitis where inflammation would be limited to lymph nodes