Appendicitis Flashcards
Pathophysiology of appendicitis?
INflammation of mucose -> submucosa -> mucualr and serosal - peritoneal - layers, Accumulation mucus -> ischaemia, allows bacterial advancement until perforation,
Localised peritonitis
Appendix becomes distended with pus, blockage of end arteries
Necrotic appendix if untreated will perforate, contents -> peritoneal cavity -> abscess or generalised peritonitis
What causes appendicitis?
50% unknown, 50% luminal obstruction
Causes of luminal obstruction
Faecolith
Lymphoid hyperplasia
IMpaceted stool
Foreign body
Congenital bands
Adhesions
prev infection
How does luminal obstruction lead to distension of appendix?
Increased mucus production -> bacterial overgrowth -> suppurative inflammtion -> impaired lympahtic andvenous drainage from appendix -> ischaemia and necrosis + possible perforation
Complications from appendicitis?
Delay or misdiagnosis ->
Perforation
Abscess formation
Peritonitis
Sepsus
Intra-abdominal adhesions
Bowel obstruction
Symptoms of appendicitis?
Periumbilical or epigastric worsening pain migrating to RUQ over 24-48 hours. Aggravated by movement
Low grade fever, general malaise, anorexia
N+V, sometimes diarrhoea and constipation
Signs of appendicits
Abdominal distension
Guarding
Rebound tenderness or percussion tenderness
Absent bowel sounds
Palpable abdominal mass or abscess
May present atypically esp in young, old, pregnenat
What to do to test pain inc hildren on exam?
Get to jump ir cough - worsens significatnly
Management of appendicitis
Emergency admission
Non-operative - antibiotics
Operative - appenectomy or percutaneous drainage of appendix abscess eg
What is the appendix?
6-10cm tube connected to caecam just before the colon
High concentration of GALT
What may be underlying cause of appendicitis?
Genetic factors - positive family history = 2 x risk
Environmental factors
INfection - E.coli, Bacteroides spp
Malignancy (1%) - neuroedicrine tumour of appendix, adenocarcinoma, mucinous cystadenoma
Which groups does perforation in appendicitis often occur?
Younger eg children
Over 50
Co-morbidities
Male
Time taken symptom onset to diagnsosis
5% mortality
Which group are more at risk of vascular sclerosis of the appendix and narrowing of the lumen by fibrosis?
Elderly
Type of pain with appendicitis?
Periumbilical or epigastric that worsens + migrates to RLQ over 24-48 hours
Often worsened by movement eg coughing
(Sudden relief may indicate perforation)
Positive findings on exam appendicitis?
Facial flushing, dry tongue, halitosis, low grade fever, tachy
RLQ pain/tender
Abdominal distension
Guarding (muscular rigidity)
Rebound tenderness
Absent bowel sounds = perforation or ileus
Palpable abdominal mass - appendix mass or abscess
Rosvings sign, Psoas sign, Obturator sign
Where is the site of maximum pain in appendicitis?
McBurneys point
2/3 eay along a line drawn from the umbilicus to anterior superior iliac spine
What is Rosvings sign?
Palpation in LLQ increaes pain felt in RLQ
What is psoas sign?
passive extension of R thigh while in L lateral pisition -> pain in RLQ
What is obturator sign?
Passive internal rotation of the flexed R thigh -? pain in RLQ
Why consider groin and scrotal examination/ pelvic examintation in GI pain?
Exclude alternative cause eg incarcerated hernia or testciular torsion
Children appendicitis how present atypically?Older age?
Non specific abdominal pain and anorexia, withdrawn
Older - minimal pain or fever - acute confusion and shock
How does appendicitis present in pregnancy?
Appendix may be displaced by gravid uterus
Later stages of pregnancy, may present with RUQ or R flank pain
N+V mistaken
How can the anatomical position of the appendix vary
A retrocaecal/retrocolic appendix may present with right loin pain and tenderness, and a positive psoas test. Muscular rigidity and tenderness to deep palpation are often absent because of protection from the overlying caecum.
A pre-ileal and post-ileal appendix may present with vomiting and diarrhoea (due to irritation of the distal ileum).
A subcaecal and pelvic appendix may present with suprapubic pain and urinary frequency; diarrhoea and tenesmus may be present owing to rectal irritation; abdominal tenderness may be lacking, but rectal or vaginal tenderness may be present on the right side; microscopic haematuria and leucocytes may be present on urine dipstick testing.
A long appendix with tip inflammation in the left lower quadrant may cause pain in that region.
Investigations to rule out alternative cause?
FBC
CRP
Urine dipstick test
