Appendicitis

Question 1

What is acute appendicitis?

Answer 1

Acute inflammation of appendix, most likely due to obst of its lumen

Typically presents as acute abdo pain: mid-abdomen→ RLQ

Assoc w fever, anorexia, nausea, vomiting, neutrophil elevation

Question 2

General pathophysiology of appendicitis?

Answer 2

Lumen distal to obstruction starts to fill w mucus→ closed-loop obstruction→ distension→ resident bacteria in appendix rapidly multiply

Question 3

Examples of bacteria in the appendix, which multiply as obstruction progresses?

Answer 3

Bacteroides fragilisandE.coli most common

Question 4

What does distention of appendix’ lumen cause (symptoms)?

Answer 4

Reflex anorexia, N&V, visceral pain.

Question 5

Aetiology of appendicitis?

Answer 5

Main cause: obstruction of lumen of appendix

Faecolith (a hard mass of faecal matter), normal stool, or lymphoid hyperplasia are main causes for obstruction

Question 6

Risk factors for appendicitis?

Answer 6

Weak
- Low dietary fibre
- Smoking (active or passive exposure)

Question 7

What is Murphy’s triad? (signs and symptoms of appendicitis)

Answer 7

• Low grade fever
• Umbilical pain migrating to RLQ
• N&V

Question 8

Other signs and symptoms of appendicitis? (excluding Murphy’s triad and special signs)

Answer 8

• Anorexia
• High/ intermediate risk score
• Age (10-30 most common)
• Flushed face and fetor
• Reduced bowel sounds

Uncomon:
- Tense rigid abdo
- Hypotension and tachycardia
- Loose stool
- Conspitation

Question 9

Special signs for appendicitis? (4)

Answer 9

• Pain at McBurney’s point (1/3 ASIS to umbilicus)
• Rosving’s sign - press on LIF = pain at RIF
• Psoas sign - extension of R thigh in left lateral position - pain
• Obturator sign - flexion and internal rotation - pain

Question 10

Investigations for appendicitis?

Answer 10

Clinical diagnosis
- Raised inflammatory markers: elevated CRP
- FBC: leukoctyosis
- Urinalysis (also need to rule out pregnancy)
- Imaging not usually done but may do abdominal USS/ CT

Question 11

Management for appendicitis? (5 things)

Answer 11

• Analgesia (paracetamol, morphine)
• Fluids/ supportive management
• Appendicectomy: NBM for solids and non-clear fluids 6 hrs prior to surgery
  
  • Lanz incision
  • Gridiron incision
• Broad spec ABs: metronidazole and cefuroxime
• DVT prophylaxis

Question 12

Potential complications of appendicitis?

Answer 12

• Rupture→ emergency surgery
• Appendix mass
• Post-op complications

Question 13

Potential post-op complications for appendectomy?

Answer 13

• Wound infection (erythema/ produce discharge)
• Anastamotic leak
  
  • Features: diffuse abdo tenderness, guarding, hypotensive/ tachycardia
• Pelvic abscess→ incision and drainage
  
  • Features: pain, fever, sweats, diarrhoea, mucus