Appendicitis Flashcards
Pathophysiology
The appendix arises from the caecum where the three teniae coli meet. It leads to a dead end.
Pathogens can get trapped due to obstruction-> leads to infection and inflammation-> gangrene and rupture. Rupture-> faecal contents and infective material are released into the peritoneal cavity this leads to peritonitis (inflammation of the peritoneal lining.)
Signs and symptoms?
The key presenting feature of appendicitis is abdominal pain. Starts as central abdominal pain that moves down to the right iliac fossa (RIF) within the first 24 hours, eventually becoming localised in the RIF. On palpation of the abdomen, there is tenderness at McBurney’s point. McBurney’s point refers to a specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus.
Other classic features are:
Loss of appetite (anorexia)
Nausea and vomiting
Low-grade fever
Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
Guarding on abdominal palpation
Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)
Percussion tenderness (pain and tenderness when percussing the abdomen)
Rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix.
Diagnosis?
Diagnosis is based on the clinical presentation and raised inflammatory markers. Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An ultrasound scan is often used in female patients to exclude ovarian and gynaecological pathology. Ultrasound can also be useful in children, where a CT scan is less appropriate due to the dose of radiation.
Appendicitis is mostly a clinical diagnosis (meaning it is based on signs and symptoms rather than diagnostic tests). Where the diagnosis is unclear, a period of observation may be used, with repeated examinations over time to see whether the symptoms resolve or worsen.
When a patient has a clinical presentation suggestive of appendicitis, but investigations are negative, the next step is to perform a diagnostic laparoscopy to visualise the appendix directly. The surgeon can proceed to an appendicectomy during the same procedure, if indicated.
Differentials?
Ectopic Pregnancy
Consider ectopic pregnancy in females of childbearing age. This is a gynaecological emergency with a relatively high mortality if mismanaged. A serum or urine human chorionic gonadotropin (hCG) to exclude pregnancy is essential.
Ovarian Cysts
Ovarian cysts can cause pelvic and iliac fossa pain, particularly with rupture or torsion.
Meckel’s Diverticulum
Meckel’s diverticulum is a malformation of the distal ileum that occurs in around 2% of the population. It is usually asymptomatic and does not require any treatment. However, it can bleed, become inflamed, rupture or cause a volvulus or intussusception.
Mesenteric Adenitis
Mesenteric adenitis describes inflamed abdominal lymph nodes. It presents with abdominal pain, usually in younger children, and is often associated with tonsillitis or an upper respiratory tract infection. No specific treatment is required.
Appendix mass?
An appendix mass occurs when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa. This is typically managed conservatively with supportive treatment and antibiotics, followed by appendicectomy once the acute condition has resolved.
Management?
Removal of the inflamed appendix (appendicectomy) is the definitive management for acute appendicitis. Laparoscopic surgery is associated with fewer risks and faster recovery compared to open surgery.
Complications of management?
Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
