appendicitis

Question 1

What is appendicitis?

Answer 1

Acute inflammation of the vermiform appendix → mainly due to obstruction of the lumen of the appendix (by Fecalith-accumulation of hardened feces, infective agents or lymphoid hyperplasia)
- Most common surgical emergency of the abdomen

Question 2

Summarise the epidemiology of appendicitis

Answer 2

The MOST COMMON surgical emergency
Can occur at any age
Most commonly occurs between 10-20 yrs

Question 3

Explain the aetiology / risk factors of appendicitis

Answer 3

• Gut organisms invade the appendix wall after lumen obstruction (e.g. by lymphoid hyperplasia, faecolith or filarial worms)
• This leads to oedema, ischaemic necrosis and perforation

Question 4

What are the presenting symptoms of appendicitis?

Answer 4

• Periumbilical pain that moves to the right iliac fossa – this is because the initial pain is due to inflammation of the visceral peritoneum and appendix itself and visceral pain tends to be poorly localised and the pain is referred to the midline. As the inflammation spreads to the parietal peritoneum, which is somatosensory, it is localised at the right lower quadrant – the point of pain is known as MCBURNEY’S POINT (1/3 of the distance from the ASIS to the umbilicus – roughly corresponds to location of base of appendix)
• Anorexia is an important feature
• Vomiting (may occur after pain)
• Constipation
• Diarrhoea

Question 5

What signs of appendicitis can be found on physical examination

Answer 5

1. General Signs
   - Tachycardia
   - Fever
   - Furred tongue
   - Lying still
   - Coughing hurts
   - Foetor with/without flushing
   - Shallow breaths
2. RIF Signs
   - Guarding
   - Rebound and percussion tenderness
   - PR pain on the right side (sign of low-lying pelvic appendix)
3. Special Signs
   - Rovsing’s Sign - palpation of the left iliac fossa causes more pain in the right iliac fossa than the left
   - Psoas Sign - pain on extending the hip (caused by retrocaecal appendix)
   - Cope Sign - pain on flexion and internal rotation of the hip (occurs if the appendix is in close proximity to the obturator internus)
   - Obturator Sign → pain on internal rotation of flexed thigh
   - Blumberg Sign → Rebound Tenderness in RLQ
4. Variations in clinical picture
   - Inflammation of retrocaecal/retroperitoneal appendix may cause flank pain or RUQ pain
   *The only sign may be tenderness on the right on DRE
   - A child may have vague abdominal pain and will not eat their favourite food
   - A shocked confused 80+ year old who is not in any pain

Question 6

What investigations are used to diagnose/ monitor appendicitis?

Answer 6

1. Bloods
   - FBC → neutrophil-predominant leukocytosis
   - High WCC (mainly neutrophils)
   - High CRP
2. Pregnancy test/ Urinary beta human chorionic gonadotropin (βhCG)- important to rule out an ectopic pregnancy in women of reproductive age who present with acute abdominal pain and features of sepsis
3. Abdo ultrasound may help
   - order if radiation risk is a concern. 1st line in pregnant women. (Rapid & can be performed at bedside)
4. CT - order if ultrasound is inconclusive or you suspect malignancy, high diagnostic accuracy but may cause fatal delay – usually go straight to surgery for diagnostic laparoscopy +/- appendicectomy
5. Erect CXR → if perforation suspected
6. abdo MRI
7. Urinalysis (exclude UTI)

Question 7

How is appendicitis managed?

Answer 7

1. Laparoscopic Appendicectomy → first choice for uncomplicated appendicitis, within 24 hours of diagnosis.
2. Give dose of prophylactic antibiotics before surgery (reduces wound infection rates). (Keep patient NBM if surgery is being considered, give analgesia and fluids in mean time)
   - Abx ⇒ cefuroxime and metronidazole
3. Pelvic Abscess (post-appendicectomy) ⇒ pain, fever, sweats, mucus diarrhoea (can be drained)

Question 8

What complications may arise from appendicitis?

Answer 8

1. Perforation
2. Appendix mass
   - Occurs when the inflamed appendix becomes covered with omentum
3. Appendix abscess
   - May occur if appendix mass fails to resolve
   - ‘swinging pyrexia’ which is a common finding in the presence of an abscess.

Treatment involves drainage and antibiotics

Question 9

Summarise the prognosis for patients with appendicitis

Answer 9

Uncomplicated appendicitis - most people recover with no long-term problems
Ruptured appendix - greater risk of complications/death