Appendicitis

Question 1

What is appendicitis?

Answer 1

Appendicitis is inflammation of the appendix and is the most common indication for emergency surgery in paediatric patients

Question 2

What percent of children presenting with acute abdominal pain will be diagnosed with acute appendicitis?

Answer 2

20-30%

Question 3

What is the appendix?

Answer 3

The appendix is an intraperitoneal hollow outpouching of the gut which arises from the caecum where the three teniae coli meet.

It is suspended, by the mesoappendix, from the terminal portion of the ileum and commonly sits retrocaecally.

The appendix is thought to act as a reservoir for intestinal flora which allows the gut to replenish its microbiome after gastroenteritis, but there are usually no long-term consequences to removing it

Question 4

What is the pathophysiology of appendicitis?

Answer 4

he typical cause of inflammation is obstruction of the opening of the appendix, as a result of either a faecolith (hardened stool) or lymphoid hyperplasia

Question 5

What are teniae coli?

Answer 5

three separate longitudinal ribbons of smooth muscle that run the length of the colon

Question 6

What is a faecolith?

Answer 6

Calcified faeces

Question 7

In which decade is appendicitis most common?

Answer 7

second decade of life

Question 8

Describe the migration of pain seen in appendicitis:

Answer 8

pain typically starts as central umbilical pain which moves down into the right iliac fossa

Question 9

Other than abdominal pain, give 4 symptoms of appendicitis:

Answer 9

1) nausea and vomiting
2) low-grade fever
3) diarrhoea
4) anorexia (loss of appetite)

Question 10

Explain why there is a migration of pain from the umbilicus to the right iliac fossa in appendicitis:

Answer 10

the initial inflammation stimulates the visceral afferent pain fibres which correspond to the T10 dermatome producing umbilical pain -> as the appendix becomes more inflamed, it irritates the parietal peritoneum which activates somatic nerve fibres and produces localised pain in the right iliac fossa

Question 11

At which anatomical point is pain found in appendicitis?

Answer 11

McBurney’s point

Question 12

Give 3 examinations findings associated with appendicitis:

Answer 12

1) tenderness in the right iliac fossa
2) guarding due to localised peritonitis
3) rebound tenderness in the right iliac fossa

Question 13

What is rebound tenderness?

Answer 13

where there is increased pain when suddenly releasing the pressure of deep palpitation

Question 14

Give four examination tests for appendicitis:

Answer 14

1) Rovsing’s sign
2) Psoas sign
3) Obturator sign
4) Hop test

Question 15

Describe Rovsing’s sign:

Answer 15

palpation of the left iliac fossa causes right iliac fossa pain

Question 16

Describe psoas sign:

Answer 16

extension of the right thigh in the left lateral position causes right iliac fossa pain

Question 17

Describe the obturator sign:

Answer 17

internal rotation of the flexed right thigh causes pain

Question 18

Describe the hop test:

Answer 18

hopping or jumping causes abdominal pain

Question 19

Describe the anatomical position of McBurney’s point:

Answer 19

one third of the distance from the anterior superior iliac spine to the umbilicus

Question 20

What is the name of the triad of classic symptoms seen in appendicitis?

Answer 20

Murphy’s triad

Question 21

Give the three symptoms of Murphy’s triad:

Answer 21

1) nausea and vomiting
2) low-grade fever
3) right iliac fossa pain

Question 22

Name 4 laboratory tests indicated in suspected appendicitis:

Answer 22

1) FBC (raised WCC)
2) U+E (nausea and vomiting can derange renal func.)
3) CRP (suggestive of inflammation)
4) Group and save (to identify blood type which will be needed for surgery)

Question 23

Name three forms of imaging that may be used to view an inflamed appendix?

Answer 23

1) ultrasound scan
2) CT scan
3) MRI scan

Question 24

Give 3 ultrasound scan findings that indicate appendicitis:

Answer 24

1) non-compressible appendix larger than 6mm
2) wall thickening
3) free fluid within the right iliac fossa

Question 25

Name four conditions that mimic symptoms of appendicitis:

Answer 25

1) Meckel’s diverticulitis
2) Ovarian cysts
3) Ectopic pregnancies
4) Mesenteric adenitis

Question 26

What is Meckel’s diverticulitis?

Answer 26

inflammation of a congenital outpouching of the small intestine that is a remnant of the umbilical cord (which is present in 2% of the population)

Question 27

True or false: all females of a child bearing age should be assumed to be pregnant until proven otherwise when presenting with abdominal pain

Answer 27

true (especially important in appendicitis when requesting X-rays and CT scans)

Question 28

What is the name for inflamed abdominal lymph nodes associated with tonsillitis and URTIs?

Answer 28

mesenteric adenitis

Question 29

How does mesenteric adenitis present?

Answer 29

Similar to acute appendicitis (fever, vomiting, abdominal pain)

Question 30

What is the most common treatment for acute appendicitis?

Answer 30

laparoscopic appendicectomy

Question 31

What is an appendix mass?

Answer 31

where the omentum sticks to the inflamed appendix, forming a mass

Question 32

How does treatment of an appendix mass differ from treatment of a normal appendicitis?

Answer 32

antibiotic therapy is commenced and the appendicectomy is delayed by several months to allow inflammation to settle

Question 33

Name and explain the new appendicitis management strategy that does not use appendicectomies:

Answer 33

active observation - patients are given fluids and antibiotics and monitored

Question 34

Give 4 complications associated with appendicitis surgery:

Answer 34

• Bleeding, infection, pain and scars
• Damage to bowel, bladder or other organs
• Removal of a normal appendix
• Venous thromboembolism (deep vein thrombosis or pulmonary embolism)

Question 35

What are the complications of a delay in presentation with appendicitis?

Answer 35

Perforation, leading to generalised peritonitis
Abscess formation, usually requiring drainage