Appendicitis

Question 1

How common is it?

Answer 1

Most common surgical emergency – lifetime incidence = 6%.

Question 2

Who does it affect?

Answer 2

Can happen at any age but highest incidence between 10-20yrs. Rare before age 2.

Question 3

What causes it?

Answer 3

Gut organisms invade appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith or filarial worms. This leads to oedema, ischaemia, necrosis and perforation.

Question 4

How does it present?

Answer 4

Symptoms

• Classically umilical pain that moves to the RIF (McBurney’s point).
• Anorexia an important feature.
• Vomiting rarely prominent – pain normally precedes vomiting in the surgical abdomen.
• Constipation normal, diarrhoea may occur.

General Signs

• Tachycardia
• Fever 37.5-38.5
• Furred tongue
• Lying still
• Coughing hurts
• Foetor +/- flushing
• Shallow breaths

Signs in RIF

• Guarding
• Rebound and percussion tenderness
• PR painful on right (sign of low-lying pelvic appendix).

Special tests

• Rovsing’s sign – (pain > in RIF than LIF when LIF is pressed)
• Psoas sign – (pain on extending hip if retrocaecal appendix)
• Cope sign – (pain on flexion and internal rotation of right hip if appendix in close relation to obturator internus).

Question 5

Conditions with similar presentations?

Answer 5

	Ectopic pregnancy
	UTI
	Mesenteric adenitis
	Cystitis
	Cholecystitis
	Diverticulitis
	Salpingitis/PID
	Dysmenorrhoea
	Crohn’s disease
	Perforated ulcer
	Food poisoning
	Meckel’s diverticulum

Question 6

Investigations?

Answer 6

• Bloods may show neutrophil leucocytosis and elevated CRP.
• USS may help but appendix not always visualised.
• CT has high diagnostic accuracy and is useful if diagnosis is unclear. Reduces –ve appendicectomy rate, but may cause fatal delay.

Question 7

Treatments?

Answer 7

• Prompt appendicectomy.
• Abx – Metronidazole + cefuroxime pre-op, reduces wound infections.
• Laparoscopy – diagnostic and therapeutic advantages (when done by an experienced surgeon), especially in women and the obese.