Appendicitis

Question 1

Define appendicitis, summarising its aetiology and epidemiology

Answer 1

Definition: Inflammation of the appendix

Aetiology:
• 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

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

Question 2

Describe the history/presenting symptoms of appendicitis

Answer 2

• Periumbilical pain that moves to the right iliac fossa
• Anorexia is an important feature
• Vomiting (may occur after pain)
• Constipation
• Diarrhoea

Question 3

What are the signs of appendicitis upon physical examination?

Answer 3

• General Signs: 
 o Tachycardia 
 o Fever  
 o Furred tongue  
 o Lying still 
 o Coughing hurts  
 o Foetor with/without flushing  
 o Shallow breaths  

• RIF Signs:
o Guarding
o Rebound and percussion tenderness
o PR pain on the right side (sign of low-lying pelvic appendix)

• Special Signs:
o Rovsing’s Sign- palpation of the left iliac fossa causes more pain in the right iliac fossa than the left
o Psoas Sign- pain on extending the hip (caused by retrocaecal appendix)
o Cope Sign- pain on flexion and internal rotation of the hip (occurs if the appendix is in close proximity to the obturator internus)

• Variations in clinical picture
o Inflammation of retrocaecal/retroperitoneal appendix may cause flank pain or RUQ pain
- The only sign may be tenderness on the right on DRE
o A child may have vague abdominal pain and will not eat their favourite food
o A shocked confused 80+ year old who is not in any pain

Question 4

What investigations are used to identify appendicitis?

Answer 4

1st line investigations:
• Bloods FBC
    o High WCC (mainly neutrophils)
    o High CRP
• CT- high diagnostic accuracy
• Pregnancy test- incase of ectopic pregnancy 

Investigations to consider:
• Abdominal ultrasound
• Urinalysis
• Abdominal and pelvic MRI in pregnancy

Question 5

How is appendicitis managed?

Answer 5

• 1st line: appendectomy + supportive care
• Adjunct: intravenous antibiotic therapy
• Note: Laparoscopy has diagnostic and therapeutic
  advantages so they are preferred by some doctors

Question 6

What are the complications of appendicitis?

Answer 6

• Perforation
• Appendix mass:
  o Occurs when inflamed appendix becomes covered with omentum.
• Appendix abscess:
  o May occur if appendix mass fails to resolve
  o Treatment involves drainage and antibiotics

Question 7

Summarise the prognosis for patients with appendicitis

Answer 7

• Uncomplicated appendicitis: most people recover with no long-­term problems

• Ruptured appendix: greater risk of
complications/death